Iranian Journal of Public Health
Volume:48 Issue: 7, Jul 2019

This narrative review aimed to reevaluate the medical tourism sector in Iran to reveal the new trends and activities in order to know the current actual share of Iran in the competitive market of global medical tourism. A holistic approach was adopted to analyze the information collected through a system of investigation that comprised the available secondary data, besides the information and statistical data about the associated organizations to this sector in Iran. Iran’s medical tourism sector is consistent with the new trends in global market, which is mainly bordered countries-based, cultural-oriented, and diasporic type of travelling. It would be more realistic in the contemporary situation to focus the promotions on the border countries, and design the policy, and implementation in accordance with their cultural and social preferences. Activities in both levels of governmental and micro-level planning are demanded, under the cover of a comprehensive monitoring system. This review will benefit researchers exploring the updated evaluation of Iran’s medical tourism; also, it provides helpful insights to authorities in both governmental and private sector.

Some studies have investigated the prevalence of osteoporosis in patients with type 2 diabetes mellitus (T2DM) in China. However, the results were inconsistent. This review was performed to estimate the prevalence of osteoporosis in T2DM patients in the Chinese mainland and to characterize its epidemiology. A literature search was conducted utilizing PubMed, Scopus, Web of Science, Cochrane Library, CNKI, Wanfang database from their inception through June 2017. A total of 54 studies evaluating the prevalence rate of osteoporosis in T2DM patients were collected. Prevalence estimates from the individual study were combined utilizing random-effect models in Stata 12.0. The pooled prevalence rate of osteoporosis in T2DM patients was 37.8%. Notably, osteoporosis was more frequent in females than in males (44.8% vs. 37.0%) and was increased with ageing (over 60: 40.1% vs. below 60: 26.5%). Osteoporosis prevalence was higher in less developed areas than in developed areas (41.0% vs. 32.7%) and almost the same between the southern and northern regions (37.6% vs. 38.2%). The prevalence rate between 2010 and 2017 decreased compared with the period between 2001 and 2009 (42.3% vs. 35.6%). Additionally, the meta-regression suggested that gender and age could significantly influence the estimation of prevalence rates respectively (P = 0.011, P = 0.022). Osteoporosis affects more than one-third of T2DM patients in China mainland. Females and older adults more likely require clinical prevention due to a higher prevalence. Further studies are needed to be conducted to incorporate and verify previous results.

Human papillomavirus (HPV) can infect the epithelium of the esophagus, but so far there is no reliable and comprehensive evidence about the prevalence and association of HPV with esophageal cancer in Iran, as high incidence region. This study aimed to evaluate the prevalence and association of HPV with esophageal squamous cell carcinoma (ESCC) in Iran. Relevant English and Persian articles published up to Aug 2017 and indexed in databases were reviewed. Frequency of HPV genotypes in ESCC cases and controls was surveyed according to regions of Iran. Data were meta-analyzed with random effects models using Comprehensive Meta-Analysis software. Overall, 14 studies were eligible including 1444 samples (1062 ESCC cases and 382 controls). HPV was positive in 269 (25.32%) of 1062 ESCC cases and in 65 (17.01%) of 382 controls. Total prevalence of HPV in both groups was estimated 0.256 (95%CI, 0.208%-0.310%). The prevalence of HPV-16 and HPV-18 was estimated 0.121 (95%CI: 0.087-0.183) and 0.046 (95%CI; 0.023-0.088), respectively. The difference in HPV prevalence in different regions of Iran was statistically significant (Q=18.20, df =4, P=0.001). In 6 case-control studies, the pooled odds ratio was estimated 1.99 (95%CI; 0.916-4.315). High-risk HPVs were observed in ESCC cases and controls from different regions of Iran. The odds ratio indicates that the HPV infection in ESCC cases was approximately 2 fold more than the controls. More case-control studies in other populations with larger sample size are necessary.

Two functional polymorphisms in the matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9) genes may contribute to periodontitis pathogenesis. However, the results were inconsistent and inconclusive. Therefore, to clarify precise associations of MMP-2 -753 C>T and MMP-9 -1562C>T polymorphisms with chronic (CP) and aggressive (AgP) periodontitis, we performed a systematic review and meta-analysis. A literature search was conducted using PubMed, Google Scholar, Embase, and Web of Science databases until 5 July 2017. The data were analyzed with CMA software, and risk estimates are expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs). Nineteen case-control studies in ten publications with 2089 periodontitis cases and 2345 controls met the criteria. The pooled ORs indicated that MMP-2 -753C>T and MMP-9 -1562C>T polymorphisms were not significantly associated with risk of periodontitis in overall analysis. Stratified analyses by ethnicity and periodontitis type indicated that the MMP-9 -1562C>T polymorphism showed a significant association with the risk of periodontitis among Caucasians and CP/AgP subgroup, whereas MMP-2 -753C>T polymorphism was significantly associated with periodontitis risk only among Asians. MMP-2 -753C>T and MMP-9 -1562C>T polymorphisms may not be associated with risk of periodontitis in overall population. However, MMP-2 -753C>T and MMP-9 -1562C>T polymorphisms might have influence on the susceptibility of periodontitis by ethnicity.

Sleep durations shorter or longer than 7 h are associated with cardiovascular diseases. We aimed to investigate the association among sleep duration, risk factors of hypertension, and cardiovascular disease in South Korea using data from a recent large-scale survey. Data produced by the Korea National Health and Nutrition Examination Survey (KNHANES) were subjected to multivariate logistic analysis. This cross-sectional, nationally representative survey was conducted from Jan 1 to Dec 31, 2011, by the Korean Center for Disease Control and Prevention. Overall, 6,466 participated. Data were analyzed using STATA version 13.0 (STATA Corp LP). The participants’ socioeconomic, physical, and lifestyle factors were statistically different between the two age groups (<65 yr and ≥65 yr). Shorter sleep durations were associated with hypertension in individuals younger than 65 yr of age. On the other hand, in participants aged ≥65 yr, both shorter and longer sleep durations were associated with hypertension, while shorter sleep durations were associated with cardiovascular diseases. Unusual sleep durations are associated with an increased prevalence of cardiovascular disease among Korean adults. The effect of sleep duration appears to be more significant in individuals with hypertension, suggesting that the management of hypertension should be prioritized in patients older than 65 year.

Gestational diabetes mellitus is one of the most frequent metabolic complications of pregnancy. Previous studies have reported that using either probiotic yogurt or a probiotic supplement reduces the incidence of gestational diabetes. However, the results were inconsistent. Thus, the aim of the present study was to investigate the association between gestational diabetes mellitus and probiotic yogurt intake during pregnancy and pre-pregnancy in Chinese women. This was a case-control study involving 123 cases with gestational diabetes mellitus and 126 controls matched for age and pre-pregnancy body mass index. Each participant was interviewed face-to-face using a structured questionnaire to collect socio-demographic characteristics, diet and exercise habits, as well as probiotic yogurt consumption (containing Lactobacillus acidophilus and Bifidobacterium) during pregnancy and pre-pregnancy. An unconditional logistic regression analysis was used to analyze the data. Mothers in both groups had similar socio-demographic backgrounds. Probiotic yogurt intake during pregnancy was significantly higher in normal pregnant women than that in women with gestational diabetes mellitus (adjusted odds ratio: 0.292, 95% confidence interval: 0.148 - 0.577, P < 0.05). There were no significant differences in probiotic yogurt consumption before pregnancy between cases and controls. Probiotic yogurt intake before pregnancy was not associated with gestational diabetes mellitus, but probiotic yogurt consumption during pregnancy was effective in reducing the risk of gestational diabetes mellitus in Chinese women. The findings from the present study may have implications for the future care of pregnant Chinese women with gestational diabetes mellitus.

Breast cancer is the most common malignant disease among the female population of Kazakhstan like in many developed countries of the world (Canada, UK, US, Western Europe), and it accounts for every 5th tumor. We aimed to assess the epidemiological aspects of breast cancer incidence and mortality among Almaty and Astana (Now Nur-Sultan), Kazakhstan residents in 2009-2018. A retrospective study using modern descriptive and analytical methods of epidemiology was conducted to evaluate the breast cancer incidence and mortality in megapolises of Kazakhstan. The average annual age-standardized incidence rate of breast cancer amounted to 61.90/0000 (95% CI=56.2-67.6) in Almaty and 61.20/0000 (95% CI=56.765.7) in Astana. The average age-standardized mortality was 19.20/0000 (95% CI=17.3-21.1) in Almaty and 19.30/0000 (95% CI=17.1-21.4) in Astana. The standardized incidence in the megapolises tended to increase (Тgr=+0.8% in Almaty and Тgr=+1.4% in Astana), while the mortality was decreasing (Тdec=−4.2% in Almaty and Тdec=−1.1% in Astana). According to the component analysis, the growth in the number of breast cancer cases was due to a population increase (ΔP=+130.4% in Almaty and ΔP=+93.2% in Astana), with a notable decrease of factors related to the risk of getting sick (ΔR=−27.9% in Almaty, ΔR=−6.1% in Astana). This is the first epidemiological study to assess the changes in incidence and mortality from breast cancer in megapolises of Kazakhstan because of screening. The results of this study can be used to improve the government program to combat breast cancer.

This study intended to investigate the effects of serum high-sensitivity C-reactive protein (hs-CRP) on the incidence of lung cancer in male patients with pulmonary tuberculosis. A total of 1091 male patients with pulmonary tuberculosis in Zhejiang Cancer Hospital, Hangzhou, China from Jan 2009 to Jan 2012 were selected as the research objects. All patients were followed up from the beginning of hospitalization. According to serum hs-CRP level, patients were divided into two groups: group A (hs-CRP < 1 mg/L) and group B (hs-CRP > 3 mg/L). The relationship between baseline hs-CRP and the risk of lung cancer in patients with pulmonary tuberculosis was analyzed by multivariate Cox proportional risk regression model, and the serum levels of hs-CRP between lung cancer patients in all groups and other non-lung cancer patients were compared. There were differences in age, drinking, smoking, diabetes history, body mass index (BMI), thyroglobulin (TG), history of hypertension and hyperglycemia among the three groups (P=0.036, 0.018, 0.040, 0.029, 0.006, 0.034, 0.020, 0.010). The serum levels of hs-CRP in patients with squamous carcinoma, adenocarcinoma and small cell carcinoma were significantly higher than those in non-lung cancer patients (P=0.022, 0.043, 0.011). The incidence rates of lung cancer in patients in group B and C were 1.37 and 1.69 times higher than that in group A, respectively. The increased serum level of hs-CRP will increase the incidence rate of lung cancer in male patients with pulmonary tuberculosis.

Indonesia as an archipelagic country, makes the efforts to fulfill the needs of medical specialists in remote areas are not easy tasks. This study aimed to explore the availability and the needs fulfillment efforts of medical specialist in remote areas; and to know whether the availability of medical specialists have met the hospital needs, and how the authorities efforts to fulfill them, also the factors that affect the effort. This qualitative research was conducted with case study approach in Haji Abdoel Madjid Batoe District Hospital (RSUD HAMBA) Batanghari Jambi and Malingping District Hospital (RSUD Malingping) in Lebak Banten. In-depth interviews were conducted with various stakeholders. The availability of medical specialist in both hospitals in number and type are inadequate. This fact indicates low retention and motivation of medical specialists to work in remote area. The major factor in both hospitals is inadequate salaries, difficult access, lack of medical equipment, also the difficulty to develop a career. However, these factors in both area ultimately boil down to the lack of government policies that support medical specialist fulfillment. The important factors that affect the lackness of effort in fulfilling medical specialists’ placement in remote areas are inadequate of infrastructures, competence and career development contraints, and the coordination between national and regional policies. The commitment of central and regional government to improve the infrastructures, competence and career developments, and regulations with respect to medical specialists in remote areas.

  To investigate the effect of caffeine citrate on the integrated brain electroencephalogram (EEG) of apnea and low birth weight infants. Overall, 212 infants with apnea and low birth weight admitted to Xuzhou Central Hospital from June 2016 to June 2018 were enrolled. The infants were divided into control group and observation group according to the random number table method, 106 cases in each group. Infants in control group were treated with aminophylline, and infants in the observation group were given caffeine citrate. All children were continuously tested by digital amplitude integrated brain function monitor. The amplitude-integrated electroencephalogram (aEEG) was used to detect sleep arousal cycle (Cy), graphic continuity (Co), lower edge amplitude value (LB) scores, aEEG continuous voltage and periodic occurrence rate, narrowband voltage and bandwidth. After treatment, scores of Cy, Co and LB increased in both groups, and the scores were significantly higher in observation group than in control group (P=0.029, 0.017, 0.047). After treatment, continuous voltage positive rate, sleep-wake cycle occurrence rate, and narrow-band lower boundary voltage increased in both groups, and the values were significantly higher in observation group than in control group (P=0.011, 0.042). After treatment, aEEG detection bandwidth and the upper boundary voltage of the narrow band decreased in both groups, and the values were significantly lower in observation group than in control group (P=0.007, 0.020, 0.032). Citrate caffeine can alleviate the brain development of low-weight infants with apnea, improve brain electrical activity and promote brain function and maturity.

We aimed to investigate the polluted working environment triggers oxidative stress and alter enzymatic antioxidant activity by a short-term interval. The experimental study, performed in 2014, involved 94 workers from the Velenje Coalmine in Slovenia, arranged into three groups according to a number of consecutive working days in a mineshaft, supported by a control group. Levels of the antioxidant enzymes (GPx, CAT, SOD) together with TAC (the combined effect of all antioxidants) and 8-isoprostane (a biological marker of oxidative stress/damage) were measured in human plasma. Workers occupationally exposed for three consecutive working days had significantly increased 8-isoprostane biomarker, a parameter of oxidative stress (P<0.001). The antioxidant levels of TAC (P<0.001), CAT (P<0.001) and SOD (P<0.001) were all significantly decreased compared to a control group. Workers in polluted working environment had significantly increased oxidative stress and altered antioxidant activity already on a third consecutive working day.

We aimed to investigate the effect of probiotic VSL#3 on NF-κB and TNF-α in rats with colitis and the correlation with TLR4-NF-κB signal pathway. Sixty Sprague Dawley (SD) rats were divided into the control, model and therapy groups (n=20) according to the random number table. Rats in the model and therapy groups were modeled for colitis, and rats in the therapy group were intragastrically administered with probiotic VSL#3. The expression of TLR4 and NF-κB protein, and the levels of NF-κB, TLR4, and TNF-α mRNA in the colon tissue were detected. The concentration of TNF-α in the serum after modeling but before intragastric administration (T0), 3d (T1) and 7d after intragastric administration (T2) was detected. The expression of TLR4 and NF-κB p65 protein, and the levels of TLR4, NF-κB, and TNF-α mRAN in the therapy group decreased (P < 0.001). At T0, T1, and T2, the concentration of TNF-α in the model and control groups increased (P < 0.001). TLR4 and NF-κB in the therapy group were positively correlated with TNF-α mRAN (P < 0.050). In conclusion, probiotic VSL#3 inhibits the expression of NF-κB and TNF-α in rats with colitis through TLR4-NF-κB signal pathway, so it is expected to be a first choice drug for the treatment of colitis.

Due to lack of information about ophthalmic economics in Iran, health policy makers unable to distribute resources optimally in terms of efficiency and equity. Therefore, we estimated the total and eye care utilization, out-of-pocket expenditures, and its association with social determinants of health in Iran in 2015. A multi-stage population-based, cross-sectional study in a random sample aged 50 yr or older in Kurdistan Province, Northwest Iran was used. The utilization rate of eye and general health care and related out-of-pocket expenditures was estimated during the recent last six months. To find the association between social factors and care out-of-pocket expenditures, we used a Heckman two-step regression model. About 81% and 37% of participants were utilized the health and ophthalmic services, respectively. Statistically significant lower ophthalmic utilization rates were observed among men, middle-aged population, illiterate participants, rural residents, daily-paid workers, and the poorest participants. The average of vision and total health-related out-of-pocket expenditures among those used these services have estimated as US$43.7 (SE: 2.6) and US$439.9 (SE: 22.8), respectively. The highest (US$ 396.6) and lowest (US$ 10.4) ophthalmic out-of-pocket costs were related to patients with Glaucoma and Central Nervous System abnormalities, respectively. Multivariate analyses confirmed an unequal probability of having the ophthalmic out-of-pocket expenditures among different subgroups especially in favor of females, older, and those with more severe visual impairment. Ophthalmic disorders reconstituted about 10% of all health services OOP expenditures on average among individuals older than 50 yr.

Curcumin and resveratrol are two polyphenolic compounds extensively investigated for their medicinal effects on inflammatory signaling. However, there is a paucity of information on the Adenosine-3’, 5’-cyclic monophosphate (cAMP) kinetics following administration of curcumin and resveratrol in biological systems. In this study, kinetic modulation of cAMP as a target detection messenger in pro-inflammatory pathways was assessed by co-administration of curcumin and resveratrol using a cellular sensor model.

To evaluate their putative activity, curcumin and resveratrol compounds were administered alone or in combination on the media culture of cAMP EPAC (exchange protein directly activated by cAMP) bioluminescence resonance energy transfer (BRET) biosensor. The study was performed at the following two centers at Tehran University of Medical Sciences (TUMS):  1- Biotechnology Research Center, and, 2- Endocrinology and Metabolism Research Institute (EMRI) in 2017. Time course kinetic of cAMP response signals were plotted. Forskolin and IBMX were used to stabilize the cAMP signals. When we treated HEK-293T biosensor cells at 10uM concentration, curcumin and resveratrol upregulated cAMP signaling. Co-administration of resveratrol and curcumin revealed an augmented cAMP level, as compared to treatments with the compounds alone. Co-administration of curcumin and resveratrol leverage cAMP kinetic response in a time-course manner. The presented methodology can be readily adopted for drug development and novel biopharmaceutical functional analyses.

Smoking hookah is considered a health problem among the adolescents, which currently has a high prevalence. The present study aimed to determine the reasons for tendency toward smoking hookah. Participants of this qualitative study were 24 adolescents from Tehran selected using purposeful sampling method in 2017. Data gathered through individual semi-structured interviews and two focus groups. Using directed content analysis approach 423 primary codes were categorized into 28 subcategories and 9 categories. Most of the participants were 16 to 18 yr old (64%), male (58%) and had high school degree (58%) and 75% of them were student. In Theory of Planned Behavior, attitude toward smoking hookah contained categories of replacement for cigarette, the pleasurableness of hookah, easy access and spending the leisure times. Subjective norms contained the categories of family, friends and society. The construct of behavioral control contained the categories of personal and social factors. Our Results could be helpful in policy-making and planning toward improving the awareness and changing the attitude and performance of the adolescents toward smoking hookah.

Egg yolk is a rich and accessible source of yolk immunoglobulin (Y immunoglobulin). Presently, polyclonal antibodies from mammalian sources are used for diagnosis. Antibody production from egg yolk gives a higher yield and turnover than that from lab animals, and invasive methods such as phlebotomy and causing stress to the animals are not required. Due to the issues regarding mammalian antibodies, we aimed to evaluate the human anti-IgG polyclonal antibody production conjugated with peroxidase in egg yolk. Population of laying hens reared in Agriculture/Isfahan University of Technology were used in 2017. After immunizing hen against pure human IgG, specific IgY (yolk immunoglobulin) was purified from the yolk by sedimentation with polyethylene glycol (PEG6000). To assess the molecular weight and activity of the product, SDS-PAGE and ELISA-test were used, respectively. The complete molecular weight of IgY was 180 kDa and the molecular weight of its light and heavy chains were 27 and 67 kDa, respectively. Antihuman IgG IgY had a purity above 90%. The product of this study can be used to measure IgG class antibodies in order to diagnose different diseases.

Electronic registry system of beta-thalassemia patients was run by Thalassemia Research Center (TRC) in 2017. The aim of the current study was presentation of therapeutic status in these patients at Mazandaran Province, Iran. Therapeutic status variables including: Name of cities and hospitals, age and sex of patients, dependent and non-transfusion-dependent, starting age of the blood transfusion and iron-chelating agents, blood group and Rh, washed blood transfusion, abnormal antibody, transfusion reactions, mean hemoglobin during the last 3 months, type of iron chelators, iron chelators dosage, serum ferritin, and the use of hydroxyurea. Overall, 1831 patients were registered [891 male (48.7%)]. Mean age of patients was 30±9.7 yr. Average of hemoglobin levels for female and male were 9.1±5.1 and 9.4±6.3 gr/dl, respectively. Seventy-six percent of transfusion-dependent patients (1385) have received iso-group PRBC (packed red blood cells), after crossmatch. The most common blood group among patient was type O-positive (35.7%). Monotherapy with desferrioxamine was most type of used iron-chelating agent in these patients (47.2%). Mean of ferritin was 3300±7800 (ng/ml). Twenty-eight percent of patients (484) have received hydroxyurea; proportion of male and female was approximately equal. T2 weighted magnetic resonance imaging (MRIT2*) was measured in 62.2% of patients. Moderate and severe hepatosiderosis was 10.1% and 2.9%, respectively. Patients with moderate and severe cardiac siderosis were 11% and 5%, respectively. Registry findings are valuable for treatment management and ensuring patients medications. It will also provide accessibility to various levels of patients’ information for health care managers and experts to help them make appropriate decisions.

The first cause of death and disability constituting to the burden of disease in Iran has been accident and injury incidents. Young people are more at risk, these accidents have a negative effect on the national gross domestic product (GDP), on the one hand, and they increase the costs of the health system on the other hand. Therefore, this study aimed to analyze the costs and epidemiological pattern of accidents. The study variables in the first 8 months of 2016 included from Tehran Province, Iran; age, sex, how to transfer to the hospital, consequences of an accident, the injured area, and costs. Overall, 400 cases were investigated by referring to the patients` files and deriving the intended data. SPSS software used to analyze the data and statistical tests of t-test and ANOVA were applied. Most accidents have happened in summer months of Jun, Jul and Aug. Most of the files (48%) were related to the age group of 16-30. The mean cost was 9024.82 dollar. In total, 39% of the road accidents had occurred by motorcycle and 90.8% of the patients discharged from the hospital. Since about half of the traffic accidents were related to the age of 16 to 30 who were the active population of a community, therefore, any disability or death in these groups could cause an economic burden on the community and increase DALY. Thus, it appears essential to develop proper programs such as education for appropriate driving and strict rules for giving driving license to these ages.

We assessed the prevalence of obesity, overweight, central obesity and their associated risk fac-tors in an urban population in Ahvaz, southwest of Iran. This population-based cross-sectional study was performed via random cluster sampling method in 6 health centers in Iran in 2015. A questionnaire was completed by each individual. Of 2575 participants, 1187 (46%) were men. Nearly 50% of the participants’ level of education was high school or higher. About 82% of the population was married and about one-third had positive family histo-ry of parental obesity. The total prevalence of obesity, overweight, and central obesity were 26.5%, 38.7%, and 28.6%, respectively. The rate of obesity in men was lower than in women (P<0.001). The prevalence of obesity increased until the age of 60 yr in both genders and decreased thereafter except for central obesity in women, which increased without any lag. Low level of education, marriage, positive history of parental obesity and parity ≥five were associated with increased odds of obesity (OR=2.14(1.52, 3.00), OR=2.4(1.75, 2.99), OR=2.7(1.71, 3.2) and 4.16(2.17, 7.65), respectively). Obesity and overweight have a high prevalence in southwest of the country, increasing with age. Although several risk factors are associated with obesity, the prevalence of obesity and overweight can be re-duced by controlling the risk factors in the community.

The aim of this study was to evaluate respiratory problems via pulmonary function testing in ce-ment transport workers at Incheh Borun border in northeast of Iran in 2016. The study was conducted on 358 male workers. All subjects were evaluated for respiratory symptoms via pulmonary function testing and completion of the American Thoracic Society questionnaire. Mean age of workers was 34.8±12.87 yr (age range 16-79 yr). Mean duration of employment was 6.1±4.36 yr. Most workers (75.4%) were illiterate or had elementary education. In addition, 56 (15.6%) subjects were smokers. Only three individuals (0.3%) had obstructive pattern. There was a significant relationship be-tween age of workers and frequency of respiratory problems (P<0.05). It is necessary to educate the workers about the health and safety regulations and use of personal protective equipment in workplace. In addition, periodic evaluation of respiratory function could help protect workers from developing occupational diseases.

Congenital Nail abnormalities are rare ectodermal defects. Autosomal recessive nail dysplasia is much rarer. Recently it has been recognized as a condition resulting in nail dystrophy in the absence of other cutaneous or extracutaneous disorders. Few case reports have identified mutations in the Frizzled 6 (FZD6) gene in families presenting with abnormal nails consistent with Non-Syndromic Congenital Nail Dysplasia. We report a family presenting, they lived in Namin a country of the Ardabil Province, northwestern Iran in 2016, for the first time in Iran in whom we identified mutations in FZD6 with abnormal nails formation.