Caspian Journal of Internal Medicine
Volume:14 Issue: 4, Autumn 2023

This study aimed to investigate the efficacy of Jumpstart Nutrition® dietary supplement (JNDS) for enhancing the skeletal muscle metabolism and function of older adults with knee osteoarthritis (KOA) by evaluating the biomarkers of aberrant levels of serum tumor necrosis factor-alpha (TNF-α), interleukin-10 (IL-10), C-reactive protein (CRP), creatine kinase-muscle (CK-MM), and aldolase-A (Aldo-A).

This twelve-week registry included 54 patients treated with JNDS mainly comprised of calcium, phosphorus, vitamin-K2, coenzyme-Q10, boswellic acid, and curcumin mixed with soy and whey protein (experimental group) and 51 patients treated with symptomatic slow-acting drugs for osteoarthritis (SYSADOA) (control group) for KOA confirmed with radiological images. At week 0 and week 12 for both the groups evaluated, the non-fasting serum levels of TNF-α, IL-10, CRP, CK-MM, and Aldo-A by using appropriate kits.

At week-twelve, the respective values of area under the ROC curves of the studied biomarkers for pooled experimental cohorts were 0.928, 0.907, 0.908, 0.927, and 0.988 having the significance of accuracy (R-square):66.28%, 47.25%, 70.39%, 65.13%, and 68.00%, indicating a satisfactory treatment policy, their mean± SD, and risk ratio, all exhibited highly significant differences (p<0.0001) and KOA-gradation was upgraded between≥2 and ≥3 from≥4 as per the Kellgren-Lawrence  scale compared to the control. Fewer patients had to use emergency medications (p<0.05).

Results suggest that JNDS may be effectively used to strengthen the skeletal muscle metabolism and function of elderly patients with KOA confirmed with the stabilization of studied biomarkers as an alternative to the treatment of SYSAD correlated with ROC curves and the Kellgren-Lawrence scale.

Hypertension (HTN) is one of the primary risk factors for heart disease and stroke worldwide. The present meta-analysis was aimed to systematically review and statistically estimate the prevalence rate of pre-hypertension (PHTN) and HTN in the Iranian child/adolescent and adult age groups.

In this study, four International databases, including PubMed, Scopus, Web of Science, and Cochrane, as well as three Iranian databases, including SID, Magiran, and IranMedex, were separately investigated for articles published before December 2021. Also, we estimated the pooled effect size for the prevalence of PHTN and HTN in children/adolescent and adult age groups. Stata software (version 14.0) was used for all statistical analyses.

From a total of 1185 articles found in database searches, fifty-one were included in the meta-analysis. The prevalence of HTN in the Iranian adult population was 26.26% (25.11 % and 26.22 % for women and men, respectively). Meanwhile, the prevalence of PHTN and HTN in the child/adolescent age group was 8.97% (95% CI 7.33 - 10.61) and 8.98% (95% CI 7.59 - 10.36), respectively.

This study provides information which can be used for various purposes, including study designing. Further nationwide surveys should be carried out to obtain accurate information on the HTN prevalence rate, particularly based on the American College of Cardiology /American Heart Association guidelines in the Iranian population.

It is pertinent to objectively assess the severity of diabetic gastroparesis and tailor treatment accordingly. The current study was planned to document gastroparesis by gastric emptying scintigraphy (GES) objectively and see the effect of medications and diet control on clinical and GES after four weeks.

A prospective, open-label randomized trial was conducted in the Department of Internal Medicine at a tertiary care teaching hospital over twelve months. Type 2 diabetic patients aged 18-65 years diagnosed with a case of delayed gastric emptying by gastric scintigraphy were included. All baseline GSCI was recorded, and then they were allotted to 3 groups – Group-1 (Levosulpiride 25mg once daily), group-2 (Cinitapride 1mg thrice daily), and Group-3 (Waitlisted control) by block randomization and followed-up weekly till four weeks. After four weeks duration, if not improved clinically, then Group-3 on diet and diabetic control only, were randomized into Levosulpiride 25mg once daily (Group 1), and Cinitapride 1mg Thrice daily (Group 2) for the next four weeks.

Forty confirmed cases with diabetic gastroparesis documented by Gastroparesis Symptom Cardinal Index (GCSI) scoring and later by Scintigraphy (GES) were included in this study. However, there was no statistically significant difference between the Levosulpiride and Cinitapride groups when all symptoms were taken into account. Levosulpiride was significantly more effective than Cinitapride in improving individual symptoms like nausea, vomiting, stomach fullness, and early satiety.

Levosulpiride is better than Cinitapride in improving the symptoms of diabetic gastroparesis but no significant effect on gastric scintigraphy.

The use of transcutaneous electrical nerve stimulation (TENS) to relieve labor pain remains controversial and existing evidence is neither strong nor consistent. This research was designed to compare TENS' effect with the injection of pethidine and promethazine in labor pain reduction.

In this trial, for 45 pregnant women in the active phase of labor, TENS electrodes were placed (two on both arms, and two over the participants’ low back) continuously for 120 minutes; and for another group 45 pregnant women, 100 milligrams of pethidine and 250 micrograms of promethazine were injected intramuscularly which could be repeated once at least one hour later. Labor pain and duration, need for labor induction/augmentation/other pain control methods/ instrumental delivery, delivery type, and maternal and newborn complications were measured in both groups.

The baseline mean visual analog scale (VAS) score, in the TENS group was 8.51±0.62 and in the pethidine and promethazine groups was 8.37±0.61 (P=0.31). While in a 120min post-intervention, it was 6.29±1.50 and 5.73±1.46 in the TENS group and the pethidine and promethazine group, respectively with no statistically significant difference (P=0.07). The labor duration in the TENS group was 6.61±1.71 hours and in the pethidine and promethazine group was 6.17±2.07 hours, with no statistically significant difference (P=0.33). In addition, no complication was recorded neither in the mothers nor newborns.

This study showed that applying TENS in the active labor phase can reduce at least two scores in patient labor pain with no significant complications.

Tennis elbow or lateral epicondylitis is a common complaint involving about a 3-5% cases in a community. Non-surgical treatment is effective in 80% of cases. Recent studies have shown the effect of autologous blood on improving the pain and function of affected patients. The present study aimed to compare the effectiveness of steroid and autologous blood local injection in controlling pain and disability in the short and long term.

The present study was a clinical trial conducted in Shahid Beheshti Hospital of Babol. A total of 60 patients were divided into 3 groups; A group injected at the site of lateral epicondylitis with steroid (methylprednisolone acetate-40mg) and another group with autologous blood (2ml of venous blood), and the other group used a brace for 3 weeks. Patients were followed-up for 15, 30, and 90 days, and the PRTEE assessment questionnaire assessed their pain and disability.

On the 15th day, there was no statistically significant difference in pain and function in the three groups, although the injectable groups were relatively more effective. On the 30th day, the local corticosteroid was significantly better than the autologous blood group, while on the 90th day, autologous blood was significantly better than the local corticosteroid. The average day, in which 25% improvement was gained, was lower in the autologous blood transfusion group.

Regarding the long-term effect of autologous blood on corticosteroid injections, it was recommended as a lateral epicondylitis treatment.

Echocardiography is routinely ordered in acute ischemic stroke workup. No standardized or structured criteria is used to select or exclude echocardiography in such settings. Moreover, the diagnostic yield of echocardiography in stroke is low in our medical center. This article presents newly proposed selection criteria for echocardiography in ischemic stroke workup.

A quality improvement project was implemented in a 385-bed community hospital in Maryland, USA. A computerized decision support tool consisting of new criteria for selecting echocardiography in ischemic stroke workup was created. 639 patients hospitalized with ischemic stroke were followed-up over 12 months after intervention, and 686 matched-controls with ischemic stroke were retrospectively analyzed from the 12 months prior to intervention. Cost-effectiveness and diagnostic yield of echocardiography in ischemic stroke were measured before and after intervention.

Following intervention, the diagnostic yield of echocardiography in ischemic stroke workup significantly increased by 51% (from 3.8% to 7.8%, odds ratio (OR) 2.1, P= 0.01). The number of echocardiography studies needed to detect and treat one patient with a cardiac source of embolism was reduced from 50 to 25 studies. The overall use of echocardiography in stroke workup significantly decreased (OR 0.4, p < 0.001). Patients with lacunar infarcts or atrial fibrillation had significant reduction in echocardiography (OR 0.2, p < 0.001 and OR 0.4, p < 0.001, respectively).

The new criteria for echocardiography selection in hospitalized patients with ischemic stroke significantly improved the cost-effectiveness and the diagnostic yield of echocardiography and reduced unnecessary echocardiography in lacunar infarcts or atrial fibrillation.

Patient anesthesia using continuous epidural infusion (CEI) has been an optimal and acceptable technique for inducing epidural anesthesia for many years. This study aimed to compare two methods of programmed intermittent epidural bolus (PIEB) with continuous epidural injection (CEI) in labor analgesia among patients receiving epidural dexmedetomidine.

This study was a randomized clinical trial. The target population was term women candidates for epidural anesthesia. After selection of sample size based on inclusion criteria and a total of 3 cc of Dexmedetomidine (0.5 µg/ml) and Ropivacaine 0.1% was injected. Furthermore, 5 ml was injected as a loading dose of Dexmedetomidine 0.5 µg /ml and Ropivacaine 0.1%. Then recorded the pain score by Patient Control Epidural Analgesia tool. What were considered as the outcomes of the study included demographic information. SPSS software Version 23 was used for statistical analysis of data.

First, the neonatal Apgar score in PIEB method was more improved, and secondly, the use of assisted delivery tools such as vacuum in PIEB method was reduced. Moreover, the duration of the first phase of labor in this method was more reduced than CEI. This was while the hemodynamic conditions of the       patients in the two groups, including vital signs and arterial gar analysis, were maintained in a stable state. As a result, patients in the group undergoing epidural anesthesia by PIEB method were associated with a higher level of satisfaction with the delivery process (p < 0.05) and induction of epidural anesthesia than patients undergoing CEI protocol.

The PIEB method is associated with further improvement in neonatal (Apgar score) and maternal outcomes (reduction in the duration of the first phase of labor and no need to use assisted delivery methods) compared to the CEI protocol, but has little effect on hemodynamic conditions or drug dosage.

Couples’ childless and one-child intention is one of the crucial challenges in all societies. Considering the aging of the world's population and the need to review birth control policies, it is necessary to take evidence-based measures. Therefore, the present study aimed to investigate the influencing factors on the tendency of couples to be childless and have only one child.

The present study is the first part of a mixed (qualitative-quantitative) study. The study is qualitative with a conventional content analysis approach. The research population consists of all couples aged 15-49 in 2021 in Babol city, who were single or childless and had no intention of pregnancy in the future. Sampling is based on the purpose, and the number of samples is 40 couples. To collect data, face-to-face and semi-structured interviews were conducted with the participants. Sampling continued until data saturation. The data were analyzed by the conventional content analysis method.

The results of the analysis include 140 codes, 30 sub-categories, 9 categories (family economic problems, uncertainty in the future security of the child, threatened priorities, uncertainty about the continuation of life, Fear of becoming a parent, lack or weakness of support, diminishing religious beliefs, social role modeling and negative experiences of childbearing) and two themes (individual limitations and social limitations). These factors indicate the mandatory conditions for childlessness or one-child choice or voluntary child-free.

The results revealed that voluntary childlessness and single-child depend on various individual and social aspects. Some of these factors have made couples choose a childless or one-child lifestyle against their will and under forced circumstances. Financial support and welfare of the government, parenting education and efforts to change the attitude of couples towards having children by the government can help to maintain and improve the health of the family and achieve the goals of encouraging population growth policies.

Endothelial dysfunction has a significant role in the pathogenesis of cardiovascular events in patients with kidney dysfunction. The present study aimed to compare the level of endothelial dysfunction in patients with chronic kidney disease (CKD) and acute kidney injury (AKI) by brachial artery flow-mediated dilation (FMD) technique. Also, we sought to find whether this non-invasive technique may assist in accurately distinguishing the acute or chronic nature of kidney failure in patients presenting with uremia for the first time.

Demographic and medical characteristics, and laboratory and renal ultrasonography data of the patients with AKI and CKD were collected and compared with a control group. Brachial artery FMD was measured using a Toshiba aplio 300 device with a 7.5 MHz linear probe.

In a total of 175 patients with a mean (SD) age of 55.96(15.54) years, FMD% was significantly lower in the CKD and AKI patients compared to the control group (Mean±SD: 16.28%±10.52%), 16.28 %±4.35%, and 24.24±5.71, respectively, p<0.001). Among the different causes of AKI, contrast-induced nephropathy (10.78%±1.75%), volume depletion (14.87%±1.22%), and post-renal AKI (15.96%±1.54%) had the lowest levels of FMD. Also, a significant correlation between FMD and eGFR (r=0.26, P<0.001), serum Hb (r=0.18, P=0.013), Na (r=0.19, P=0.011), BUN (r=-0.21, P=0.005) and Cr (r=- 0.13, P=0.084) was reported.

Compared to the control group, CKD and AKI patients showed greater levels of endothelial dysfunction as evidenced by lower brachial artery FMD. However, the FMD technique did not appear to be a practical method in differentiating CKD and AKI in patients presenting with uremia for the first time.

Helicobacter pylori (H. pylori) has infected about 50% of the world’s population and it is the main cause for peptic ulcer, gastric adenocarcinoma and even a major cause for gastric MALT lymphoma.

This study was performed in Mazandaran, Sari, situated in North of Iran. Three-hundred and twenty-eight adult patients with endoscopically approved gastric or duodenal ulcers or erosions and H. pylori infection were randomly divided into 2 groups to receive either 14 days PABT (Pantoprazole 40 mg, Amoxicillin 1 g, Bismuth 425 mg (all twice daily) and Tetracycline 500 mg four times a day) and PACM (Pantoprazole 40 mg, Amoxicillin 1g, Clarithromycin 500 mg, and Metronidazole 500 mg, all twice daily). To evaluate H. pylori eradication, fecal H. pylori antigen test was performed 8 weeks after treatment.

The eradication rates were 94.51% in the PATB and 91.46% in PACM group based on the intention to treat analysis. Moreover, the eradication rates were 95.58% and 92.72% according to per-protocol analysis, respectively. Also, both groups had very low rates of severe side effects.

Regarding the ideal eradication rates achieved by both treatment groups and the low rates of severe side effects, both treatment protocols can be prescribed for H. pylori eradication in North of Iran.

The most common psychiatric disorder in childhood is Attention-deficit/hyperactivity disorder (ADHD). Researchers have studied the effects of micronutrients on ADHD in recent years, but vit D deficiency has received less attention. In this study, serum vit D levels were compared between healthy and ADHD children.

This case-control study was carried out, in 2020, on 6-to-12-years-old children. There were 45 children with ADHD in the case group and 45 healthy children in the control group. Intravenous blood samples were taken from each child to measure serum vitamin D levels. A p-value < 0.05 was considered as significant.

Mean serum vit D levels in children with ADHD (17.34±8.37 ng / ml) were significantly lower than those in the control group (23.02±10.97 ng / ml) (P= 0.007). There were no significant differences in mean serum levels of vit D due to ADHD subtypes. Mean serum vit D levels were not significantly associated with the gender of children with ADHD. There was an inverse correlation between vit D levels and the severity of ADHD, but it was not statistically significant.

The present study showed that children with ADHD had significantly lower serum vit D levels than healthy controls.

Helicobacter pylori (H. pylori) infection is strongly related to peptic ulcer disease, chronic gastritis, and gastric malignancies. Therefore, H. pylori eradication is necessary in these cases. This study was aimed to compare the efficacy of 14-day reverse hybrid therapy with standard 14-day concomitant regimen for H. pylori eradication in Iran.

Of the 317 patients with dyspepsia and H. pylori infection enrolled in the study, 153 and 164 patients were randomly assigned to reverse hybrid and concomitant groups, respectively. The reverse hybrid regimen containing pantoprazole, amoxicillin, clarithromycin, and metronidazole was taken every 12 hours in the first 7 days, however, Clarithromycin and Metronidazole were discontinued within the next 7 days. Patients in the concomitant group also received the same drugs for 14-day. Eradication confirmation tests were used 8 weeks after the end of treatments.

A crowd of 281 patients continued the trial until the end. H. pylori eradication rates based on intention to treat analysis were 71.2% (109/153) and 83.5% (137/164) in reverse hybrid and concomitant groups, respectively (P = 0.007). By the per-protocol analysis, rates of eradication were 85.8% (109/127) and 89% (137/154), respectively (P = 0.428). Severe side effects were few in both groups. More side effects were observed in concomitant group (p < 0.001), however, the severity of side effects was not statistically different between the two regimens (P = 0.314). Reverse hybrid regimen was better tolerated (98% vs. 91.5%, P= 0.009).

Both 14-day reverse hybrid and concomitant regimens have a fair response rate in Iran.

Autophagy is a pathway for the degradation of cytoplasmic components, which plays an essential role in various cellular and physiological processes, including cell renewal and survival, and immune responses. While recent studies have shown that they can play a role in cancer treatment, the precise mechanisms of autophagy in leukemogenesis are not fully understood. We have assessed the expression levels of LC3 and BECLIN1 as two crucial autophagy mediators in patients with leukemia.

This cross-sectional study was performed on bone marrow or peripheral blood samples of 61 leukemia patients (24 AML, 20 ALL, and 17 CML) and compared to 18 healthy controls. Real-time PCR was used to quantitate gene expression. SPSS statistics 16.0 and Graph Pad Prism 8.4.2 software were applied for statistical analysis.

While BECLIN1 expression was significantly lower in AML, ALL, and CML patients as compared to the control group (p < 0.05), LC3 showed significantly different expression only in the AML patients (P= 0.03). There was no significant correlation between the expression levels of BECLIN1 with LC3 (p> 0.05). Whilst the AML LC3high group had a significantly lower lymphocyte count (P= 0.023), the AML BECLIN1low group had a significantly higher MPV levels (P= 0.044). Furthermore, ALL LC3high group indicated a significantly lower HCT count (P= 0.017).

Significant changes in the expression levels of BECLINI and LC3 in hematologic malignancies may indicate a possible role for autophagy in their pathogenesis. However, further studies are warranted to confirm these findings.

Nowadays, surgical procedures are assessed based on the state of an individual. This study aimed to investigate the effect of lumbar spinal stenosis surgery on the patient’s quality of life and motor functions in Kashani and Alzahra Hospital in Esfahan.

In the present cross-sectional study, 40 patients aged between 50-70 were respectively evaluated who underwent lumbar spine stenosis surgery in Al Zahra and Kashani Hospitals in Esfahan University of Medical Sciences, Esfahan, Iran, during 2020-2021. The SF-36 questionnaire was used as a research tool. The visual analog scale (VAS), and spine functional index (SFI), were measured initially before surgery and 6 months and 9 months after surgery.

The mean scores of the SF-36, SFI, and VAS scores questionnaire were 87.95±4.94, 21.38±1.24, 6.07±0.69 (p<0.001) before surgery, 89.77±5.25, 19.73±1.40, 5.37±1.56 (p<0.001) six months after surgery, and 94.70±5.34, 18.63±1.56, 4.57±0.81 (p<0.001) nine months after surgery, and all were significant. Improvement in the domains of general health, role-physical, role disorder due to impaired physical health, social function, emotional role, and bodily pain was evident. Also, the overall quality of life was enhanced but energy levels and role disorder due to impaired mental health showed no improveme.

Not only does lumbar spinal stenosis surgery significantly improve the general health, role-physical, and the social function of the patients but also enhances their quality of life.

Prostate cancer (PC) ranks as the second most commonly diagnosed neoplasia and the fifth cause of death in men with cancer, with an increasing trend in incidence. The aim of this study was to investigate the epidemiological situation of prostate cancer and relationship with the human development index (HDI) in the Asian continent.

All accessible data sources from the 2019 Global Burden of Disease study were used to estimate the prevalence, mortality and disability-adjusted life years and burden prostate cancer in Asia from 1990 to 2019. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs) and disability-adjusted life-years (DALYs). All estimates were presented as counts and age-standardized rates per 100 000 population, with uncertainty intervals (UIs). Concentration Index analysis and Concentration Curve were used to determine the relationship between Prostate cancer burden and human development index.

The highest incidence of prostate cancer in Asia in 2019 is Japan (90.5 per 100,000) and the highest mortality rate is Georgia (27.87 per 100,000). The highest DALY, YLL and YLD of prostate cancer is Georgia. The results showed that the percentage of changes in the incidence in 1990-2019 was positive in all countries of the Asian continent except for Afghanistan and Kyrgyzstan. The results of the concentration index showed that the incidence and mortality of prostate cancer is more concentrated in countries with a high HDI level. Examining the DALY, YLL and YLD index also showed the value of concentration index, which shows that DALY, YLL and YLD of prostate cancer are more concentrated in countries with high HDI level.

Given that the incidence, mortality and burden of prostate cancer are increasing in most Asian countries and are mostly concentrated in the HDI drawers, obtaining accurate estimates in these countries to prepare for the potential change in public health burden due to this disease which is very important.

Rapid economic progress and cultural-social changes have led to lifestyle changes and increased risk of breast cancer all around the world, including Iran. This study aims to investigate the 30-year incremental pattern of breast cancer in patients of Shahid Rajaei Radiation Therapy Center in Babolsar, North of Iran.

In this cross-sectional study, the data were retrospectively extracted from the physical and electronic files of patients diagnosed with breast cancer from 1992 to 2021 every 5 year by census method, during the study, overall, 1326 patients' information out of 6199 patients was analyzed using SPSSV.22 software at the level of p-value ≤ 0.05.

The average age of patients was 49.84 ± 11.26 years, which has been increasing over the years of study. 6143(99.13%) patients were women, the mean and standard deviation of their BMI was 29.63 ± 6.00, the number of patients with stage 1 is increasing, and patients with stage 3 is decreasing. 871(65.70%) people went through Radical Mastectomy (MRM), 261(19.68%) people experienced metastasis. There was a statistically significant relation between the type of surgery, stage of cancer, metastasis, and local recurrence within the years of study (p<0.001).

Breast cancer and the age of getting it have increased in recent years. However, advanced stages as well as metastasis and local recurrence have decreased during the investigated years. Therefore, it is recommended to continuously warn women about the risk factors and develop suitable disease screening programs and implement them effectively.

End-stage renal disease (ESRD) is a serious chronic disease that affects many organ systems. Skin manifestations that are commonly seen in ESRD can significantly impair the quality of life in these patients. Early recognition and management of mucocutaneous disorders can improve quality of life and decrease morbidity. This study aimed to evaluate the skin manifestations in ESRD patients undergoing hemodialysis.

In this cross-sectional study 150 patients undergoing hemodialysis in the Nephrology Department of Shahid-Beheshti Hospital in Babol were enrolled. The demographic and clinical data were assessed. Analysis was done by SPSS 22 and significance level was under 0.05.

The mean duration of hemodialysis was 8.7 months. The most common skin findings in patients include xerosis 84.7%, pallor 82.7%, pruritus 67.3%, hyperpigmentation 40%, purpura 28%. Skin infections were detected in 36% of patients (fungal 28%, bacterial 10.7%, and viral 5.3%). Nail, hair and mucosal changes were observed among 65.3%, 38% and 17.3% of patients respectively. No significant correlation was detected between skin findings and duration of dialysis.

The findings of the present study showed that skin manifestations are highly prevalent among patients with ESRD. Prompt diagnosis and management of the dermatological disorders may improve the quality of life in the affected patients.

Although the association between first-trimester increased nuchal translucency (NT) and chromosomal defects is well-defined, there is little knowledge about the importance of increased NT in fetuses with normal karyotypes. Hence, this study was designed to evaluate outcomes of normal karyotype fetuses with increased NT.

This observational retrospective study was conducted on 720 pregnancies with increased NT (>3mm) at 11 to 13 weeks of gestational age in Yas Hospital, Tehran, Iran, from 2016 to 2020. Study outcomes were incidence of preeclampsia, intrauterine growth restriction) IUGR (, preterm labor, fetal anomaly, cardiac malformations, hydrops fetalis, abortion, and intrauterine fetal death (IUFD) in pregnancies without evident chromosomal karyotype abnormalities.

Out of 720 participants who underwent karyotyping in the study center, 523 fetuses had normal karyotype results. In the pregnancies assessed for outcome, 357 (68.3%) reached live birth, 104 (19.9%) aborted, and 62 (11.9%) resulted in IUFD.
Study outcomes including preeclampsia (<0.001), IUGR (<0.001), preterm labor (<0.001), fetal anomaly (<0.001), cardiac malformations (<0.001), hydrops fetalis (0.017), abortion (<0.001), and IUFD (<0.001) resulted in a statistically significant difference in the distribution of cases across NT intervals.

This study demonstrated adverse pregnancy outcomes increased with increasing NT despite normal karyotyping. Hence, tight observation of mothers and fetuses should be done in normal karyotype fetuses with increased NT.

The increase in serum phosphorus level is an independent risk factor for mortality in patients with chronic renal failure or undergoing dialysis due to end-stage renal disease. (1) Proton pump inhibitors (PPI) are the general name given to agents used to suppress stomach acid. In this study, the clinical benefit of using PPIs in addition to drugs used for phosphorus control was investigated.

153 patients with end-stage renal disease were included in the study. The data of the patients who had been on hemodialysis for at least 6 months and using calcium acetate for at least 1 month were recorded in the SPSS 21 program. The patients were analyzed in two groups according to whether they used PPI or not. Anamnesis, patient follow-up, laboratory, and treatment forms collected from hemodialysis centers were used.

Of the 153 patients in the study, 49% were males and the mean age was 65.11±11.23. The mean duration of patients on dialysis was 48.5 months. Hypertension was found to be the most common comorbidity with 75.8% prevalence among the patients. The mean phosphorus levels of the patients using calcium acetate together with PPI were found to be approximately 1.2 mg/dl lower (p= 0.000).

It should be taken into account that the use of PPI together with calcium acetate, which is still common as a phosphorus binder in developing countries, can contribute to controlling phosphorus levels.

Our purpose was to investigate the association between Mammographic breast density (MBD), a known strong marker for breast cancer and metformin and aspirin use and duration of use alone or simultaneously, in a sample of Iranian women considering other confounding factors.

In a cross-sectional study, 712 individuals were selected out of women referred to two university hospitals for screening mammography. Participants’ information was collected with a questionnaire. Four-category density scale (a = almost entirely fatty, b = scattered fibroglandular densities, c= heterogeneously dense, and d = extremely dense) was categorized as low (a&b) and high (c&d) density.

The mean age of the participants was 49.80 ± 7.26 years. Sixty-five percent of women belonged to the high and 35% to the low MBD category. Both aspirin and metformin had a significantly negative association with MBD, however, when confounding factors were entered into the models, only aspirin after adjustment for age and BMI had an inverse association with MBD (OR = 0.53, 95% CI: 0.35-0.94). Simultaneous use of metformin and aspirin (OR = 0.44, 95 %CI: 0.17-1.12) was associated with lower MBD. Furthermore, in women who used metformin (OR = 0.23, 95% CI: 0.09-0.62) and aspirin (O R= 0.35, 95% CI: 0.17-0.72) for 2 to 5 years, MBD was significantly lower. However, after the adjustment of confounding factors, these associations were not statistically significant.

It seems metformin and aspirin intakes are associated with MBD. However, further studies with more sample size are needed.

Hyperostosis is a common consequence of chronic rhinosinusitis with nasal polyps (CRSwNP) and other chronic rhinosinusitis, affecting mainly structures of the ethmoid labyrinth, frontal and maxillary sinuses. These neo-bones are found in advanced stages of rhinosinusitis causes exacerbation because of ostia outflow blockage. Frequent relapses of the disease due to hyperostosis restenosis, represent a problem in the treatment of chronic frontal sinusitis. We report our cases experience about the treatment of frontal chronic sinusitis because of frontoethmoidal area hyperostosis, treated by modified lothrop procedure, achieving sufficient clinical effect.

A 52-year-old female (CRSwNP) with right side frontoethmoidal area totally obstructed by 25 × 15 × 10 mm bony mass, with total opacification of the right frontal and left maxillary sinuses, right frontal sinus anterior wall defect. A 63-year-old male (CRSwNP) with a 23 × 10 × 10 mm bony mass arising from the right frontoethmoidal area which causes total opacification of the right frontal sinus, inferior and posterior sinus wall defect.

Modified lothrop procedure is a method of choice for frontoethmoidal bone hyperostosis surgery to be performed endoscopically. Endoscopy provides excellent visualization of anatomy and a better approach to bone hyperostosis zone.

Gallbladder agenesis is a biliary tract related congenital malformation with an incidence of 10–65 per 100,000 and associated with other congenital abnormalities. GA is usually asymptomatic, but sometimes patients become symptomatic. The most usual symptoms are jaundice, abdominal pain in the right upper quadrant, nausea and vomiting. We reported a case of GA and choledochogastric fistula in a patient with history of cholangitis.

A 70-year-old man presented to Emergency Department of Modarres Hospital with jaundice, fever, right upper quadrant abdominal pain, nausea and vomiting. Clinical examination and lab test demonstrated cholangitis. He underwent ultrasonography, abdominopelvic CT scan and ERCP. ERCP revealed a CBD fistula. Due to recurrent symptoms, he underwent operation and hepaticojejunostomy was done.

In our knowledge, the case of GA and choledochogastric fistula is rare. Furthermore, this type of abnormalities rarely presented with cholangitis, so probable anatomical malformation of the biliary tract should always be considered as a differential diagnosis in patients with biliary disease signs and symptoms

Ensuring vascular access is essential for dialysis patients. This can be achieved through an arteriovenous anastomosis (fistulae), a central venous catheter, or an arteriovenous graft. However, in some cases vascular access to the patient's blood is not possible.

A multi-vascular male patient, who had been undergoing dialysis for 17 years, was presented to our renal department. There was no possibility of vascular access to the patient’s venous network for dialysis. A peritoneal dialysis catheter was inserted, but it was malfunctioning. An attempt was made to place a HeRO AV Graft, but it did not succeed due to contraindications from the patient's venous network, as shown by the computed tomography. While trying to solve the problem in order to dialyze the patient during his hospitalization, he experienced severe shortness of breath with tachypnea (pulmonary edema), along with acidosis and hyperkalemia. A temporal dialysis catheter was urgently inserted into the left femoral artery and isolated ultrafiltration was performed, and by removing 1500 ml of ultrafiltration, the patient improved significantly. During the subsequent days, he underwent another 11 dialysis sessions using the femoral artery catheter. While he was hospitalized and being dialyzed via the femoral artery, a successful effort was made to catheterize the right external jugular vein, from which he continues to be dialyzed today.

The patient’s treatment through the placement of a temporal dialysis catheter in the femoral artery enabled him to survive. It is our belief that such a solution could be helpful in similar cases.

As a new point, some very rare features can be revealed as initial diagnosis of acute lymphoblastic leukemia (ALL) without any evidence of lymphoma-like behavior which after initial recovery, presents with new evidence of lymphoma. Herein, a case of the immunophenotypes of blast cells in B-cell precursor acute lymphoblastic leukemia originated from MYC gene-related that was evidenced later by burkitt lymphoma feature.

Our case was initially diagnosed as a typical B-cell ALL cells with L1 morphology in peripheral blood smear and bone marrow aspiration that was not recovered and referred again that was finally featured as burkitt’s lymphoma with L3 morphological feature.

Thus, in the primary diagnosis of B-cell ALL and especially in cases with treatment failure, the final feature of burkitt’s lymphoma should be potentially in mind.