Tehran University Medical Journal

---

This study was performed in order to improve the knowledge about Craniopharyngioma tumors, and tried to present extensive datas about the signs and symptoms, the clinical process and the treatments and their complications of the patients with Craniopharyngioma, admitted in the hospitals of Tehran university during 15 years (1355-70). Ultimately, these datas have been compared with those in the reputable books and new medical papers And the results are present at the end of the discussion. Undoubtedly, this study is not free of the limitations of retrospective studies. Our patients-contrary to the textbooks are predominantly males And also their most common chief complaints are neurological manifestations, and headache (82%) is the most common one. There is only a little difference in the prevalence of some of the endocrinologic and ophthalmic manifestations between our datas and what in the texts, while, in some others, we can see a great diversity between the 2. For instance, decreased libido in men and amenorrhea in women, among our patients are prominently less than what we study in the books And blood pressure disturbances, sensory and motor symptoms and urinary incontinence have not been seen in our patients. In most cases, CT scan leads to diagnosis and its diagnostic accuracy in 2 times higher than that of the simple radiography and it can show the sella enlargement obviously. In a majority of cases (More than 95%), excision a part of the tumor (From just limited to the biopsy area to 90% of tumor mass) was the only therapeutic measure. In only a few patients, tumor excision was followed by radiotherapy, that showed the better results. The most common delayed complication was the recurrence of the disease.

---

Pseudomembrane colitis (PMC) and antibiotic associated colitis (AAC) are acute disease of the colon. In the case of in adequate treatment, the disease will often become chronic and my lead to the dysplasia of the epithelial cells of the infected areas. Previously because of poor knowledge. Treatment in this case, one of the method for treatment was surgical ablation of the large intestine while the patients could have been treated with oral vancomycin. In this study the following results were obtained: Out of 2517 enterocolitis patients under study, 1384 were men and 1133 women. By anaerobic culture method, 132 cases C.Difficile were isolated from the total samples and Hela cell culture method, toxin was determined in 36 samples (1.43%).

---

Nelson's syndrome is usually characterized by hyperpigmentation, elevated level of ACTH, and pituitary adenoma, which is frequently available as macroadenoma. It is usually occurred in the patients suffering from Cushing's syndrome. Growth of tumor has been revealed in 10-30% of the patients following adrenalectomy. Tumors are often benign in Nelson's syndrome. The selected treatment of Nelson's syndrome are transsphenoidal or transfrontal microsurgery. The role of radiation as prophylactic effect in the patients following adrenalectomy is unknown. In this research Nelson's syndrome have been studied on the patients records who have been hospitalized in Dr.Shariati hospital during the last 10 years. The achieved results show that, among the 49 patients suffering from Cushing syndrome who have referred after operation, 11 patients (22.4%) of them have been affected with Nelson's syndrome. The syndromes have been appeared after 3-9 months and with regard to occurrence of Nelson's syndrome in some patients immediately after bilateral adrenalectomy, it is recommended that selecting of the patients for bilateral adrenalectomy should be studied accurately

---

Some of the endocrinologic diseases, especially Acromegaly, Cushing and Pheochromocytoma have multiple effects on blood glucose metabolism and regulation in non-diabetic patients. In this retrospective survey, records of patients of Tehran Medical Sciences University hospitals have been reviewd. Of 124 Acromegals, GTT was performed for 51 patients, being impaired in 18%. To evaluate diabetes, FBS and BS of 90 patients were checked, overt diabetes was detected in 27%. Among 90 Cushing patients, blood glucose was checked in 60 cases, 47% of these patients had levels above the normal range, and 39% had glucosuria. Among 80 Pheochromocytoma patients, 16 cases (26.5%) had overt diabetes. In comparison with other studied, we have obtained a little different results concerning diabetes and impaired GTT prevalence

---

The lower respiratory tract is vulnerable to infection by a wide variety of microorganisms, because it is one of the organ systems which communicate directly with the environments. Although viruses and fungi can cause lower respiratory tract infections, bacteria are the dominant pathogens. Among bacteria the common causes of lower respiratory tract infection is Streptococcus pneumoniae, Mycoplasma pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, Haemophillus influenzae and Legionella species. This study has been carried out to investigate pathogenic bacteria isolated from sputum of 220 patients with suspected pulmonary infection. The results were obtained as follow: Mycoplasma pneumoniae: 17 cases 22.7 percent, Mycobacterium tuberculosis: - cases - percent, Streptococcus pneumoniae: 17 cases 22.7 percent, Klebsiella pneumoniae: 12 cases 16 percent, Haemophillus influenzae: 10 cases 13.3 percent, Staphylococcus aureus: 15 cases 20 percent, Pseudomonas aeroginosa: 4 cases 5.3 percent.

---

Pheochromocytoma is a rare disease. A retrospective study of the signs and clinical course of this disorder was performed by evaluating medical records. Our fidings indicate that the prevalence of pheochromocytoma was equal in men and women, and most patients (56%) were in their second and third decades of life. In 10% of the cases, the disease was bilateral, and in 13% it was outside the adrenal (totally para-aortic). The tumor was more common on the right side (8%), and 3.5% were familial. Almost all cases had a history of hypertension and hypertensive crises. Attack-like episodes of clinical symptoms and signs and hypertension were observed in 98%, headache in 71% and profuse perspiration in 68% of the cases. An abdominal mass was palapated in 13% of the cases, 26% had overt diabetes, 23% had ECG changes. Malignancy was observed in 4%, with metastases to the liver (n=2) lung (n=1) and spine (n=1). In the latter four cases, the metastic lesion was histologically proven to be pheochromocytoma. In three of the 28 female cases, the first hypertensive crisis occurred during pregnancy causing abortion in one case.

---

Accurate measurement of refractive error in uncooperative patients and young children, requires cycloplegia. The aim of the present study was to determine whethere cyclopentolate by itself or in combination with 4 times instillation of atropine can be used as a substitute for 10 times instillation of atropine. From 1994 to 1996, 39 patients aged 2-12 years were included in this study. Cycloplegia was undertaken by four different methods in subsequent visits: cyclopentolate 1%, 4 times instillation of atropine, 10 times instillation of atropine plus tropicamide and 10 times instillation of atropine. 26 patients (53% male, mean age: 6.4 years) completed the four stages of the study. Spheric refraction was significantly different between cyclopentolate and 4 times and 10 times atropine groups, but we didn't find any significant difference in cylindric refraction between groups. It seems that 10 times instillation of atropine is still the best method of cycloplegia in pediatric eye examination.

---

It is now generally recognized that anaerobic bacteria may be involved in most human bacterial infections that follow any form of surgery or are related to those body sites that have a large anaerobic population. Anaerobes must therefore be sought in a wide variety of clinical specimens. In this study, 3015 specimens of patients (1684 male and 1331 female) with periodontitis (160 cases), abcess (305), sinusitis (33) and enterocolitis (2517) wer investigated. The anaerobic isolates from patients with periodontitis were 244 cases, abscess 32, enterocolitis 42.

---

It is now generally recognized that anaerobic bacteria may be involved in most human bacterial infections that follow any form of surgery or are related to those body sites that have a large anaerobic population. Anaerobes must therefore be sought in a wide variety of clinical specimens. In this study, 3015 specimens of patients (1684 male and 1331 female) with periodontitis (160 cases), abcess (305), sinusitis (33) and enterocolitis (2517) wer investigated. The anaerobic isolates from patients with periodontitis were 244 cases, abscess 32, enterocolitis 42.

---

Informations regarding 152 patients of cancer of tongue in cancer institute from 1978 to 1998 was collected and analyzed. From these cases, 53.3 percent were male with a mean age of 54.49 years (SD=16.23) and the mean age of female was 2.5 years more than of male. Positive lymphadenopathy in men was positive and significantly more than that of female (P<0.05). The physical appearance of the tumor was ulcerative (66.7 percent). Most of the referrals were in the range of T1 (62.8 percent) and were operated. Information from 88 patients was evaluated and it was found that 23.9 percent of the patients has died. One year survival was 92.05 percent and 3 years survival 83.3 percent and it was confirmed that advanced stage of the illness decreases the survival rate (P<0.001).

---

Frozen section is a useful method in the diagnosis of different malignancies including those of thyroid origin. However, there are still controversies about its application, sensitivity and specificity for thyroid neoplasm. In this study, diagnostic value of frozen section (FS) was compared with permanent histopathologic and Fine Needle Aspiration (FNA). In this study, which was conducted in process research method, permanent sample, FNA, and frozen section results in 214 patients was compared. All of these 214 patients had been seeking medical evaluation for thyroid nodules between years 1997 and 1999 in Shariati hospital. All pathologic evaluations were performed by pathology staff of this hospital. Permanent pathology was considered as the gold standard so the specificity, sensitivity and diagnostic precision of FNA and FS were evaluated on the basis of its results. We use Macnemar test for this purpose. The number of patients during this period were 214 (160 women and 54 men). Mean age of our patients was 42.3±5.4 and their age ranged between 12 to 84 years. Pathologic results revealed that 163 of the patients (76 percent) had benign lesions, and 51 of them (24 percent) had malignant lesions. Thyroid malignancies comparised papillary carcinoma (70 percent), follicular carcinoma (13.5 percent), papilofollicular carcinoma (6 percent), medulary carcinoma (6 percent), Hurtle cell carcinoma (4 percent) and anaplastic carcinoma (5 percent). FNA was done in all of the patients before surgery and was able to determine the status of nodules in 150 patients. Sensitivity, specificity and precision of FNA in these 150 patients were 72, 96 and 90 percents respectively. When FNA was unable to determine the status of a nodule (64 remaining patients), FS was applied to do the job. A sensitivity of 36 percent, specificity of 85 percent and precision of 73 percent was found in this group of patients. Macnemar test showed that there is no significant difference between FNA and FS methods. This study showed: when FNA is not conclusive, FS will not bring any further benefit. It seems that only in suspicious cases of papillary, undifferentiated and medulary carcinomas, FS can be useful in certifying the results of FNA and choosing the appropriate surgical plan. We should wait for permanent sample reports in the case of follicular or Hurtle cell carcinoma.

---

Background: Sub clinical hyperthyroidism is a state of subnormal serum TSH and T3,T4 within normal range, although usually without overt clinical manifestation but many disastrous complications especially in senile patient. In Iranian people, serum TSH is generally assayed by IRMA method. This study is aimed to determine the value of low serum TSH in these patients, better management and decision when encountered.

Materials and Methods: The populations under study are guys with serum TSH lower than 0.5mu/l and normal thyroid hormones without known thyroidal and non-thyroidal illness. A basal serum TSH and TSH 30 minutes after TRH injection intra venous were sampled and correlation of clinical signs and symptoms and basal TSH with sub clinical hyperthyroidism was considered.

Results: The population under study was categorized into five groups and prevalence of sub clinical hyperthyroidism was noted. In patients with b.TSH equal or lower than 0.1mu/l, 100%, 0.1-0.2mu/l, 75%, 0.2-0.3mu/l, 38.5%, 0.3-0.4mu/l, 14.3% and TSH levels greater than 0.4mu/l, were all normal. After analyzing of these data and determination of sensitivity and specificity of IRMA, it was concluded that IRMA is not sufficient to distinguish sub clinical hyperthyroidism, although there is a good linear (r=0.68 P<0.001) and cubic (r=0.79 P<0.001) relationship between b.TSH and d.TSH.

Conclusion: Since TRH test is not cost effective for all cases, TSH levels lower than 0.25mu/l, can be considered as sub clinical hyperthyroidism and levels more than 0.4mu/l, as normal. In cases with TSH level between 0.25 and 0.4mu/l, TRH test is needed in high-risk patients.

---

Background: Scleroderma is an important chronic disease with unknown ethiology and two subtypes: limited type: Skin involvement limited to distal of extremity and face. Diffuse type: Skin involvement is both distal and proximal of extremity, face and thrunk. Thyroid dysfunction is a main problem in these patients but there is no published data of Iranian scleroderma patients
Methods: This is a cross-sectional study to determine the prevalence of hypothyroidism (clinical, subclinical and autoimmune) in patients with scleroderma 125 patients with scleroderma selected and T3, T4, TSH Anti Tpo Ab and Anti TG Ab measured in them.
Results: 33 patients with scleroderma had hypothyroidism. (%26/4). Two patients with scleroderma had hyperthyroidism. (%1/6). %12/8 had clinical hypothyroidism. And %13/6 had subclinical hypothyroidism, %33/3 of patients with subclinical hypothyroidism and positive autoantibody had limited type. Where as %66/6 of patients with subclinical hypothyroidism and autoantibody had diffuse type, %28/5 of patients with clinical hypothyroidism and positive auto anti body had limited type. Where as %71/4 of patients with clinical hypothyroidism and auto anti body had diffuse type. All of patients with hyper thyroidism had diffuse type and autoantibody positive.
Conclusion: It seems hypothyroidism has an increased prevalence in patients with scleroderma and we suggest that thyroid function test must be done in primary evaluation of these patients

---

Background: Metabolic syndrome is a complex of metabolic disorders that contemporary occurrence in a person is more than the risk of occurrence of each one separately. this syndrome has gained researcher's attention because of its relationship with cardiovascular disease and diabetes type II and its high prevalence in populations
Methods: A cross-sectional study performed on 1110 participants, 20-74 years old with cluster sampling. All of them had interview and special questionnaire were filled. Epidemiologic and demographic data were about hypertention cardio vascular disease and related lab data.
Results: The prevalence of metabolic syndrome was 32.1% that it was significantly more in women than men .this prevalence increased with age and BMI in both sexes .the most common metabolic disorder was TG>=150. 19.2% have none, 21.1% have one, 27.6% have two, 20.8% have three,9% have four and 2.3% have all criteria of metabolic syndrome.
Conclusion: Approximately one third of population of Yazd have metabolic syndrome and according to other statistics of Iran, this prevalence is more than U.S and Europe. It seems there is an urgent need for a national multicenter program for determinding risk factors for metabolic syndrome.

---

Background: Premature coronary artery disease (CAD) has a familial predisposition and occurrence. We determined the prevalence of CAD and related risk factors in individuals with a history of premature CAD in their first-degree relatives.
Methods: This study included 700 healthy individuals with a history of premature CAD in their parents or siblings in Tehran Heart Center in 2003-2004. History of smoking, diabetes mellitus (DM) or hypertension was taken. Fasting levels of blood sugar (FBS), triglycerides (TG), cholesterol, LDL and HDL were measured. Noninvasive studies for CAD were performed with resting echocardiography (ECG) and ECG with exercise tolerance test (ETT). Patients with positive findings for ischemia in these tests underwent a myocardial perfusion scan and if positive proceeded to coronary angiography.
Results: The mean age of our subjects was 35.2 (15-65) years. DM was found in 5.3%, smoking in 14.7%, hypertension in 20.6%, cholesterol above 200 mg/dl in 39.9%, TG above 150 mg/dl in 58.6%, LDL above 130 mg/dl in 38% and HDL below 40 mg/dl in 32.6%. In addition, 6.4% had ECG changes and 3% echocardiographic abnormalities in favor of ischemia. ETT was positive in 7.3% and myocardial perfusion scan in 2.1%. Coronary angiography showed 50-70% stenosis in eight patients (1.1%) and >70% in four patients (0.6%).
Conclusion: High cholesterol, TG and LDL and low HDL were found among our subjects. Risk factor determination in these individuals may prove to be beneficial. Noninvasive tests for CAD yield low true-positive results and are not recommended in the population as a whole. In certain subgroups, including those with persons older than 40 years and diabetic patients, these tests may be useful.

---

Background: Anxiety is a complex phenomenon with important results. In fact anxiety is a biologic process that has repetitive biological and physiological effect on the biological structure of brine. From long time ago anxiety and fear has bean one of the important psychological issues and for the control of anxiety different drugs with different mechanisms have been presented and understanding mechanisms that are involved lead us to newer drugs discovery. In this research the effect of morphine on the anxiety in the adult Male rats in the Ventral Tegmental area (VTA) and Nucleus Accumbens (NAc) was studied.

Methods: The elevated plus maze was used in combination with the percentage of time spent in the open arms of the maze (OAT %) and the percentage of entries into the open arms (OAE %) to measure anxiety. Increases in the OAT% and OAE% indicate an anxiolytic effect (reduction in anxiety), whereas decreases in the OAE% and OAT% indicate an anxiogenic effect. Adult male rats, weighing 200-240 grams, underwent surgery. After five days, the rats were injected with saline and three different doses of morphine (2.5, 5, and 7.5 µl/rat). Experiment one included the injections into the VTA. In the second experiment, these injections were in the NAc. Behavioral tests were conducted between 12 pm and 4 pm and each animal was used once for each experiment.

Results: In the first experiment, although these doses of morphine injected into the TVA had no effect on the OAE%, a dose of 5µl/rat increased the OAT%, showing a decrease in the animals' anxiety. In the second experiment, doses of 2.5µl/rat injected into the NAc induced a significant increase in the OAT% and OAE%, there by displaying decreased anxiety in the animal. However, no significant change in the activity of the animals was observed.

Conclusion: As a Result of these experiments, it seems that different doses of morphine can decrease anxiety, probably through interaction with gabaergic system.

---

Background: An outlier is an observation that lies an abnormal distance from other values in a random sample from a population. Outliers sometimes deal with to abnormality in obtained results from collected data and information. known outlier data by researchers, physicians and other persons that work in medical fields and sciences is important and they must control data before getting result about outlier data, effect of them in information bias and how to remove & control to obtain minimum bias and exact data .in this paper we had trying by known technique and tests to control them and minimized the errors related to them.
Methods: This paper has been done on 30 student's height in Tarbiat Modares University that measured by meter in smoothing area. We applied some methods such as Z-test, Grub test and graphical methods to determine outliers. In this paper the advantage and disadvantage of methods were evaluated and finally compares with each other.
Results: The above tests showed that the data values 153, 110 among collected data were outliers. All of the methods showed that the above data were outliers. Calculation quartiles and intermediate quartiles showed that the observations under 125 and upper 141 were mind outliers and if the observation under 119 and upper 147 is the sever outliers. According to upper situations the amounts of 110 and 153 is the sever outliers and resulted from all methods.
Conclusion: The results showed that all methods were useful in determine outlier data and between them Quartiles were important to known severe and mild outliers. Also Grub test with p-Value is very useful to report outliers.

---

Background: Several randomized controlled trials have demonstrated the safety and efficacy of drug eluting stents (DES) in selected groups of patients with less complicated diabetes. We conducted this study to determine how an unselected group of diabetic patients in Iran fare following DES implantation.

Methods: Data were collected on 147 consecutive diabetic patients who underwent percutaneous coronary intervention (PCI) with the implantation of at least one DES at the Tehran Heart Center from June 2003 to September 2005. Clinical follow-up was performed by timely scheduled visits at one, four and nine months following DES implantation. Nine months of follow-up was completed for 94.5% of the patients. The primary endpoint was the occurrence of major adverse cardiac events (MACE), which include cardiac death, myocardial infarction and target vessel revascularization (TVR). In-hospital complications were the secondary endpoint.

Results: A total of 158 coronary artery lesions were treated with DES in 147 diabetic patients (mean age = 56.4±8.92 years, 57.1% were men). During the nine-month follow-up, MACE occurred in 3.4% of patients, with a myocardial infarction rate of 1.4% and TVR rate of 1.4%. Considering one patient who underwent TVR due to acute stent thrombosis following angioplasty (during hospitalization) the total number of TVR reached 3 (2%). Only one patient (0.7%) died of cardiac death, which occurred after the procedure and before discharge. In-hospital complications occurred in six patients (4.1%) five patients suffered from myocardial infarction.

Conclusions: PCI with DES seems to be safe and effective in diabetic patients. However, more studies with larger study populations and longer follow-up are required to confirm this issue.

---

Background: Radiation to some parts of the heart is unavoidable in the therapeutic course of primary tumors in many kinds of cancer, including breast cancer. The aim of this study was to assess the frequency of acute and subacute cardiac complications following radiotherapy in patients with left breast cancer.
Methods: In this study, we enrolled 53 patients with left breast cancer who underwent mastectomy or lumpectomy between September 2005 and September 2006 in Imam Khomeini Hospital Complex, and subsequently underwent chemotherapy with anthracyclines (<450mg/m²) and Endoxan plus taxane/fFluorouracil followed by radiotherapy. In all patients, electrocardiography and echocardiography were performed before initiation of radiotherapy, immediately after radiotherapy and again three and six months later to check for radiotherapy-induced cardiac complications such as pericardial effusion, valvular lesions, left ventricular dysfunction, conduction system disturbances and other variables.
Results: Thirty-nine patients completed the follow-up period. Among these, 10 (25.6%) patients experienced cardiac complications following radiotherapy. Among these, mild pericardial effusion in seven (53.85%) patients, mild mitral regurgitation in three cases (23.08%) and Right Bundle Branch Block (RBBB) in two cases (15.38%) were the most common complications. We found no correlation between cardiac complication and tumor dose, dose fraction and type of chemotherapy protocol. We noted no cases of new or more serious complications, such as cardiomyopathies or coronary artery disease, nor any changes in ejection fraction by the end of the follow-up period.

Conclusion: In patients with left breast cancer, acute and subacute cardiac complications following radiotherapy are not serious and have no clinical significance. Further studies are needed for more assessments in this area.

---

Background: There are several evidences that genetic factors besides environmental triggers have important role in initiating the rheumatoid arthritis (RA). The aim of this study was to investigate the association of rheumatoid arthritis with different subtypes of HLA DR4 in Iranian patients.

Methods: In an un-matched case control study, 110 rheumatoid arthritis patients (case) and 56 knee osteoarthritis patients (control) of outpatient clinic in Shariati Hospital were entered to the study. After blood sampling from case and control groups, DNA was isolated by using salting-out method and HLA DR4 and its subtypes were detected. Association of HLA DR4 and its subtypes with rheumatoid arthritis, rheumatic factor and clinical manifestations of diseases was evaluated.

Results: Eighty nine (80.9%) of rheumatoid arthritis patients were female and 21 were male. Thirty four of the RA patients (30.9%) and eleven subjects from the control group (19.6%) were HLA DR4 positive (p=0.12). The most frequent subtype of HLA DR4 in RA patients was 0404 and in control group was 0401 (p=0.03). There were not statistically significant association between HLA DR4 and age of disease onset, family history, morning stiffness and rheumatoid factor. Joint swelling and tenderness had association with HLA DR4 (p=0.04 and p=0.03).

Conclusion: Although there were no statistically significant association between rheumatoid arthritis and HLA DR4, but prevalence of this HLA was higher in patients than control. It is possible that in some ethnics, other HLAs may have role in pathogenesis of disease.