مجله غدد درون ریز و متابولیسم ایران
سال سوم شماره 3 (پیاپی 11، پاییز 1380)

Reduction of serum calcium and phosphorus due to nutritional problems has fundamental importance in regard with metabolic bone diseases especially rickets and osteomalacia. As the most abundant serum protein, and the most important calcium binding protein, albumin is necessary for evaluation of total calcium changes. It is also a poor indicator of protein intake. Extracting basic and extensive information in this repect can provide health progrmmers of the country with suitable guides in order to prevent the rising of possible deficiencies. In this descriptive research, a random sample of 1300 children were chosen form the population of rural and urban students aged 8-10y in 23 provinces of the country and blood was taken from them. The levels of calcium, phosphorus and albumin for all samples were checked in the same laboratory and the same manner. Serum calcium was correctd according to the level of albumin. The mean levels for calcium, phosphorus and albumin were 8.6±0.7 mg/dL, 4.9±0.9 mg/dL, and 4.6±0.6 gr/dL respectively. There were not significant differences for the serum calcium and albumin levels in the two sexes, but the serum level of phosphorus was higher in boys than in girls (P<0002). The difference between serum calcium, phosphorus and albumin of rural and urban areas was not significant. Calcium less than 8.8 mg/dL was observed in 61% of the whole sample (58% urban and 62% rural) for both sexes. Calcium was less that 7.5 mg/dL for 6.4%, between 7.5 and 8 mg/dL for 8.4% and between 8 and 8.8 mg/dL for 46%. There were only two cases in Booshehr province with calcium more than 10.8 mg/dL. Average calcium was less than 8.0 mg/dL for East Azerbaijan, Ardebil, and Isfahan provinces. It was less than 8.5 mg/dL for Tehran, Chaharmahal, Zanjan, Semnan, Kerman, Kermanshah, Hamedan and Markazi provinces. Hypocalcemia did not differ significantly for rural and urban areas and for the two sexes. Phosphorus was less than 3.9 mg/dL for 6.2% of the whole population (5.6% boys and 7.1% girls). Hypophosphatemia did not differ significantly for rural and urban areas and for the two sexes. Hyphophosphatemia was observed in Isfahan, Tehran and Khoozestan by 27%, 20% and 18% respectively. Albumin was less than 4.0 g/dL for 12.8%, of the whole population (12.7% boys and 13.7% girls). Hypoalbuminemia was observed in Ardebil, Khoozestan and Tehran by 65%, 42% and 41%, respectively. Hypocalcemia was accompanied by hypophosphatemia in 5% of the cases. The correlation between serum calucium and phosphorus (P<0.001 and r = 0.334) and phosphorus and albumin (P<0.001 and r = 0.153) were significant. This study shows the existence of hypocalcemia in about three fifths of the students aged 8-10y in the country, 5% of which are accompanied by hypophosphatemia. The results of this study demonstrate the need for immediate attention and programming to carry out an etiologic survey and extensive policy making to prevent and remove the nutritional problems of the children and the adolescent, especially in connection with metabolic bone diseases.

Diabetic osteopenia is a recognized but neglected complication of diabetes mellitus. Most studies have reported low BMD values in type 1, but the BMD results in type 2 is often conflicting. Considering the high prevalence of diabetes type 2 and the importance of osteopenia in postmenopausal women together with its socioeconomic and health burdens, we designed a controlled study of BMD in postmenopausal diabetic women. Proximal femoral and lumbar BMD findings in the subjects were compared to the healthy postmenopausal controls. BMD results from 65 postmenopausal women, aged 45-65 years old, with diabetes type 2 were compared with 65 age matched controls. BMD at proximal femur (neck, ward, trochanter) and lumbar spine (L2-L4) was performed using DEXA. Subjects were categorized as “diabetic – non osteopenic” (or high BMD) and “diabetic osteopenic – osteoporotic” (or low BMD) based on whether their femoral neck T-score were above or below –1, respectively. Serum levels of FBS, 2hpp glucose, HbA1C, Ca, Ph, alkaline phosphatase, urinary Ca and Na were also assessed between two subgroups. Mean BMD value of ward area in diabetic women was 0.644±0.165 g/cm2 vs. 0.705±0.138 g/cm2 in controls (P<0.03). Trochanteric mean BMD in cases was 0.658±0.21g/cm2 vs. 0.737±0.99 in controls (P=0.01). But at femoral neck and lumbar spine no significant difference was seen between two groups. The osteoporotic subgroup of diabetic patients showed higher levels of HbA1C, alkaline phosphase and 24h urinary Ca and Na, but lower levels of serum Ca and Ph, however, the differences did not reach statistical significance. Estrogen consumption was more common in high BMD patients (P=0.05). There was no significant difference between the case and control groups in respect of absent vertebral fractures in the course of recent five years. Age and span of time following menopause, appear to be major risk factors for osteopenia in diabetic patients. Despite higher body mass index in diabetes and considering the protective role of obesity on bone mass, there seems to be a significant decrease in ward and trochanteric BMD values in diabetic patients, indicating that factors other than obesity could affect their BMDs.

Diabetic nephropathy is the most common cause of ESRD. Proteinuria has an important role in rapid progression to ESRD. Pentoxifylline (PTX) is a drug with TNF-α suppression effect and hence reduction of proteinuria and slowing of progression of diabetic nephropathy. To evaluate this hypothesis of PTX effect in comparison with captopril, we studied 40 type 2 diabetics with macroproteinuria (> 300 mg/day), who had no contraindication for PTX and didn’t take PTX or ACEI for the past year. We didn’t change the profile of diabetes or HTN drugs of our patients. We planned a cross over study in two 2-month periods of PTX or captoril therapy spaced with a one-month washout period. At beginning and the end of each treatment period we measured blood pressure, FBS, creatinine and 24-hour urine collection for volume, creatinine and protein. PTX reduced proteinuria by 0.44±0.63g/day in comparison with 0.1±0.22g/day with captoprial (P = 0.008). In conclusion PTX is superior than captopril in reducing proteinuria in type 2 diabetic patients.

The relationship between thyroid disorders and glaucoma is not clear. This study aimed at determining the prevalence of thyroid dysfunction in patients with glaucoma. 174 patients with open angle and non-open angle glaucoma (OAG and NOAG) visiting Farabi Hospital were selected using simple non-random sampling. Intraocular pressure (IOP) and thyroid function tests (TFT) were measured and the patients were divided into different groups according to their thyroid function status (hypo-, eu- and hyperthyroid). Mean age of the patients was 59±11 years. Among all patients, 32% had OAG, and others had NOAG. Of 174 patients, 1.7% were subclinically hypothyroid and 3.4% were subclinically thyrotoxic. The mean intraocular pressures of the hypo-, eu- and hyperthyroids were 16.5±4.4, 16.5±6.9 and 21.9±6.1 mmHg, respectively, which shows no significant difference. No significant difference in the prevalence of thyroid disorders was found between those with OAG and NOAG. Compared to other studies the prevalence of thyroid disorders in patients with glaucoma is higher than that of normal population. Our findings controvert the results of some other studies, in which higher prevalence of hypothyroidism in OAG than that of NOAG was observed.

Prevalence of thyroid diseases increases with age. 4% to 17% hypothyroidism and 2% thyrotoxicosis has been reported in elderly population over 60 years of age. The age and sex distribution of all thyroid antibodies in men has shown no significant variation with aging, but a marked increase with age was shown in women. Some studies have suggested that thyroid autoimmunity is exacerbated in iodine sufficient areas. To evaluate geriatric thyroid function in iodine deficient area we conducted this study in Rasht, which is a known iodine deficient district in North Iran. The study included physical exam for goiter and thyroid function tests on 128 healthy elderly residents of an old people’s home in Rasht. Mean age of 42 males was 72.5±7.5 years and 86 females 73.9±10.6 years. 23 cases (18%) including 4 men (8%) and 19 women (21%) had clinical goiter. 8 cases (6.25%) had TSH>5 mU/L. Tsh was > 10mU/L in 2 of them (1.5%). Only 2 cases had T4<4.5 μg/dL, who suffered from secondary hypothyroidism. Anthithyroid antibodies were negative in all the subjects. There was no significant age related change in T4, FTI, and TSH among different age decades. In either sex, T3 was significantly decreased in older subjects. In this study, incidence of hypothyroidism was 6.25% equally in both genders, and all these patients had subclinical hypothyroidism, surprisingly, with negative thyroid autoantibodies. These findings are in contrast with the high incidence of hypothyroidism and antithyroid antibodies shown in other studies. This difference might be due to iodine deficiency in this area.

Thyroid nodules are one of the most common problems, especially in endemic areas, and their importance is due to probability of cancer. Because FNA is easy and cost-effective, it is usually the first step in diagnosis and evaluation of these nodules. This method is highly dependent on the clinician’s skill and pathologist’s experience. In this prospective study, 153 patients (112 F, 41 M, F/M= 2.73) from 1997-2000 in Bank Melli Hospital were studied. The mean age±SD of patients was 40.5±13 years. FNA was done for all of these patients and results of FNAs and surgical specimens of these patients were reported by a single pathologist. On FNA, 133 cases (87%) were nonmalignant (including colloid cyst, colloid adenoma, nodular hyperplasia, thyroiditis), 10 cases (6.5%) were suspicious, 6 cases (3.9%) were papillary carcinoma, 3 cases (2%) were follicular carcinoma and 1 case (0.65%) was Hurthle cell carcinoma. The results of pathologic specimens were as follows: 125 (81.7%) were multinodular or nodular goiter, 16 (10.4%) were papillary carcinoma, 3 (3.2%) were follicular carcinoma, 1 (0.65%) was Hurthle cell carcinoma, and 8 (5.2%) were Hashimoto’s thyroiditis. FNA sensitivity was 75%, specificity was 97%, positive predictive value was 79%, and negative predictive value was 95.5%. The percentage of malignancy of nodules in males (24.4%) was significantly (P<0.05) greater than in female (8.9%) as shown in other studies. FNA is a suitable method for cancer diagnosis in thyroid nodules with an acceptable specificity and NPV. Precise sampling and pathologist’s expertise would increase the sensitivity and PPV. Keywords:

Surgery is the common therapy for advanced thyroid cancers with local invasions to trachea. There are many patients suffering from postoperative relapses or according to their poor general conditions are not eligible for an operation. Regardless of different types of thyroid cancers, utilization of Nd-YAG laser as an effective method leads to evacuation of tracheal invasion of tumor, removal of stenosis and improvement of respiratory condition. An uncontrolled clinical trial was performed in patients who were seeking medical advice in Masih Daneshvari hospital from 1997 to 2001. All patients had local invasions of tumor, tracheal stenosis and symptoms of obstructive respiratory discomfort relevant to stenosis. After bronchoscopic evaluations all patients underwent Nd-YAG laser therapy through photocoagulation and photoevaporation processes under local anesthesia. The eleven patients in the survey (5 men and 6 women) had mean age of 49.7 for men and 55.5 for women. Patients underwent laser therapy for 8 to 25 sessions that lasted 6 months up to 3 years. All patients after finishing their own specific therapy periods were discharged from hospital with a dramatic change in their health condition and utter removal of their obstructive symptoms. No complication was detected during one-year follow up period. This trial reveals that Nd -YAG laser treatment provides an excellent method of resuscitating patients with life threatening tracheal obstruction and enables symptomatic treatment. Besides achieving good results and avoiding an operation and its probable complications, Nd -YAG laser can be introduced as a practical and safe tool for improving the health condition and quality of life during the rest of life in such patients.

Different effects of nitrogen mustard-containing chemical weopons on respiratory, hematologic and gastrointestinal systems, skin, eyes, and also their mutagenic and teratogenic effects have been reported, but effects on endocrine system had not been recognized until 15 years ago. Although it was known that similar substances used as chemotherpeutic agents can stop spermatogenesis and cause ovarian failure, these effects are seen in the course of continuous use and cannot be extended to chemical weoponry. During Iran-Iraq war, Endocrine Research Center, for the first time in the world, conducted extensive research to identify effects of chemical weapons. During the first week after contact with these substances, serum levels of thyroid hormones decrease and reverse T3 increases. T4 and FT4I increase 3 weeks after the exposure, but T3 and FT3I levels are still depressed in the fifth week. TSH level is not importantly affected. These changes are not present in soldiers exposed to nerve gases. Changes in thyroid hormones resemble severe burns and are due to pituitary-thyroid axis hypofunction and decreased periphereal conversion of T4 to T3. Serum cortisol and ACTH tend to increase one week after the injury ACTH continues to rise until the fifth week, but cortisol decreases gradually, dropping remarkably in the 5th week. Thus, at the beginning the strong stress brings about a rise in plasma cortisol and ACTH, but 3-5 weeks following the exposure, nitrogen mustard exerts direct effects on the adrenal gland. During the first weeks, total and free testosterone, and dehydroepiandrosterone fall dramatically. Serum levels of LH and FSH are normal, but they respond inadequately to GnRH. In the third week LH, and in the fifth FSH and prolactin rise and reach normal levels after 12 weeks. Sperm count shows remarkable decrease in most victims of nitrogen mustard in the years following injury. Testicular biopsies showed complete or relative cessation of spermatogenesis. On the whole, effects of nitrogen mustard-containing weaponry during the first weeks are due to stress and resemble burns. On the other hand, these substances have direct effects on DNA replication in cells, with negative effects on spermatogenesis, which can last for many years. It is recommended that hormone activities of chemical weaponry victims, especially testicular function and spermatogenesis, should be monitored for some years after exposure.