Journal of Research in Medical Sciences
Volume:16 Issue: 12, Dec 2011

Apolipoprotein E (ApoE) gene encodes an important protein in reforming injuries of central nervous system (CNS). It is assumed that various ApoE alleles may be functionally different. The purpose of this study was to investigate the distribution of ApoE genotypes in multiple sclerosis (MS) patients in a small cohort of Iranians. In this case-control study, blood samples of patients and healthy volunteers were collected (n = 40) from Neurology Clinic of Alzahra Medical Complex. The ApoE genotypes were determined using DNA extracted from the samples by polymerase chain reaction (PCR) techniques followed by digestion with HhaI restriction enzyme. The results were adjusted for age of MS onset, sex, expanded disability status scale (EDSS), and type of MS (primary or secondary progressive). Results were statistically analyzed using chi-square test. The ApoE3/E3 genotype was detected in the majority of MS patients and the control group. Frequency distribution of E4 allele did not differ significantly between the two groups. There was no difference between ApoE allele and age of disease onset, sex, EDSS or type of MS. We found no significant differences in genotype frequency between MS patients and the control group. Despite the fact that small sample size was a limitation for our study, it seems that ApoE polymorphism may not be useful as a marker for screening MS patients.

In this study, we aimed to investigate the possible effects of sertraline on blood glucose and lipid levels as risk factors for cardiovascular disease in depressive patients. Eight male and twelve female depressive patients, diagnosed according to DSM-IV criteria, were included in this study. The subjects aged 19-50 years, did not smoke, and had normal body mass index (BMI), homeostasis model assessment-estimated insulin resistance (HOMA-IR) values, blood pressure, blood glucose, insulin and lipid levels. Sertraline therapy (50 mg/day) was started. Patients with diabetes mellitus, heart disease, pregnancy, and those taking other drugs were excluded from the study. Blood glucose, insulin, high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), and triglyceride values were measured in patients before, and at the 4th, 8th and 12th weeks after treatment with sertraline. Moreover, HbA1C levels were measured at the beginning and at the end of the treatment (at 12th weeks). There were no significant differences in physical examination (blood pressure, BMI, body weight, height, waist circumference) and laboratory findings (glucose, HDL-C, LDL-C, HOMA-IR and HbA1C levels) at the 12th week after of treatment with sertraline compared to pretreatment values. However, insulin levels at the 4th, 8th and 12th weeks significantly increased compared with pretreatment values. Likewise, triglyceride levels at the 8th and 12th weeks significantly increased compared with pretreatment values. Sertraline-treated patients have to be followed up for blood insulin and triglyceride levels. In addition, their treatment plan needs to be adjusted as necessary to prevent possible metabolic changes.

An inverse association between serum adiponectin level and metabolic syndrome was seen in few studies. The aim of this study was to assess the association between serum adiponectin levels and metabolic syndrome in a sample of Iranian women from Kerman. In a cross-sectional study 946 subjects were studied to determine the prevalence of metabolic syndrome and in a case control study (170 subjects for each group) the association between serum adiponectin levels and metabolic syndrome were investigated. Metabolic syndrome was defined using International Diabetes Federation (IDF) criteria. Socio-demographics factors and measures of waist circumference, blood pressure and lipid profiles were collected. Serum adiponectin level was measured by ELISA method. The prevalence of the metabolic syndrome was 36.7%. Mean of serum adiponectin level in individuals with metabolic syndrome was lower than individuals without it (10.5 ± 4.1 and 13.45 ± 5.6 µg/ml, respectively, p < 0.001). Low level of adiponectin was a good predictor for metabolic syndrome (a range of β coefficients out of -2.03 to -2.85 according to five models). Systolic blood pressure, body mass index (BMI) and diastolic blood pressure were independent predictors of serum adiponectin (p values were 0.001, 0.009 and 0.034, respectively). We found that adiponectin is negatively associated with metabolic syndrome. Systolic and diastolic blood pressure and BMI were identified as independent predictors.

This study was conducted to evaluate the effects of consuming thermally oxidized oil supplemented with pectin on liver glutathione peroxidase activity, serum malondialdehyde and lipid profiles in male Sprague-Dawley rats. Fifty growing male Sprague-Dawley rats were randomly divided into different groups. The diets differed only in their fat and pectin content. The diets had fresh sunflower oil or thermally oxidized sunflower oil. The diets were supplemented with pectin in the amount of 50 g/kg diet or not supplemented. Thus, there were four experimental groups: "fresh oil", "oxidized oil", "fresh oil + pectin", "oxidized oil + pectin". Study duration was 42 days. Non parametric, Kruskal-Wallis and Mann-Whitney tests were used to evaluate mean values of variables in groups. Following oxidized oil consumption, peroxide, p- Anisidine, thiobarbituric acid, free fatty acid values and total polar compounds increased but iodine value was decreased. In the oxidized oil group compared to the fresh oil group, total cholesterol, high density lipoprotein cholesterol and malondialdehyde increased (p < 0.05). Serum malondialdehyde was decreased in the “oxidized oil + pectin” group compared to the oxidized oil alone (2.82 ± 0.51 vs. 3.61 ± 0.72 nmol/ml; p < 0.05). Total cholesterol decreased in both groups containing pectin compared to their respective diets without supplementation (70.10 ± 10.75 vs. 81.20 ± 13.10 mg/dl; p < 0.05). Pectin consumption could decrease serum malondialdehyde and cholesterol in the diet that contains oxidized oil. Pectin supplementation could decrease the detrimental effects of thermally oxidized oil.

During August 2009, novel H1N1 influenza virus began causing illness in Isfahan. Since rates of hospitalization and mortality due to the disease have varied widely in different countries, we described the clinical, radiologic, and demographic features of H1N1 hospitalized patients in a hospital in Isfahan. This cross-sectional study was conducted in Alzahra Hospital during September 2009 to February 2010. Totally, 216 patients with confirmed, probable, or suspected cases of 2009 influenza A (H1N1) were admitted. Most patients were female (50.5%). Mean age of patients was 26.6 ± 19.5 years. The most common complains on admission were respiratory symptoms (91.6%, n= 198), fever (88.4%, n = 191), myalgia (65.7%, n = 142). In addition, 120 patients (56%) had at least one underlying medical disorder. Thirty-six patients (16.7%) died. Mortality was higher in children under 5 years old (10/36, 10%) and female cases (63.9% of died patients). Predicting variables affecting mortality were intensive care unit (ICU) admission and procalcitonin (PCT). Antiviral treatment was prescribed for 200 (92.5%) of the 216 patients. Based on the findings of the present study, novel H1N1 influenza is highly prevalent among the youth. Moreover, it causes a relatively high morbidity rate. Therefore, people need to be encouraged to have vaccination against 2009 H1N1. Early diagnosis and treatment is related to less admission and shorter duration of hospitalization.

Strength improvement of the shoulder muscles is a major goal in rehabilitation or athletic conditioning programs. The purpose of this study was to determine the effect of shoulder core exercises on the isometric torque of glenohumeral joint movements. A total of 36 healthy females with no history of shoulder injury enrolled in this study. Subjects were randomly assigned into the control group (n = 18, 22 ± 2.19 years of age) or experimental group (n = 18, 21 ± 2.05 years of age). Subjects in experimental group performed shoulder core exercises, using progressive resistance training, three times a week for six weeks. Subjects in control group performed no exercise. The isometric torque of shoulder movements were measured with Dynatorq device in isolated test positions of glenohumeral muscles at the beginning and after six weeks in both groups. Shoulder core exercise training led to an increase in maximal isometric torques of shoulder scaption at 0º and 90º arm elevation, external and internal rotation, horizontal adduction and extension movements (p < 0.001 in all instances). No significant difference was found between initial scores and scores after six weeks in the control group (p > 0.05). These findings indicated that shoulder core exercise training leads to an increase in peak torque for all glenohumeral movements that can be considered in glenohumeral muscles strengthening programs.

Heart failure is a common health problem with poor prognosis. The gold standard for diagnosis is echocardiography but it is not always reachable, especially in emergency conditions. NT-pro-brain natriuretic peptide (NT-proBNP) is a novel indicator for the diagnosis of heart failure and is being used in routine tests in emergency rooms. This study was conducted to compare NT-proBNP levels between hospitalized congestive heart failure (CHF) patients and outpatients. This study was designed as a single-centre, prospective, and controlled trial. Blood samples and data were collected from a total of 119 patients with shortness of breath admitted to Emergency Department, School of Medicine, Marmara University. Patients were primarily diagnosed with decompensated heart failure according to the Framingham criteria and aged above 18 years. A total of 92 patients were included in the study after exclusions. NT-proBNP measurements were made by immune fluorescent method. Available data were compared between hospitalized patients and outpatients. NT-proBNP levels were significantly higher in hospitalized patients compared to outpatients, and this finding was correlated with the clinical status of the patients. The mean NT-proBNP value of the patients was 9741.9 ± 8973 pg/ml (range: 245-35000) while the mean NT-proBNP value of patients diagnosed with non-decompensated CHF was 688.9 ± 284.5 pg/ml (range: 115-1450.65). NT-proBNP can be used as an easy diagnostic method for CHF. A certain cut-off value may be determined in further multi-centre controlled trials with larger patient groups.

Renal transplantation is the treatment of choice for most patients with end stage renal disease. In addition, renal biopsy is the gold standard to assess the causes of renal allograft dysfunction. This study was designed to evaluate and designate renal lesions according to Banff schema. In this cross-sectional study, all renal allograft biopsies obtained from renal transplant patients at Alzahra and Noor referral hospitals in Isfahan during 2006-2008 were studied. Evaluations were made according to the Banff classification 2009. Clinical data was collected from the pathology database and analyzed using SPSS. A total number of 161 subjects were studied out of whom 68% were male and 32% were female. The donor source was living unrelated in 85%, living related 9.9% and cadaveric in 5% of cases. Pathologic results showed 22.4% acute tubular necrosis (ATN), 13.7% interstitial fibrosis and tubular atrophy (IF/TA) grade II, 9.9% IF/TA (Grade III), 6.8% acute T-cell mediated rejection (TCMR-IA), 5.6% TCMR-IB, 5% borderline change, 5% infarction, 4.3% TCMR-IIA, 4.3% TA/IF (Grade I), 3.7% acute antibody-mediated rejection (ABMR), 1.9% (TCMR-IIB) and 17.4% other lesions. The most common causes of graft dysfunction after kidney transplant were IF/TA, no evidence of any specific etiology (NOS) and ATN. Living donors were found to be important sources for kidney transplantation in Iran.

Lichen planus is recognized as an inflammatory disease of the skin with different morphologic patterns. Different treatment modalities, including topical and systemic corticosteroids, methotrexate, cyclosporine, azathioprine, topical calcineurin inhibitors, and psoralen plus UVA (PUVA), have been suggested for lichen planus. Although the efficacy of narrowband UVB (NBUVB) for treatment of lichen planus has been shown, no randomized clinical trial has compared NBUVB versus systemic corticosteroids for treatment of the disease. In the current study, we evaluated the efficacy of NBUVB versus systemic corticosteroids in the treatment of the lichen planus. Forty-six patients with confirmed diagnosis of lichen planus were randomly selected. The subjects were randomized into two groups of 23 to be treated with either systemic corticosteroids or NBUVB. All of the selected cases had generalized lichen planus that involved at least 20% of the body area and their pruritus was resistant to antihistamine drugs. Patients in the systemic corticosteroids group were treated with prednisolon 0.3 mg/kg for 6 weeks. NBUVB was performed three times a week for 6 weeks. The maximum dose of NBUVB was 9 J/cm2. Data regarding demographic characteristics of the patients was also collected. All collected data was analyzed using SPSS15 and statistical tests including analysis of variance (ANOVA), chi-square, and t-test. 46 patients (23 patients in systemic steroid group and 23 patients in NBUVB group) were evaluated. There was a significant difference between the 2 groups regarding the efficacy of the treatment. According to chi-square test, NBUVB was significantly more effective than systemic steroid in treatment of generalized lichen planus (p = 0.008). According to the results, patient satisfaction was also significantly higher in the group treated with NBUVB as compared with the systemic corticosteroids (p = 0.012). Overall, the results of our study and other previous studies showed that NBUVB may be regarded as an effective treatment for generalized cutaneous lichen planus. This treatment may be especially utilized when there is contraindication for systemic corticosteroids or other immunosuppressive drugs.

Routine episiotomy is a controversial issue among gynecologists. The aim of this study was to compare early maternal and neonatal complications of restrictive episiotomy and routine episiotomy in primiparus vaginal delivery. In this descriptive cross-sectional study, two groups of primiparus normal vaginal delivery (NVD) cases with routine and restrictive episiotomy were studied. Immediately and in the first 24 and 48 hours after delivery, specific charts were used to compare the two groups in terms of perineal laceration size, neonatal Apgar score and post-delivery. For data analysis, SPSS was used to conduct student t-test and Kruskal-Wallis test. A p-value < 0.05 was considered significant. Forty primiparus pregnant women were studied in each group. Episiotomy was performed in 7.5% of the restrictive group. Perineal laceration was measured as 3.68 ± 0.47 cm and 1.21 ± 1.1 in routine and restrictive episiotomy groups, respectively (p < 0.05). Intact perineum or first-degree laceration was seen in 80% of the restrictive group. However, second- and third-degree laceration were respectively observed in 75% and 15% of the routine episiotomy group (p < 0.05). Pain relief (immediately, 24 and 48 hours after delivery) was significantly higher in the restrictive group (p < 0.05). On the contrary, no significant differences in Apgar scores at the first and fifth minutes after birth was found between the two groups (p > 0.05). Restrictive episiotomy results in low maternal complications. Therefore, avoiding routine episiotomy in unnecessary conditions would increase the rate of intact perineal and minor perineal trauma and reduce postpartum delivery pain with no adverse effects neither on maternal nor neonatal morbidities.

The aim of this study was to compare the efficacy of azithromycin vs. fluticasone in treatment of adenotonsillar hypertrophy (AH). In a clinical trial, 39 AH patients were selected using convenience time-based sequential sampling method. The subjects were randomized into two treatment groups. Patients in group A (fluticasone) and B (azithromycin) were respectively treated with fluticasone spray and azithromycin suspension for a 6-week period. Data regarding the grade of obstruction (based on tonsillar size), level of adenotonsillar hypertrophy, and obstructive sleep apnoea (OSA) symptoms (including mouth breathing, snoring, hyponasal speech, and sleep apnoea) were collected by a self-administrated questionnaire before treatment, as well as 1 week and 8 weeks after treatment. Twenty AH patients in group A and 19 AH patients in group B were studied. AH related symptoms, including mouth breathing, snoring, hyponasal speech and sleep apnoea, improved significantly in both groups (p < 0.05). We also found a statistically significant reduced grade of obstruction among patients in both groups. However, fluticasone was not effective on adenotonsillar hypertrophy. One week after treatment, outcomes related to apnoea and hyponasal speech were better in group B than group A. Decreases in mouth breathing and snoring were not significantly different between group A and B. Azithromycin seems to be more effective than fluticasone in improving AH-related symptoms.

This study aimed to determine the types of elder abuse, their risk factors and the characteristics of abusers among abused elderly people aged above 60 years in Isfahan. In this descriptive cross-sectional study, abused elderly individuals aged above 60 years that referred to the centers of competent jurisdiction with complaint against a person harassing them were studied during 2008-2009. The demographic profiles of the abused and abusers were collected by physicians who worked in forensic medical centers, using a questionnaire. The type of abuse was classified as physical, emotional, sexual and neglect. The prevalence of physical, emotional and sexual abuse as well as neglect in 68 individuals who were intentionally abused was 100%, 100%, 0% and 11.8%, respectively. Abused subjects were healthy, unemployed and illiterate men and women (similar sex distribution) with moderate monthly income who lived with their families, mainly in cities (p < 0.05). The abusers mainly were healthy and illiterate men, mostly the sons of the abused person, living in cities (p < 0.05). Forty six (67.6%) patients had previous history of abuse, 43 (63.2%) had more than one previous record and in 45 ones (66.2%) the previous abuse was repeated. There was no relation between elder abuse and drug and alcohol abuse (p > 0.05). The findings of this study provided a sense about the probably high prevalence of elder abuse in our community and its related risk factors.

By providing a picture from published articles in a field, bibliometric studies can inform policy-makers in their challenging research funding decisions. In this regard, we applied bibliometric analysis to the Iranian pediatrics articles published in PubMed indexed journals between 1975 and 2007. We evaluated all pediatric articles that had been published from Iran in different PubMed indexed journals from 1975 to 2007. Journal data (i.e. date of publishing, journal name, impact factor of the journal, language), authors data (i.e. number of authors, international collaboration, affiliation of the corresponding author), and paper characteristics [i.e. type of article, research design, study population (neonate, infant, child, and adolescent), and specialty] were registered. During this period of time, 819 articles from Iran had been published in PubMed indexed journals, with a sharp increasing trend after 2002. Impact factors were up to 25.8. Paper had an international co-author in 13.7%. Regarding study population, 24.1% of studies were published on neonates, 23.6% on infants, and the remaining 66.3% of studies were performed on children and adolescents from 2 to 18 years old. Infectious disease was the most frequent area of research, followed by public health and metabolic disease. Original articles were the most frequent type (89.7%) of the published articles. Study design was cross-sectional in 51.2%, retrospective in 36.3%, and prospective in 11.6%. Clinical trials made up 4.8% of the total papers. Contribution of Iran in production of pediatrics science is showing a sharp increase after 2002, this pattern is in parallel with other research fields.

Acylated ghrelin, biologically active form of ghrelin, activates growth hormone (GH) secretagogue receptor 1a and play a role in regulating of energy balance. The purpose of this study was to survey relationships between acylated ghrelin with GH, insulin resistance, lipid profile, and cardio respiratory function in lean and obese men. Nineteen obese men (body mass index 31.0 ± 3.5 kg/m2, aged 27.5 ± 5.8 year) and the same number of lean men (body mass index = 18.47 ± 2.1 kg/m2, aged 26.9 ± 5.6 year) were selected if they had no experience of regular physical activity during six month ago. After 12 hour fasting, blood samples were collected and blood parameters as well as maximal oxygen uptake (as indicator of cardiorespiratory function) was assessed. Insulin levels and HOMA-IR (insulin resistance index) were higher, and GH, acylated ghrelin and maximal oxygen uptake levels were lower, in obese versus lean men (p < 0.01). No significant differences were observed in systolic and diastolic blood pressure, fasting blood glucose, and lipid profiles between the two groups (p > 0.01). Plasma acylated ghrelin concentrations in obese and lean men were negatively correlated to body weight (r= -0.50, r= -0.43, respectively), body fat percent (r = -0.53, r = -0.44, respectively), body mass index (r = -0.53, r = -0.49, respectively), insulin (r = -0.42, r = -0.40, respectively) and HOMA-IR (r = -0.48, r = -0.45, respectively), and positively correlated to GH levels (r = 0.37, r = 0.31, respectively) and maximal oxygen uptake (r = 0.33, r = 0.31, respectively) (p < 0.01). No significant correlations were observed between plasma acylated ghrelin concentrations and systolic and diastolic blood pressure, fasting blood glucose, and lipid profiles in both groups (p > 0.01). Obese and lean inactive young men had different levels of acylated ghrelin, GH, insulin, insulin resistance index, cardiorespiratory function and body fat percent. Body fat percent, insulin, and GH levels appear to be best determinant factors of acylated ghrelin levels. Also, in both obese and lean young men, higher levels of cardiovascular function were associated with higher levels of acylated ghrelin.

Interferon-β (IFN-β) is an effective drug in multiple sclerosis (MS) but it may cause acute exacerbation of MS following the initiation of treatment. This study evaluated patients with rapid exacerbation of MS (REMS) following the initiation of IFN-β. We retrospectively reviewed the clinical records of 2350 MS patients who started treatment with IFN-β and were registered with Isfahan MS Society (IMSS). Patients with REMS within 24 hours after initiation of IFN-β treatment were selected and their demographic and clinical data were extracted. We identified nine patients with REMS following the initiation of IFN-β. Their mean age at the time of treatment with IFN-β was 37.3 ± 6.28 years. Seven patients had REMS after initiation of IFN-β 1a and two patients after IFN-β 1b. The course of disease in all of these patients was relapsing-remitting. However, all had converted into secondary progression within the first year after occurrence of REMS following the initiation of IFN-β. This study may indicate that the effects of IFN-β are not purely anti-inflammatory and a small percentage of MS patients experience REMS following the initiation of IFN-β. Future studies are needed to validate our findings.

Takayasu's arteritis (TA), also known as pulseless disease or occlusive thromboaortopathy, is a form of vasculitis of unknown cause that chiefly affects the aorta and its major branches, most frequently in young women. We describe an 18-year-old female with a soft and pulsatile mass in the left side of her neck.

The growing interest in filler injection requires a more comprehensive knowledge about the complications of this procedure. A total of 5 cases with debilitating chronic complications following filler injection who were referred to Al-Zahra hospital, Isfahan are presented in this report. The outcome of treatment for two of the cases was satisfactory. In one case the treatment led to failure. A case committed suicide, the remaining case had received vitamin E injection which caused severe necrosis and scaring. All fillers are considered foreign bodies and may provoke the immune system to varying degrees. Most complications are, however, caused by the technique of injection not the filler itself. Experience of physicians along with adequate knowledge about fillers and their complications can definitely guarantee a better outcome.

Cushing syndrome is one of the diseases associated with adrenals secreting too much cortisol. The syndrome was first described by Harvey Cushing in 1932.1 It can be caused either by a tumor originating from the corticotroph cells located in pituitary glands, called corticotroph adenoma, or primary adrenal hyperplasia. It can be also the consequence of some other rare conditions such as ectopic corticotropin-releasing hormone (CRH) causing increased adrenocorticotropic (ACTH) secretion and macronodular adrenal hyperplasia (a primary pigmented nodular adrenal disease).2,3 To manage the situation, previous articles demonstrated some strategies including two main groups of surgical treatments and non-surgical procedures.Surgical interventions are very important to completely cure this condition. Pituitary surgery, referred to as transsphenoidal operation, is the treatment of choice for patients with secondary disease.2 However, in some situations, e.g. in patients with recurrent or persistent Cushing syndrome and those not responding to medical therapies after the surgery, the effectiveness of pituitary surgery is under question. Such patients are the best candidates for bilateral adrenalectomy. Some previous articles outlined this method.4 Laparoscopy is one of the methods recently used for adrenalectomy. During the surgery, some complications may occur which deteriorates patient's condition with noticeable rates of 9.5 to 12%. These complications are bleeding, organ damages, pain and deep vein thrombosis.7,8Although in recent years the experts have achieved great improvements in management and treatment of the patients suffering from Cushing syndrome, some controversies still exist. In this manuscript, we explained a new method to accomplish a reliable bilateral adrenalectomy to manage the disease and cure the condition completely.After opening the abdomen, left adrenal gland is determined and adjacent vessels are ligated. Then, the enlarged adrenal gland would be entirely removed. However, adrenalectomy at the right side is not as simple as the left side. Renal vein detachment from the inferior vena cava can be a serious complication of right adrenalectomy if it is performed without enough exposure and experience. Massive bleeding in such clinical setting may significantly compromise patient's outcome. To avoid this complication during the procedure we can perform a new method explained below.Access to the right gland cannot be obtained by conventional retraction of the liver and it is necessary to mobilize the right hepatic lobe by fully incising the falciform ligament, the right triangular ligament, and rotating the right lobe medially. In this procedure, the bare area of the liver is dissected from the diaphragm. Care must be taken to avoid twisting and occluding the vena cava during this maneuver. After medial rotation of the liver in the proper position, the right adrenal and inferior vena cava can be directly visualized. This excellent exposure makes adrenalectomy very simple and minimizes the risk for renal vein detachment as a significant complication.This method was conducted on 6 cases admitted due to Cushing syndrome in Alzahra Hospital, Isfahan, Iran. While no major complications were observed, favorable outcomes were found in the 6-month follow-up period.Based on our experience, bilateral adrenalectomy via a midline incision is a promising and acceptable technique for patients with Cushing syndrome. However, due to excess adipose tissue and lack of enough exposure, adrenalectomy by lumbotomy in such patients has prominent limitations. Therefore, midline incision provides feasible exposure for direct visualization of both adrenals.

Cushing syndrome is one of the diseases associated with adrenals secreting too much cortisol. The syndrome was first described by Harvey Cushing in 1932.1 It can be caused either by a tumor originating from the corticotroph cells located in pituitary glands, called corticotroph adenoma, or primary adrenal hyperplasia. It can be also the consequence of some other rare conditions such as ectopic corticotropin-releasing hormone (CRH) causing increased adrenocorticotropic (ACTH) secretion and macronodular adrenal hyperplasia (a primary pigmented nodular adrenal disease).2,3 To manage the situation, previous articles demonstrated some strategies including two main groups of surgical treatments and non-surgical procedures.Surgical interventions are very important to completely cure this condition. Pituitary surgery, referred to as transsphenoidal operation, is the treatment of choice for patients with secondary disease.2 However, in some situations, e.g. in patients with recurrent or persistent Cushing syndrome and those not responding to medical therapies after the surgery, the effectiveness of pituitary surgery is under question. Such patients are the best candidates for bilateral adrenalectomy. Some previous articles outlined this method.4 Laparoscopy is one of the methods recently used for adrenalectomy. During the surgery, some complications may occur which deteriorates patient's condition with noticeable rates of 9.5 to 12%. These complications are bleeding, organ damages, pain and deep vein thrombosis.7,8Although in recent years the experts have achieved great improvements in management and treatment of the patients suffering from Cushing syndrome, some controversies still exist. In this manuscript, we explained a new method to accomplish a reliable bilateral adrenalectomy to manage the disease and cure the condition completely.After opening the abdomen, left adrenal gland is determined and adjacent vessels are ligated. Then, the enlarged adrenal gland would be entirely removed. However, adrenalectomy at the right side is not as simple as the left side. Renal vein detachment from the inferior vena cava can be a serious complication of right adrenalectomy if it is performed without enough exposure and experience. Massive bleeding in such clinical setting may significantly compromise patient's outcome. To avoid this complication during the procedure we can perform a new method explained below.Access to the right gland cannot be obtained by conventional retraction of the liver and it is necessary to mobilize the right hepatic lobe by fully incising the falciform ligament, the right triangular ligament, and rotating the right lobe medially. In this procedure, the bare area of the liver is dissected from the diaphragm. Care must be taken to avoid twisting and occluding the vena cava during this maneuver. After medial rotation of the liver in the proper position, the right adrenal and inferior vena cava can be directly visualized. This excellent exposure makes adrenalectomy very simple and minimizes the risk for renal vein detachment as a significant complication.This method was conducted on 6 cases admitted due to Cushing syndrome in Alzahra Hospital, Isfahan, Iran. While no major complications were observed, favorable outcomes were found in the 6-month follow-up period.Based on our experience, bilateral adrenalectomy via a midline incision is a promising and acceptable technique for patients with Cushing syndrome. However, due to excess adipose tissue and lack of enough exposure, adrenalectomy by lumbotomy in such patients has prominent limitations. Therefore, midline incision provides feasible exposure for direct visualization of both adrenals.

We read with great interest the article by Minakari et al. regarding the effects of treatment with subcutaneous octreotide and oral midodrine in cirrhotic patients with ascites who continued to receive their standard diuretic treatment1 and we would like to comment on their results.First, the administration of midodrine for 3 days caused a non-significant increase in mean arterial pressure (MAP). In this respect, we have recently described a delay in the improvement of systemic hemodynamics after the initiation of midodrine in nonazotemic cirrhotic patients with ascites.2 Nevertheless, midodrine caused a significant decrease in plasma renin activity (PRA), which together with the significant increase in glomerular filtration rate (GFR), strongly indicate a marked increase in systemic vascular resistance possibly due to a concomitant significant decrease in cardiac output. Moreover, it can be suggested that midodrine-induced systemic hemodynamic improvement enhanced the natriuretic response to diuretic treatment3 as shown by a remarkable mean weight decrease of 3.65 kg at the end of the study.On the other hand, octreotide induced a significant reduction in PRA, an increase in MAP and GFR, although not significant, and a mean weight decrease of 2.23 kg, which was possibly resulted from increased diuresis. Overall, these results indicate beneficial effects of octreotide on systemic hemodynamics and renal function considering that treatment duration was only 3 days. However, we and other investigators have previously shown that multiple-dose treatment with subcutaneous octreotide alone impairs systemic hemodynamics and renal function in cirrhotic patients with ascites despite a significant decrease in circulating renin and aldosterone levels.4-7 In this regard, several lines of evidence have suggested a direct inhibitory effect of both somatostatin and its analogue octreotide on renin production.8-10 Given the questionable splanchnic vasoconstrictive effect of chronic treatment with octreotide alone,4-7 an inappropriate suppression of renin-angiotensin axis could be harmful for systemic hemodynamics and renal perfusion. In contrast, we have shown that the addition of octreotide to diuretic treatment suppresses only the diuretic-related component of the activation of renin-angiotensin axis while its basal stimulation is maintained.4,11 This leads to improvement of systemic hemodynamics,4 possibly due to enhanced activity of the endogenous vasoconstrictors by the decrease in glucagon levels,12 renal function and natriuresis.4 Consequently, the effects of octreotide in the study by Minakari et al. are likely to be attributed to its addition to diuretic treatment and not octreotide per se.In conclusion, the addition of octreotide or midodrine to standard diuretic treatment in cirrhotic patients with ascites deserves further attention.