mohammad ali yaghoubi

A rare case of severe prolonged persistent Teriparatide-induced hypercalcemia (14.3mg/dL on admission) in an osteoporotic patient after ceasing the Teriparatide is reported. This 67-year-old female was admitted with polyuria, xerostomia, constipation, progressive weakness, and a history of Triparatide use due to a previous osteoporotic fracture. Her serum calcium, PTH, and vitamin D levels had been normal before starting Teriparatide. Ninety six hours after ceasing the Teriparatide along with rehydration and Calcitonin treatment, the patient's serum calcium levels returned to normal. Severe Teriparatide-induced hypercalcemia does not follow any defined pattern and may persist for days and can usually be controlled through ceasing the Teriparatide, rehydration, and close monitoring of the serum calcium level and symptoms.
        Level of evidence: IV

Due to the growing issue of medical errors, ensuring safer, and evidence-based prescribing practices, a training course on rational drug prescription for medical students is mandatory. Currently, the training course on rational drug prescription in Mashhad University of Medical Sciences and other faculties has not been defined for medical interns. The present study investigated the effects of a pharmacy-based rational pharmacotherapy training course on improving medical students’ pharmacotherapy knowledge and skills.

In 2023, thirty internal internship students of Mashhad University of Medical Sciences were assigned to the intervention and control groups. A pre-test survey was administered to all participants at the beginning of their internal internship. The intervention group underwent a seven-day course on rational pharmacotherapy at the hospital pharmacy unit. In contrast, the control group had their regular internship training. Post-tests were conducted for both groups at the end of their internal internship period. Ultimately, the pre-test and post-test scores were compared between the two groups.

A total of 30 interns with an average age of 24.88 ± 0.97 years were included in the study. There was no significant difference in their basic level of prescription knowledge between the two groups (p=0.314). Following intervention, a substantial improvement was noted in the overall post-test score of the intervention group (P=0.001).

A pharmacy-based pharmacotherapy training course can substantially improve medical students’ pharmacotherapy knowledge and skills. The present findings advocate for the integration of such courses into the medical education curricula, aiming to enhance rational drug prescription practices among future physicians.

Fasting during Ramadan is a religious obligation and may pose a risk to diabetic patients. This study aimed to stratify diabetic patients based on the International Diabetes Federation- Diabetes and Ramadan International Alliance (IDF- DAR) guideline for the risk of fasting before Ramadan. 

A total of 317 diabetic patients attending the endocrinology clinic at Ghaem Hospital, Mashhad, Iran, participated in this cross-sectional study. The American Diabetic Association (ADA) criteria were applied to diagnose diabetes. Various parameters, including diabetes type and duration, complications, and risk factors were recorded to determine IDF-DAR-based risk. Then patients were stratified into high (IDF-DAR>6), medium (IDF-DAR: 3.5-6) and low (IDF-DAR: 0-3) risk groups accordingly. 

 Out of the 317 patients included in the study, 115 (36.3%) patients were categorized as low risk, 127 (40%) as moderate-risk, and 75 (23.7%) as high-risk groups. 

  According to the IDF-DAR guideline, majority of the patients fell into the low and moderate risk categories, suggesting that they should not be entirely exempted from fasting during the holy month of Ramadan. However, the validity of this patient stratification in various fasting populations needs to be evaluated through prospective longitudinal studies.

There are inconsistent results about the effect of gastric bypass surgery on thyroid function tests in morbidly obese subjects. The aim of this study was to investigate the changes in thyroid function tests and insulin resistance status in euthyroid morbidly obese subjects before and three months after gastric bypass surgery (GBS).

Twenty-nine subjects with morbid obesity (BMI≥40) were enrolled in this before-after study. Patients with known thyroid disorders or a history of thyroid ablative therapy, users of drugs that affect thyroid function, or fasting blood sugar and insulin were excluded. TSH, Free T4, total T3, fasting blood sugar and insulin level, and BMI were measured before and 3 months after GBS. Statistical analysis was performed with appropriate tests and p<0.05 was considered significant.

Body mass index (BMI), insulin sensitivity index (HOMA-IR), and total T3 significantly decreased after bypass surgery (all with p<0.001) but no significant changes were seen in TSH (P=0.203) and FreeT4 (P=0.33). There was a significant negative correlation between changes in HOMA-IR and changes in FreeT4 (P=0.038, r= -0.38). There was no statistically significant correlation between the percentage of excess BMI loss (%EBMIL) and changes in T3 (P=0.66), Free T4 (P=0.92), TSH (P= 0.27), and HOMA-IR (P=0.17).

Although significant changes can occur in BMI, insulin sensitivity index, fasting blood sugar, and T3 in short-time follow-up after bariatric surgery, significant TSH and FreeT4 changes may need longer follow-ups.

Hypocalcemia is a common complication of total thyroidectomy (TT). This study was designed to investigate the effect of preoperative vitamin.D (Vit.D) status on the occurrence of post-total thyroidectomy hypocalcemia.

Patients who underwent TT without parathyroidectomy were divided into three groups based on their preoperative Serum Vit.D levels (<20 ng/ml, 20-30 ng/ml, and ≥30 ng/ml were considered deficient, insufficient, and normal Vit.D levels, respectively). Serum levels of calcium and phosphorus were measured before and 24 hours after surgery in all patients. The patients were examined for clinical symptoms and signs of hypocalcemia postoperatively. In cases with positive clinical symptoms and signs of hypocalcemia and/or calcium levels <8 mg/dl, PTH level was measured before starting calcium infusion, while serum calcium and phosphorus levels were also measured 24 hours later.

Among 100 patients enrolled in this study, 81% were females. The mean age was 36.60±8.32 years. Before surgery, the mean Vit.D level was 26.9±16.89 ng/ml, while 47% of cases had normal Vit.D level, 32% had insufficient vitamin levels, and 21% had Vit.D deficiency. Twenty-four hours after surgery, the calcium (P=0.356) and phosphorus (P=0.743) levels were not significantly different between the three Vit.D groups. A comparison of postoperative PTH levels between the three Vit.D groups showed no significant difference (P=0.596).

Based on our findings, preoperative serum Vit.D levels did not affect postoperative serum calcium levels.

Diabetic nephropathy is the main cause of end-stage kidney disease in diabetic patients. Several inflammatory markers related with diabetic nephropathy have been investigated so far. It is necessary to identify easily available and cost-effective indices. We aimed to determine the relationship between the neutrophil to lymphocyte ratio and mean platelet volume with diabetic nephropathy.

This cross-sectional study was performed from 2021 to 2022 in diabetes clinic of Ghaem hospital, Mashhad.  Patients with type II diabetes were categorized into two groups: without and with nephropathy (urinary albumin excretion greater than 30 mg/24h or GFR less than 60). Patients’ data, including demographic data, past medical and drug history and lab data were gathered and analyzed.

In total, 100 diabetic patients including 50 with (mean age=64.04±7.40 years) and 50 without nephropathy (mean age=56.06±6.36 years), were studied. Patients with nephropathy were older, had a longer history of diabetes and a higher blood pressure (P < 0.05). However, the distribution of gender, weight, height, and BMI was not significantly different the two groups (P>0.05). The absolute neutrophil count was not significantly different between the two groups (P>0.05), while the mean platelet volume, neutrophil% and neutrophil/lymphocyte ratio were significantly higher in patients with nephropathy (P<0.05).

According to our findings, patients with diabetic nephropathy had higher mean platelet volume, neutrophil%, and neutrophil/lymphocyte ratios compared to diabetic patients without nephropathy.

The precise mechanisms underlying the pathogenesis of hypertension is not yet fully understood. However, higher production of organic acids and unmeasured anions has been suggested to increase the anionic gap and lead to the progression of hypertension. Limited investigations have been performed to clarify the association of hypertension with the anionic gap. In this study, we determined the relationship between the anionic gap and systolic and diastolic blood pressure.

In this cross sectional study, blood pressure of 88 hypertensive patients was measured by the standard method and the anionic gap was then calculated by measuring the serum sodium, chloride, and bicarbonate levels.

The mean age of patients was 62.68 ± 13.14 years old, and 53 patients (61.1%) were female. The mean systolic and diastolic blood pressures (SBP and DBP) were 141.87 and 83.54 mmHg, respectively. The mean anionic gap (AG) was 9.18. There was a direct and significant association between anionic gaps and SBP (P= 0.0001, r= 0.62), DBP (P= 0.01, r= 0.26) and mean arterial blood pressure (MAP) (P= 0.001, r= 0.49). The multivariate regression analysis showed that sodium levels and AG significantly predicted SBP, DBP and MAP.

Our findings indicates that increasing the production of endogenous organic acids and unmeasured anions might lead to increased AG, and consequently, increase in the rate of hypertension.

The prevalence of hyperuricemia shows an increasing trend among kidney transplant recipients. The association between metabolic syndrome and hyperuricemia among the recipients of kidney transplants may consequently lead to reduction in graft survival. In this regard, the present study aimed at comparing the kidney transplant recipients with and without metabolic syndrome in terms of the prevalence of hyperuricemia.

  This cross-sectional study was carried out on kidney transplant recipients who were referred to the Kidney Transplant Clinic of Montaserieh Organ Transplant Hospital, Mashhad University of Medical Sciences, from 2019 to 2020. The serum uric acid, anthropometric data, renal function, glucose levels, and lipid profile of the study participants were evaluated.

  According to our findings, higher mean uric acid levels were reported in recipients with metabolic syndrome (6.9 ± 1.51 mg/dL), compared to recipients without metabolic syndrome (6.11 ± 1.47 mg/dL; P < .001). It was also found that 55.6 and 38.5% of the cases with and without metabolic syndrome had hyperuricemia, respectively (P < .05). Additionally, the results showed no significant association between hyperuricemia and the number of metabolic syndrome criteria (P > .05). A comparison between recipients with and without hyperuricemia revealed significantly lower levels of tacrolimus in the hyperuricemia group (P < .05). Regarding serum Tacrolimus levels, no significant difference was found between recipients with and without metabolic syndrome (P > .05). Moreover, there was no significant difference between recipients with and without hyperuricemia (P > .05) or metabolic syndrome (P > .05) in terms of serum cyclosporine level.

The findings of the current study indicate that kidney transplant recipients suffering from metabolic syndrome have higher mean serum levels of uric acid than those without metabolic syndrome.

Studies examining the effect of Empagliflozin in patients with type 2 diabetes have reported different results regarding the effect of this drug on electrolytes and lipid profiles. This study aimed to evaluate the effect of Empagliflozin on electrolytes and lipid profiles in patients with type 2 diabetes.

In this systematic meta-analysis, clinical trials published in the Web of Science, Scopus, PubMed, and Cochrane Library databases up to April 2022 were reviewed. Information on the mean and standard deviations of electrolytes, including phosphate, calcium, sodium, potassium, magnesium, and lipid parameters, including total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides, before receiving Empagliflozin was extracted from the selected studies and analyzed.

A total of seven clinical trials with 398 patients were analyzed. The sodium, potassium, phosphate, and magnesium levels remained unchanged or slightly changed after receiving different doses of Empagliflozin. Estimation of the standardized mean difference of calcium after receiving 10 mg of Empagliflozin was insignificant. The standardized mean difference in levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides was insignificant after receiving different doses of Empa gliflozin.

Administration of Empagliflozin in patients with type 2 diabetes does not affect phosphate, calcium, sodium, potassium, magnesium, total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. However, further research is needed due to the small number of studies and conflicting results on the issue.

Primary hyperparathyroidism (pHPT) is defined by the excess level of parathyroid hormone (PTH). Parathyroid adenoma is responsible for about 80% of all pHPT. Parathyroid adenoma with cystic feature and atypical pathology is recognized as a rare entity. Technetium-99m methoxy isobutyl isonitrile ([99mTc]Tc-MIBI) scintigraphy has favorable detection rate for ectopic gland as well as the brown tumors. SPECT/CT plays critical role in localizing abnormal tracer uptake. Herein, we report a severely hypercalcemic patient with cystic atypical parathyroid adenoma and mediastinal uptake, which was confined to a sternal lytic lesion (suggestive of brown tumor), which highlights the importance of SPECT/CT in [99mTc]Tc-MIBI imaging.

Ectopic increase of adrenocorticotropic hormone (ACTH) or ectopic Cushing syndrome is a rare initial presentation of small cell carcinoma and carcinoid tumor of the lung. Here, we reported a 36-year-old male with atypical symptoms of Cushing syndrome managed by Etomidate that had a central pulmonary nodule, and pathologic evaluation of pulmonary lobectomy revealed the diagnosis of well-differentiated, low-grade typical carcinoids of lung.

There is no definitive finding about the association between vitamin D deficiency and autoimmune hypothyroidism. On the other hand, there is evidence that trace elements such as zinc undergo changes in the presence of hypothyroidism. This study was aimed to compare the prevalence of vitamin D and zinc deficiency in patients with hypothyroidism and healthy people in Birjand in the winter of 2016. In this case control study, 50 hypothyroid patients referred to endocrinology clinic of Vali-e-Asr Hospital in Birjand and 50 healthy subjects were selected from the general population. The two groups were matched in terms of age, gender and body mass index. After obtaining informed consent, blood samples received from participants and sent to laboratory for Vitamin D, Ca, Zinc, TSH and Anti TPO measurement. Data were analyzed by SPSS version 19 with the help of Chi-square, independent T test, Mann Whitney test, Pearson and Spearman Correlation tests and logistic regression test. P Overall 88% of patients and 68% of healthy subjects suffered from vitamin D deficiency (P = 0.016). 16% of the case group and 4% of the control group suffered from zinc deficiency (P = 0.046). In the case group, TSH was inversely and significantly associated with vitamin D (r = -0.530, P <0.001) and calcium (r = -0.551, P <0.001) and correlated directly and significantly with Anti TPO (r = 0/628, P <0.001). Also Anti TPO was inversely and significantly correlated with vitamin D (r = -0.286, P = 0.44). The results of this study showed that the prevalence of vitamin D and zinc deficiency in patients with hypothyroidism is significantly higher than the normal people. It is recommended that people with hypothyroidism be monitored for vitamin D and zinc deficiency.

Lipoprotein a is a risk factor for coronary artery disease. Although many studies have been conducted in the non-diabetic population that shows the role of increasing plasma Lp (a) concentration and atherosclerotic disease, this role is not clear in the diabetic population. Therefore, the aim of this study was to determine the relationship between plasma lipoprotein levels and cardiovascular risk factors in patients with type 2 diabetes.
Subjects & This study was performed in the diabetic clinic of Imam Khomeini Hospital in Tehran ,from 2005 to 2007. A total of 346 patients were selected from 600 patients with type 2 diabetes. To measure the association of high levels of Lp (a) and cardiovascular risk factors, patients were divided into two groups of normal Lp (a) ( 35mg / dl) and risk factors between the two groups were compared by statistical tests.
Our results showed that there was a positive and significant correlation between Lp (a) and total cholesterol (r=0.217, P Serum levels of Lp (a) have a significant positive correlation with lipid variables (other than triglyceride) and higher levels than 35mg /dl with increased risk factors for cardiovascular disease in diabetic patients.

Recently, there has been an increasing trend toward the use of sustainable materials. Sustainability helps the environment by reducing the consumption of non-renewable natural resources. Concrete – the second most consumed material in the world after water – uses a significant amount of non-renewable resources. As a result, an experimental investigation was conducted to study the hardened properties of concrete constructed with 10% and 15% recycled Asphalt pavement aggregate (RAP) (fine) as well as 6% silica fume. This experimental program consisted of six mix designs. The hardened properties of concrete were compared with the provisions of the international design codes (U.S., Australia, Canada, Europe, and Japan) and previous researchers’ suggested equations as well as a database of conventional concrete. Results of this study show that the RAP mixes test results fall within a 95% confidence interval of a nonlinear regression curve fit of the conventional concrete splitting tensile test database. Furthermore, using RAP in the mix designs decreases compressive strengths around 25% and splitting tensile strength up to 30%. To overcome inferior hardened properties of RAP mixes, silica fume (6%) has been added to the RAP mixes. Results of the mixes including both RAP and silica fume show comparable hardened properties (both compressive and splitting tensile strength) with conventional concrete.

To describe a case of bilateral squamous cell carcinoma in right nasal and left temporal conjunctiva, simulating bilateral pterygium Case report : A reddish fibrovascular pterygium-like lesion was observed in the nasal side of bulbar conjunctiva on the right eye and temporal conjunctiva of the left eye. Medical examination not revealed any coexistent malignancy elsewhere excisional biopsy showed squamous cell carcinoma (SCC) insitu. Topical mitomycin-C (0.02%) one drop 4 times daily for two weeks postoperation had an excellent outcome. Bilateral pterygium-like lesion especially in area of conjunctiva that are exposed to sunlight radiation may be a malignant lesion; so early excisional biopsy with supplement of mitomycin-C result in long time relief without systemic association or recurrence.

Many factors effect on pregnancy and its outcome. Although, the role of nutrition on the outcome of pregnancy has not been confirmed, it was determined that the nutritional status of pregnant woman affect the pregnancy outcome considerably. Therefore, this study was done to compare the energy and nutrient intake of pregnant women in Sabzevar city (north-east Iran) with the values recommended by Dietary Reference Intakes.Methods and Material: This cross-sectional analytic study was done on 561 pregnant women who were selected by using cluster sampling method from all the municipal regions of Sabzevar city. They are including who no disease and like to be in this research. Their nutritional intake in the last 24 hours was recorded, using the food recall technique, by filling a questionnaire for three days. The data of the nutritional intake were analyzed by using the Food Processor (CAT-2 factory and the U.S.A country) software for each person to find the exact amount of nutrient each woman had received. Also, their pregnancy time was evaluated by sonography. The obtained data were statistically analyzed by SPSS version 11.5. Descriptive statistics and one sample t test were used to compare data with the values recommended by Dietary Reference Intakes. The mean pregnancy duration was 4/29±3/2 months. The results of our study showed that mean energy and all nutrient intakes except vitamin B12, phosphorous, sodium, and selenium in our study sample were less than the values recommended by Dietary Reference Intake. Having considered the low nutritional status in pregnant women in our region, educational programs regarding the recommended nutrition for pregnant women should be prepared.

To evaluate the visual outcomes and complications of low power transpupillary thermotherapy (TTT) in patients with neovascular age-related macular degeneration (AMD). The study included 20 eyes of 17 patients. Diagnosis of exudative AMD was established on the basis of fundus examination and fluorescein angiography (FA). TTT was performed using a diode laser at 810 nm wavelength, spot size of 2.5 to 4 mm and duration of 60 seconds for each spot with power settings between 300-600 mw (20% reduction). Follow-up visits were scheduled 1 and 6 weeks and 1, 3 and 6 months after the procedure and yearly thereafter. Patients were followed for at least 6 months. Cases with persistent leakage from CNV in late frames of FA were referred for another treatment option. Patients included 10 men (12 eyes) and 7 women (8 eyes) with mean age of 70.71±9.8 (range 50-84) years. Baseline best-corrected visual acuity (BCVA) ranged from 20/50 to 20/1300. Post-TTT regression of leakage (clinically and angiographically), and improvement or stabilization of visual acuity, was not statistically significant (P=0.14). Post-TTT complications included subretinal prepapillary hemorrhages in 2 eyes, vitreous hemorrhage in 2 eyes and macular infarction in one eye. At final follow-up, fibrosis of the CNV was detected in 7 (35%) eyes and flat chorioretinal atrophy with hypopigmentation was seen in 11 (55%) eyes. There was no significant difference between cases with flat atrophy and those with fibrous scars in terms of BCVA (P=0.91). Subgroup analysis showed that patients with better visual acuity (≥20/60) had poorer visual outcomes after TTT (P=0.03). Overall, in spite of the low threshold, visual acuity remained unchanged or decreased. Although TTT can occlude choroidal neovascularization, it could not prevent retinal complications and occurrence or progression of chorioretinal atrophy or subretinal fibrosis.