Caspian Journal of Internal Medicine
Volume:9 Issue: 3, Summer 2018

Multiple sclerosis (MS) is an inflammatory demyelinating disease, which is considered as a common autoimmune disorder in young adults. A growing number of evidences indicated that the impairment in non-neural tissues plays a significant role in pathology of MS disease. There are bidirectional relationship, metabolic activities and functional similarity between central nervous system (CNS) and kidneys which suggest that kidney tissue may exert remarkable effects on some aspects of MS disorder and CNS impairment in these patients compels the kidney to respond to central inflammation. Recently, it has been well documented that hormonal secretion possesses the important role on CNS abnormalities. In this regard, due to the functional similarity and significant hormonal and non-hormonal relationship between CNS and kidneys, we hypothesized that kidneys exert significant effect on initiation, progression or amelioration of MS disease which might be regarded as potential therapeutic approach in the treatment of MS patients in the future.

Cytomegalovirus (CMV) infection is one of the most common infectious diseases in pregnant women in terms of global impact and is related with many adverse health consequences during pregnancy. For the first time, we performed a systematic review and meta-analysis study to evaluate the possible association between CMV infection and preeclampsia (PE).
A comprehensive literature search to identify the relevant papers published earlier than February 2018 was performed in PubMed, ISI (Web of Science), Google Scholar and SCOPUS databases. We followed the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for design, analysis and interpretation of results. Pooled odds ratio (OR) and 95% confidence intervals (CI) were estimated using a random-effects meta-analysis model. Heterogeneity was assessed with Q-test and I2 statistics.
A total of 13 studies including 6158 pregnant women (2734 women with PE and 3424 healthy controls) met the eligibility criteria. The results of meta-analyses based on PCR (OR: 3.09; 95% CI:0.72–13.24; I2=57.3%), IgG-ELISA (OR: 1.24; 95% CI:0.83–1.85; I2=71%) and IgM-ELISA (OR: 1.04; 95% CI:0.66–1.65; I2=0.0%) demonstrated that CMV infection could not be a potential risk factor for PE.
In conclusion, results of the present study demonstrated that CMV infection could not be a potential risk for developing PE. More epidemiological and experimental studies are needed to investigate the impact of CMV infection on the development of PE.

Major depressive disorder is a severe, heterogeneous, common medical illness and a leading cause of disability throughout the world that poses a significant public health issue. Previous studies have shown rapid antidepressant effects following a single administration of ketamine. This study aimed to assess the impact of route of administration and dose of ketamine for the reduction of depressive symptoms and compare the effects of different doses and methods.
A double-blind clinical controlled trial was done on 100 patients with a primary diagnosis of major depressive disorder who were assigned into two groups of 50 subjects at a dose of 0.5 mg/kg and 0.75 mg/kg ketamine and each group was divided into two groups of 25 subjects following a single dose of intravenous bolus and infusion of ketamine. The patient’s severity of depression was evaluated with Hamillton Depression Rating Scale and Beck Depression Inventory scores after 2 days, 7 days, 30 days and 60 days of ketamine administration, then the results were compared between groups.
According to Hamilton and Beck score, the treatment response in investigated patients was 64% and 60%, respectively.
These data suggest that ketamine effect is related to drug dose and type of administration. The dose of 0.75 mg/kg of ketamine is more effective than 0.5 mg/kg and a bolus injection of low-dose ketamine (0.5 mg/kg) is more effective than infusion and in high-dose ketamine (0.75 mg/kg), there was no difference between the methods of drug administration.

Asthma is one of the most common chronic diseases and may cause psychiatric disorders affecting the patients’ quality of life. In our study, we evaluated the effect of omalizumab treatment on anxiety disorder and depression using Beck Depression Scale (BDS) and State Trait Anxiety Inventory (STAI).
Anxiety level was determined with STAI, whereas depression level was evaluated by BDS. Patients were asked to mark the questionnaires to reflect their emotional state before treatment, and to reflect their emotions they are feeding in the current moment. All patients receiving omalizumab treatment were included in the study. Patients with known neuropsychiatric disorder were excluded from the study.
A total of 20 patients with mean age of 50.25 years were enrolled in the study. Gender distribution was: 5(25%) male patients and 15(75%) female patients. All patients with severe asthma received omalizumab treatment. The omalizumab treatment period was shown for mean 17.6 months (2-40 months). In anxiety scales, there was statistically significant difference compared with pretreatment and posttreatment periods. Depression (moderate to severe) was present in 12 patients before omalizumab treatment and 3 patients after omalizumab treatment.
Uncontrolled asthma as a chronic disorder can cause depressive symptoms and worsen quality of life. We believe by controlling asthma, quality of life will improvein such patients. In appropriate indication, omalizumab can improve depression and anxiety in asthma patients.

Iron overload influences negatively on bone mineral density (BMD) but the results of studies regarding serum ferritin (SF) and BMD are conflicting.This study aimed to determine the association of SF and BMD in the elderly.
All participants of the Amirkola cohort selected between 2011-2012, aged > 60 years were classified as high or normal ( 1089 subjects (women, 44.7%) were studied. High SF was observed in 366 (33.6%) and LBMD in 874 (80.2%) subjects. The two groups of SF were similar regarding biochemical parameters and demographic characteristics except MetS, overweight /obesity and diabetes which were more prevalent in high SFgroup. BMD g/cm2 at both measurement sites was significantly higher (P=0.001 for both) and the prevalence of LBMD was significantly lower (74.1% vs 83.1%, P=0.001) in high SF group by OR= 0.60 (0.44-0.81). After adjustment for all biochemical and demographic variables, the association remained significant by adjusted OR= 0. 68 (0.49-0.94).
These findings show a negative association between high SF and LBMD indicating a beneficial effect of high SF in the elderly. Regarding detrimental effect of iron overload on bone mass, these findings require further studies.

Cirrhosis as the final stage of progressive fibrosis of liver can affect other organs such as lungs, kidneys and heart. "Cirrhotic cardiomyopathy" involves the electrophysiological abnormalities such as QT interval prolongation. We assessed correlation between corrected QT interval prolongation and severity of cirrhosis based on Child Classification in each ECG lead.
In this case-control study, the patients attending the outpatient clinic and inpatient department of internal medicine of Velayat Hospital in Qazvin were enrolled from September 2014 to July 2015. Total samples were 74 patients, half of which were used as controls. Cirrhosis severity was determined as per Child Classification. Both groups had Ca2, Mg2, K tested and 12- lead ECG was obtained. The QT interval was corrected by two different formulas: (1) QTc=QT/√RR (QTc1); (2) QTc=QT.75 (heart rate-60) (QTc2). To analyze the data, the software SPSS Version 16 and Mann-Whitney, Pearson’s chisquare test-Kruskal-Wallis, and t-tests were used.
The mean of QTc1 and QTc2 was longer in cirrhotics than the control group. There was a significant correlation between Child score and length of QTc1 in leads: III (p=0.032), AVL (p=0.041), V2 (p=0.049), V6 (p=0.015). There were significant differences in length of QTc1 in leads: V3 (p=0.031) and V6 (p=0.021); and QTc2 in lead V3 (p=0.039) between Child Classification.
Cirrhosis can induce QTc interval prolongation. Lead V3 has statistically significant correlation with the severity of cirrhosis based on child classification. We propose that QT interval prolongation be added as a criterion for prioritizing liver transplantation.

Identifying the predictors of pain is important for both health professionals and researchers, because pain has repeatedly been found to be a strong predictor of activity limitations and participation restrictions. The objective of this study was to determine the predictors of pain presence and severity in a large, well-designed sample of community dwelling individuals with multiple sclerosis (MS).
This was a cross-sectional study. A center-stratified random sample including 188 persons with MS were recruited from three major MS clinics in the Greater Montreal, Canada. Main outcomes included pain prevalence and severity. Predictor variables included depression, anxiety, perceived health status, fatigue, sleep problems, and perceived cognitive deficits. Participants completed three questionnaires: the first asked about the socio-demographic and clinical information of the subjects, the second assessed the pain characteristics of the subjects, and the third covered the predictor variables.
The prevalence of pain in our sample was 42%. MS- related disability was found to be in the main predictor for both pain presence and intensity. Fatigue also was a main contributor to pain presence. The results of this study also showed that pain was associated with higher levels of depression, anxiety, sleep problems, and perceived cognitive deficits, and diminished perceived health status.
The results of this study indicated that pain is a common symptom among people with MS. Pain presence was predicted by MS-related disability and fatigue, while pain intensity was only predicted by MS severity.

Current literature has been focused on types of obesity with normal BMI (body mass index), but metabolically unhealthy.This study evaluates the prevalence of metabolical phenotypes of obesity. We also identified the best obesity index in predicting the components of metabolic syndrome (MetS).
A cross-sectional study has been conducted on 164 women over 60 years. Anthropometric parameters, body fat percentage (%BF), and biologic criteria were measured to assess the types of obesity. Unhealthy metabolic was defined by modified Adult Treatment Panel III, and obesity based on BMI≥25.ANOVA and logistic regression were utilized for the association of MetS components and obesity phenotypes, and linear regression logistic for finding the best MetS related obesity index.
The prevalence of metabolically unhealthy was 45.7%, out of which 33.3% was among the individuals with normal BMI.Logistic regression has shown that triglyceride (TG) (OR=3.30, p There is a high prevalence of unhealthy metabolic among the elderly women,even with normal weight.There were different associations between MetS components and various obesity phenotypes.TG was the most powerful indicator for the prognosis of unhealthy metabolic phenotypes which was independently correlated with the WC, %BF and BMI.

Polycystic ovary syndrome (PCOs) is an endocrine-metabolic disorder. This study intends to determine the comparison of insulin resistance (IR) and metabolic disturbance in overweight/obese and normal-weight of young women with polycystic ovary syndrome.
Using a comparative cross-sectional study design in 2015, 27 normal weight (18
112 women with PCOS participated in this study. The mean age was 22.4±3.48 years in the normal PCOS group (n=27) and 24.4±5.06 years in the overweight/obese PCOS patients (n=85). BMI had a significant straight correlation with insulin resistance (p3.15) vs. 8.3% (5) in the normal group (P13µU/ml) vs. 10.3% (7) in the control group (p Overweight/obese PCOs patients revealed higher insulin resistance and lower insulin sensitivity, and also greater TG and LDL cholesterol. Priority of management of insulin resistance and lipid profile should be considered on identifying these potentially major complications.

The present study evaluated the lifestyle behavior patterns and its associations with demographic factors in the Iranian population.
A total of 8244 people aged 25-70 years who participated in a national survey in 2011 were included in the study. Factors related to lifestyle (such as diet, physical activity, and tobacco use) have been collected using a questionnaire. A self-organizing map was used for cluster analysis and a multinomial logistic model was used for assessment of associations.
Seven clusters were identified as the following: cluster 1 (15.84%): healthiest lifestyle; cluster 2 (12.45%): excessive consumption of sweet tasting soft drinks, salt, and fast food; cluster 3 (33.73%): no recreational physical activity; cluster 4 (6.86%) alcohol consumption, smoking, and consumption of sweet tasting soft drinks; cluster 5 (14.18%): less salt and oil intake and lack of physical activity; cluster 6 (7.85%): no use of dairy products; cluster 7 (9.08%): the most unhealthy lifestyles; excessive work-related physical activity and smoking and unhealthy diet. Male gender was associated with higher odds of being in clusters 4 and 7. Individuals who were in unhealthy lifestyle clusters were mostly less educated and more self-employed or laborers.
A very small percentage of individuals was in the healthy lifestyle cluster yet they had poor nutrition. Health policy-makers should pay more attention to low recreational physical activity among elder people and in middle-aged and housekeepers, and also to high work-related physical activities that have a strong tendency to be in a cluster with smoking among workers and less educated men.

It has been implicated that obstructive sleep apnea (OSA) is associated with increased risk of cardiovascular disease including stroke, myocardial infarction, coronary artery disease (CAD) and hypertension. The aim of this study was to investigate the correlation between OSA and severity of atherosclerosis assessed by angiography.
This study included 337 patients undergoing diagnostic coronary angiography at Tehran Heart Center, Iran. The Gensini score was obtained from each patient for coronary angiogram, and OSA were assessed by using Multivariable apnea prediction (MAP) risk index on the day of cardiac catheterization. The Gensini scores increased in accordance with increases in the MAP value.
The prevalence rates of three-vessel disease were 68.0% in OSA group and 32.0% in non-OSA group. The MAP index was the most significant independent determinant for the Gensini score.
The independent association between OSA and CAD, even after adjustment for traditional confounders, suggests that, OSA should be taken into account when considering risk factors for CAD.

Generally, conservative interventions including physiotherapy modalities and manual therapy have been recommended in the management of carpal tunnel syndrome (CTS), but this subject has not been studied in diabetic patients with CTS. Therefore the aim of this study was to investigate the effects of manual therapy on diabetic patients with CTS.
Thirty diabetic patients with CTS were randomly divided into two equal groups: modality group and manual therapy group. Participants in the modality group received transcutaneous electrical nerve stimulation (TENS) and therapeutic ultrasound (US) and patients in the manual therapy group received manual techniques for the median nerve and its surrounding structures. Interventions were applied 3 times weekly for 4 weeks in both groups. Visual analogue scale (VAS), symptom severity scale (SSS), functional status scale (FSS) and median neurodynamic test (MNT) were evaluated before and after the interventions in both groups. Paired t-test and independent t-test were used for statistical analysis.
Paired t-test revealed that all of the outcome measures had a significant change in the manual therapy group, whereas only the VAS and SSS changed significantly in the modality group at the end of 4 weeks. Independent t-test showed that the variables of SSS, FSS and MNT in the manual therapy group improved significantly greater than the modality group.
Manual therapy techniques applied to mechanical interface of the median nerve and nerve mobilization possess more appropriate and valuable effects on hand difficulties than modalities in diabetic patients with CTS.

Measurement of glomerular filtration rate (GFR) and monitoring of it in any patient on nephrotoxic drugs is very important. Recently, cystatin C (cys-C) has been introduced as a better marker for determining and monitoring renal function than creatinine especially in a mild decrease of GFR. This study was done to assess the change of GFR measurement based on serum Cys-C and creatinine and their comparison in children with acute pyelonephritis on amikacin.
All children with acute pyelonephritis who were admitted in Nephrology ward were enrolled in this study. Serum creatinine, serum cys-C and the GFR calculation based on them were measured in patients on the day of admission (day zero) and then on days 3 and 7 after the start of treatment with amikacin and p-value less than 0.05 was considered significant.
Among the 70 children, 61 patients were females and the others were males. Mean age was 42.66±41.53 months. Estimated GFR based on creatinine on day 0 (before amikacin administration), 3 and 7 were 72.41±20.89 ml/min/1.73 m2, 78.42±21.15 ml/min/1.73 m2 and 80.5±22.43 ml/min/1.73 m2, respectively. Moreover, GFR based on cys-C during these days were 116.23±58.9 ml/min/1.73 m2, 116.49±53.31 ml/min/1.73 m2 and 108.37±51.02 ml/min/1.73 m2, respectively (p According to this study, decrease of GFR calculation based on Cys-C was seen and estimated GFR was not changed according to creatinine. So, we recommend the use of cys-C for the monitoring of renal function in any patient treated with nephrotoxic drugs such as amikacin.

One of the lithotripsy complications is urinary tract infection (UTI) and sepsis after extracorporeal shock wave lithotripsy (ESWL). The aim was to study the prophylactic effect of antibiotics on UTI after ESWL.
This randomized double-blind clinical trial was carried out on 600 patients admitted to Babol Clinic hospital in 2014-2015. Patients were randomly divided into treatment group (receiving 200 mg ofloxacin and control group (receiving placebo. The effect of prophylactic antibiotics on the incidence of bacteriuria after ESWL and the impact of variables such as gender, age, urolithiasis size and location and underlying diseases in the incidence of UTI after ESWL were evaluated.
Totally, 67 of the population had positive urine cultures. Twenty-nine (10.13%) of them were in the treatment group (n=286) and 38 (13.01%) of them were in the control group (n=292). All 67 patients had asymptomatic bacteriuria. Escherichia coli and proteus were the grown microorganisms in most samples. The mean age of sample population was 44.8±23, and 67.16% of patients with positive urine culture were older than 45 years.
The results indicated that prophylactic antibiotics prior to ESWL in patients with urinary calculi and negative urine culture had no significant decrease in urinary tract infection after lithotripsy. It is better that the use of prophylactic antibiotics is limited to patients with risk factors.

Lead-related infections that might develop after pacemaker implantation associated with high mortality and morbidity rates are challenging to manage and pose high-cost. Patients with lead-related infections usually present with fever, chills and fatigue and the treatment can be challenging unless the implant system is extracted.
A 66-year old male patient who underwent dual chamber pacemaker and implantable cardioverter defibrillator was admitted to the emergency service with a six-week history of complaints of hiccups and fever. After a detailed investigation, lead-related infective endocarditis was the diagnosis. The patient was initiated on antibiotic therapy and lead extraction was performed.
Patients with signs of infection who underwent pacemaker implantation may present with atypical symptoms such as hiccup. In these cases, imaging, particularly echocardiography, should be performed as soon as possible and the localization of the pacemaker leads and signs of infective endocarditis should be investigated.

Hip involvement in ankylosing spondylitis (AS) is a common extraspinal arthritic manifestation, which is associated to a worse functional outcome. Little data are available on the effectiveness of conservative treatment strategies. The TNF inhibitors have been proven effective on AS activity parameters. Their structural effect on hip disease however, little is studied.
We describe four new cases of reparative changes of a damaged hip joint after treatment with TNF inhibitors. The average of age was 32.5 (27- 36) years. There were 3 men and 1 woman. Hip involvement was bilateral in all cases. Etanercept was prescribed in 3 cases and infliximab in 1 case. At baseline, all patients had a painful and limited hip with high disease activity and an important functional impairment. After an average of 5.5 years of treatment with TNF inhibitors, the BASRI hip evaluated in antero-posterior x-rays of the pelvis remained unchanged at 2.4. The average of mean hip joint space was 2.9mm (2.3-3.6). A widening in hip joint space was observed in all cases with less subchondral cysts.
TNF inhibitors seem to be effective on hip joint disease in patients with AS.

Bilateral rupture of the patellar tendon is a very rare injury, which takes place in relation to chronic systemic diseases. These injuries are known causes. Some of these causes are particular in patellar tendon rupture and another are in quadriceps tendon rupture.
70-year-old diabetic man with simultaneous bilateral patellar tendon disruption of proximal insertion without trauma, receiving long-term hemodialysis.
In the present study, we report a case of patellar tendon rupture that has two differences with literature: first, renal failure is a known risk factor for quadriceps tendon rupture, and secondly, the prevalent age of patellar tendon rupture is less than 40 years. Clinical picture, diagnosis, pathogenesis and treatment are discussed. Finally, the literature is reviewed based on previous studies.

Melanoma is a neoplasm derived commonly from melanocytic cells of skin. Although coetaneous presentation of malignant melanoma is easily recognizable, the presentation of melanoma in other organs is so confusing. In particular, when it metastasizes to other organs, many bizarre figures and unusual organs may be involved. In this report, we present a case of primary duodenal malignant melanoma.
A 68-year-old man presented with a history of iron deficiency anemia. The upper gastrointestinal endoscopy showed a prominent papilla of duodenum along with an ulcerative lesion adjacent to second part of duodenum. Histopathologic evaluation showed a high-grade malignant neoplasm involving the bowel wall which was labeled for S100 protein and markers of melanocytic differentiation; Melan-A indicating the definitive diagnosis of malignant melanoma of the second portion of duodenal mucosa.
In patients with a history of iron deficiency anemia, any GI symptom should be evaluated carefully. However, the diagnosis of primary GI melanomas in patients without any history of melanoma is possible. Full medical investigations are recommended in these patients with primary mucosal lesions.