Tehran University Medical Journal

---

Background: Headache is one of the most common problems that bring patients to doctors' offices. Many physicians order neuroimaging studies after taking the history of the patient and performing a physical examination. These neuroimaging studies are often requested due to the probable existence of an intracranial lesion. However, at times they are requested to allay the fears of patients or even doctors. Most of these studies are normal and the question arises whether there is any indication for requesting neuroimaging studies for a patient with an isolated headache.

Methods: We studied 146 patients with headache who had been referred for CT scan to the imaging center of Imam Khomeini Hospital during 2004-2005. For each patient, a questionnaire, including the medical history and accompanying neurological symptoms, was filled out and CT scan results were gathered.

Results: The mean of age of the patients was 37.8 years, and 69% were female. Only 10 patients (6.8%) had a brain lesion in the CT scan. Accompanying neurological symptoms were more frequent in patients with abnormal rather than normal CT scans. There was a meaningful correlation between abnormal CT scan and paresthesia, ptosis, paresia, diplopia, visual loss, convulsion, vomiting and vertigo. A statistical correlation existed between gender and positive CT scan.

Conclusions: Many patients with headache have normal brain CT scan results. Thus, better criteria are warranted for requesting neuroimaging including accurate patient history and neurological examination in order to prevent unnecessary radiation exposure. MRI instead of CT scan would be a better first step toward the evaluation of the possible existence of brain lesions.

---

Background : Septic Arthritis is an acute infection of intra-arthicular space. Delay in diagnosis and in appropriate treatment may lead to prolongation of treatment duration and poor outcome. We decided to evaluate clinical aspects of this disease in our department pediatric department, Imam Khomeini Hospital complex, Tehran, Iran during a 10 years period.

Methods : In a retrospective cross-sectional study, 60 patients with age from 1 month to 14 year-old during 1996-2005 were evaluated. The demographics characteristics, clinical observations (signs & symptoms) and paraclinic values were gathered from medical records and analyzed with statistical tests.

Results : Pain and Swelling was seen in all, joint limited motion in 80% ( 50 cases) claudicating in 64% ( 38 cases), fever in 80% ( 48 cases), monoarticular disease in 80% ( 48 cases) and polyarticular one in 20% ( 12 cases) of them. Hip was most Common involved joint 62% ( 37 cases), elevated ESR was seen in all patients. CRP was positive in 85% ( 51 cases). Leuckocytosis was found in 65/8% ( 17 cases) of cases. In infectious cases, Staphylococcus aurous was responsible organism in 65.6% ( 16 cases), klebsiella in 12.4% ( 3 cases), Streptococcus pneumonia in 12.3% ( 3 cases), group b streptococcus in 4.1% ( 1 case), Hemophilus Influenza type b in 4.1% ( 1 case) of study patients. With therapy ESR was normalized in 64% ( 39 cases) and CRP was normalized in all patients.

Conclusions: In general, all children with complaint of fever, pain, and limited joint motion or claudicating should be suspected for septic arthritis.

---

Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Multiple myeloma is a plasma cell dyscrasia characterized by proliferation of plasma cells in bone marrow associated with the production of monoclonal immunoglobulins. In recent years, the use of arsenic trioxide, formerly approved for treatment of acute promyelocytic leukemia has been considered for refractory myeloma treatment. This study was designed and carried out to evaluate the efficacy and possible side effects of ATO on patients with refractory multiple myeloma.

Methods: This study carried out on myeloma patients whose diseases were at least refractory to two standard treatment regimens conducted in Ghazi Tabatabaei Hospital in Tabriz- Iran. Arsenic trioxide was administered as an intravenous infusion at a dose of 0.25 mg/kg/d for 5 d/week during the first two consecutive weeks of each 4-week cycle with two week rest. Patients who completed one 4-weak cycle were evaluated for response to treatment.

Results: Twelve patients with refractory disease to conventional treatment regimens received arsenic trioxide. The response to the treatment assessed based on the amount of serum proteins electrophoresis of the 10 patients. Stable disease observed in four patients (33%), progressive disease in five patients (41.6%), complete response in one (3.8%) and the remaning two patients could not be assessed for response (because of increased liver enzymes after the first week). One patient completed six cycles. Some adverse events such as: increase liver enzymes and serum creatinine, neutropenia, pruritus, nausea, vomiting, lower extremities edema, and noninfectious diarrhea were observed.

Conclusions: The use of arsenic trioxide is promising in treatment of refractory multiple myeloma.

---

Background: Atherosclerotic vascular disease is a major cause of morbidity and mortality in patients with end-stage renal diseases on maintenance hemodialysis. Early atherosclerotic changes of the arterial wall can be evaluated by measuring intima-media thickness (IMT), and looking for the presence and structure of plaques and parameters of vascular resistance. In this study we investigated the relationship between carotid IMT and pulsatility index (PI) or resistive index (RI) values in hemodialysis patients.

Methods: Sixty hemodialysis patients (27 females and 33 males median age 41.7 years) and 60 healthy volunteers (32 females and 28 males, median age 37.8 years) underwent ultrasonography of common carotid artery for the determination of IMT, PI and RI.

Results: Bilateral IMT was significantly higher in hemodialysis patients than in control group (P<0.001). Left carotid artery RI and PI were found to be significantly higher in hemodialysis patients than in the controls (P<0.001). Right carotid artery RI and PI had no significant statistical differences between the two groups (P=0.18 and P=0.78, respectively). There was a moderately significant negative correlation between the left carotid IMT and left RI and PI in the controls (r= -0.42, P=0.001 and r=- 0.43, P<0.001, respectively).

Conclusion: PI and RI values of the left coronary artery increased as did IMT in hemodialysis patients. Therefore, measurement of RI and PI values together with IMT are recommended for early diagnosis of atherosclerosis in hemodialysis patient.

---

Background : Chemotherapy-induced nausea (CIN) in the anticipatory and acute phase is the most common side effect in cancer therapy. The purpose of this study was to investigate the effect of ginger capsules on the alleviation of this problem.

Methods : This randomized, double-blind, placebo-controlled clinical trial was performed on 80 women with breast cancer between August till December 2009 in Imam Khomeini Hospital, Tehran, Iran. These patients underwent one-day chemotherapy regime and suffering from chemotherapy-induced nausea. After obtaining written consent, samples were randomly assigned into intervention and control groups. Two groups were matched based on the age and emetic effects of chemotherapy drugs used. The intervention group received ginger capsules (250 mg, orally) four times a day (1 gr/d) and the same samples from the placebo group received starch capsules (250 mg, orally) for three days before to three days after chemotherapy. To measure the effect of capsules a three-part questionnaire was used, so the samples filled every night out these tools. After collecting the information, the gathered data were analyzed by statistical tests like Fisher’s exact, Kruskal-Wallis and Chi-square using version 8 of STATA software.

Results : The mean ± SD of age in the intervention and placebo groups were 41.8 ± 8.4 and 45.1 ± 10 years, respectively. Results indicated that the severity and number of nausea in the anticipatory phase were significantly lower in the ginger group compared with placebo group (P=0.0008, P=0.0007, respectively). Also, the intensity (P=0.0001) and number (P=0.0001) of nausea in the acute phase were significantly lower in the ginger group. On the other hand, taking ginger capsules compared with placebo did not result in any major complications.

Conclusion: Consuming ginger root powder capsules (1 gr/d) from three days before chemotherapy till three days after it in combination with the standard anti-emetic regimen can help to reduce the anticipatory and acute nausea.

---

Background: The aim of this study was to assess the association of serum adiponectin and a set of traditional cardiovascular risk factors with carotid artery intimal-medial thickness (CIMT) and coronary artery calcium score (CACS), as markers of subclinical atherosclerosis in subjects with early type 2 diabetes mellitus.

Methods: Carotid artery intima- media thickness (measured by B-mode ultrsonography), coronary artery calcium score (determined by high resolution computed tomography), serum adiponectin, Fasting blood sugar, serum lipids, body mass index (BMI), systolic blood pressure, diastolic blood pressure and mean arterial pressure were measured in 123 asymptomatic newly diagnosed cases of type 2 diabetes mellituss and 152 age and sex matched healthy control subjects.

Results: Serum adiponectin and lipids were significantly lower in those with type 2 diabetes mellitus (P<0.01). Left, right and mean carotid artery intima- media thickness, coronary artery calcium score, fasting blood sugar, systolic blood pressure, diastolic blood pressure and mean arterial pressure were significantly higher among diabetic patients compared to healthy controls (P<0.05). Mean carotid artery intima- media thickness was positively and independently related to age (P<0.001) and triglyceride (P=0.01) in diabetic group. Coronary artery calcium score was associated positively with age (P=0.004) and inversely with high density lipoprotein (HDL) cholesterol (P=0.002) among diabetics.

Conclusion: Although adiponectin was lower in diabetics compared to controls, it had no significant association with carotid artery intima- media thickness and coronary artery calcium score as markers of subclinical atherosclerosis. In patients with type 2 diabetes in addition to age, serum triglyceride levels are correlated with carotid artery intima- media thickness, while HDL cholesterol is inversely correlated with coronary artery calcium score.

---

Background: Colorectal Cancer (CRC) is the third common cancer in the world. One of the pathways in colorectal tumor genesis is Microsatellite Instability (MSI+). MSI is detected in about 15% of all colorectal cancers. Colorectal tumors with MSI have dis-tinctive features compared with Microsatellite Stable (MSS) tumors. Due to the high percentage of MSI+ in patients with CRC in Iran, screening of this type of CRC is im-perative. In current study, two markers (BAT-26 and BAT-25) were used to determine an appropriate screening technique with high sensitivity and specificity to diagnose MSI status in patients with CRC. Methods: Allelic variation in two markers (BAT-26 and BAT-25) was analyzed in tis-sues and sera of 44 normal volunteers and tumor and matched normal mucosal tissues as well as sera of 44 patients with sporadic colorectal cancer by Real Time PCR (Hy-bridization probe) and High-Performance Liquid Chromatography (HPLC) techniques. The sensitivity and specificity of Real Time PCR and HPLC compared with sequencing as gold standard. The data were statistically analyzed using Student’s t-test and 2 or fisher exact test, where applicable with (P<0.05). Receiver-operating-characteristic (ROC) curves were used to evaluate the sensitivity and specificity. Results: The sensitivity and specificity of BAT-26 with Real Time PCR method (Hy-bridization probe) were 100% in comparison with gold standard method. Whereas the sensitivity and specificity of BAT-26 and BAT-25 with HPLC were 83%, 100% and 50%, 97%, respectively. Neither HPLC nor Real time PCR could detect circulating DNA with MSI property in sera. Conclusion: The sensitivity and specificity of real time PCR in MSI detection is the same as sequencing method and more than HPLC. BAT-26 marker is more sensitive than BAT-25 and MSI detection with Real time PCR could be considered as an accu-rate method to diagnose MSI in CRC tissues not sera.

---

cBackground: Choriocarcinoma is a highly malignant form of gestational trophoblastic disease. It is characterized by metastatic potential, rapid growth and deeply invasion into blood vessel and then widespread dissemination metastasis. However, the most common sites of metastatic choriocarcinoma are lung, vagina, liver, and brain. But, metastatic choriocarcinomas rarely is extended to gastrointestinal system. It is im-portant to keep in mind that despite extensive metastasis, choriocarcinoma is very curable disease. Due to high responsibility of this disease, early diagnosis of choriocarcinoma and treatment with chemotherapy can prevent mortality and morbidity of these patients. In this case report, we present a rare case of metastatic choriocarcinoma in the small bowel after normal term pregnancy. Case Presentation: A 34-years-old woman G4, P4, L4 presented with abnormal postpar-tum vaginal bleeding (45 days) and unresponsive to usual medical and surgical therapy (oxytocine, metergene, antibiotic, and double curettage). The patient was admitted in the Ghaem Hospital, Mashhad University of Medical Sciences in April 2013. She suf-fered from rectal hemorrhage and severe weakness. Because of unsuitable condition (shock), laparotomy was performed and small bowel involvement was observed. Seg-mental resection of small bowel detected metastatic choriocarcinoma of the lesion. We couldn’t rescue our patient due to unresponsive to combination chemotherapy (actino-mycine, methotrexate, cyclophosfamide, vincrystine, etopuside). Conclusion: In abnormal postpartum hemorrhage, we should consider the possibility of choriocarcinoma. Although, it is important to note rare manifestations of metastatic choriocarcinoma of small bowel in massive gastrointestinal hemorrhage.

---

Background: Gonadotropins are commonly used for superovulation in human and animals to retrieve more oocyte and increase chance of pregnancy. Ovarian stimulation in assisted reproduction technology produces lower implantation rates per embryo transferred than natural and ovum donation cycles, suggesting suboptimal endometrial development due to the hormones used to recruit more oocytes. Due to the frequent use of gonadotropins in the treatment of infertility in successive periods, the aim of this study was to determine the endometrial changes in response to repeated ovarian stimulation. Methods: This experimental interventional study has done in research center of Hamadan university of medical sciences in 2012. NMRI female mice six weeks old were used in this study and divided into 7 groups (5 each). The mice in group 1, 2, 3 and 4 received 1, 2, 3 and 4 times pregnant mare serum gonadotropin (PMSG) and 48 hours later 7.5 IU human chorionic gonadotrophin (hCG) respectively. For each group were considered a control group which received on time gonadortropin injection. The mouses were killed 13-16 hours after hCG injection and middle part of uterine horn cut for histological study using Hematoxylin and Eosin staining. The parameters that studied were surface epithelium of endometrium, glandular epithelium, and endometrial height and axis of uterine gland. Results: Our results showed that there are no significant differences in glandular epithelium, axis of glands and height of endometrium in experimental groups (P>0.05). The height of surface epithelium showed significant increases after ovarian stimulation in experiment group (P≤0.03). Our results showed that there are no significant differences in glandular epithelium, axis of glands, height of endometrium and height of surface epithelium between control groups and also it's experimental group (P>0.05). Conclusion: Changes in the height of surface epithelium could be one of the reasons for decrease implantation rates with repeated ovarian stimulation.

---

Background: Red Blood Cell's (RBC)’s folate may be related to decreased risk of colorectal adenoma. Methylenetetrahydrofolate reductase (MTHFR) is a key regulatory enzyme in folate metabolism. The MTHFR C677T polymorphism is located in the Exon 4 region and is associated with the change of folate level. This study evaluated the associations between RBC’s Folate levels and colorectal adenoma risk, taking into account whether this associations is modified by MTHFR Polymorphism. Methods: In a case-control study conducted from January to October 2007 in Endoscopy-Colonoscopy ward of Shahid Faghihi Hospital, Shiraz. Participants were 177 case of colorectal adenoma who had pathologic-confirmed adenomatous polyps in full colonoscopy examination and 366 controls without polyps in full colonoscopy. Fasting venous blood were drawn from patients in order to determine RBC’s folate and to identify the MTHFR polymorphism by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Results: Gender Distribution in the patient group were 57.6% male and 42.3% female and control group consisted of 55.1% male and 43.9% female. 50.2% of cases and 49.2% of controls were in the age group “45 years and above”. The T allele frequency was 56.6% in control group and 34.4% in colorectal adenoma patients. There was a significant association between T allele in -677 position of MTHFR gene and colorectal adenoma susceptibility (OR: 1.85, 95% CI: 0.76-4.24, P<0.001). Mean concentration of RBC’s folate was not statistically significant among three groups with TT genotype (mutation homozygote), CT genotype (heterozygote), and CC genotype (wild-type homozygote) (P>0.05) but mean concentration of RBC’s folate was the lowest in TT genotype compare with two other genotype. Odd's Ratio for low (<140ng/ml) versus high level of RBC’s folate in participants with TT genotype was (OR: 2.08, 95% CI: 0.10-2.19, P<0.05) as compare with the CC ones. Conclusion: The result of this study suggested an inverse association between RBC's folate concentration and colorectal adenomas risk, which may be more relevant for those with the MTHFR TT genotype.

---

Background: Personal characteristics such as gender, ethnicity, disability, age, goals and personal expectations and academic variables such as the number of classes and grades are among the factors that could have an important role in the development of student satisfaction. Besides these factors, the relationship between emotional intelligence (EI) and academic satisfaction has received little attention. Methods: This descriptive cross-sectional study was done in Tehran University of Medical Sciences, Tehran, 2013. Cluster sampling was applied in this study. First, faculties randomly selected from Tehran University of Medical Sciences then randomly selected classes from the faculties. Self-report and Barr-On's emotional Intelligence questionnaires were used to collect data and measuring the variables of educational satisfaction. Questionnaires were completed by students. Overall reliability test using Cronbach's alpha coefficient was 0.73. The cut-off point of questionnaires was considered 70. This means that scores below 70 points showed the low level of satisfaction and scores more than 70 points were considered as a high level of satisfaction. Results: One hundred sixty eight students participated in the study. Average emotional intelligence was 3.25±0.45, the scale of consciousness 3.44±0.59, the self-control scale 3.90±0.59, scale spontaneous 3.17±0.46, Social skills 3.30±0.59, social consciousness 3.24±0.67, satisfactory academic 96.55±14.66 respectively. There was a significant relationship between self-consciousness and educational satisfaction (P=0.002) but self-control variable did not significantly correlated with educational satisfaction (P=0.249). The results showed that emotional intelligence on academic satisfaction can be explained. A change in the variance in one unit emotional intelligence was as much as five unit of the variance student satisfaction in based on standardized beta coefficient. There is a positive and direct relationship between them. Conclusion: The promotion of education satisfaction will increase indirectly possibility of job satisfaction in students in the future. Our results showed self-awareness and motivation skills in students increase their educational satisfaction.

---

Background: Standard treatment of Gestational Trophoblastic Disease (GTD) is chemotherapy. Single-agent chemotherapy regime including Methotrexate (MTX) or Actinomycin. Single-agent is widely used in treatment of persistent trophoblastic disease. We reported an uncommon toxicity of low-dose single-agent methotrexate in a patient. Case Presentation: A 20-year-old woman, primary gravid after two months missed period and spotting with diagnosis of incomplete abortion with uterine size equivalent of ten weeks pregnancy (8-10 cm) underwent evacuation curettage. In serial follow-up, based on rise of beta-hCG titer and absence of metastatic disease, it was categorized as low-risk persistent trophoblastic disease. She was referred to gynecology oncology center of Ghaem Hospital, Mashhad University of Medical Sciences in May 2014. Because of rise of beta-hCG titer, after complete metastatic work-up and lack of disease in other sites, persistent disease was diagnosed and candidate for chemotherapy (single agent low-dose). The patient received first course of therapy with MTX (50 mg/m², intra muscular). Unfortunately, after two days of treatment she developed uncommon severe toxicity, fever, severe nausea and vomiting, tachycardia, and generalized weakness. Also, we found hematologic abnormality (WBC: -14000-15000 µI, platelet- 540 µI and sever neutropenia), and abnormal rising in liver function test (SGOT, SGPT) (three to four times) and renal function test (BUN and Creatinine) (two times). In addition, she had disseminated erosive lesion in all of body especially in face. Due to the fatal side effects of chemotherapy, she was admitted to intensive care unit (ICU). Fortunately, after two to three weeks, she was improved by conservative management. After few weeks beta-hCG titer was in normal limit. However she had normal serial beta-hCG in one year of follow-up. Conclusion: It is important to emphasis unpredictable side effects of chemotherapy with low-dose methotrexate.

---

Background: Congenital hypothyroidism is a major but preventable cause of mental backwardness in infants. In case of hypothyroidism in fetuses, certain complications will occur in vital organs like the central nervous system and the skeleton. Before screening programs were introduced, congenital hypothyroidism was diagnosed with delay due to its few and non-specific symptoms during the first days of life. Given the difference in reference range for various races and populations, this study was aimed to determining a natural range for thyroid hormones used in the screening of infants.

Methods: In a descriptive cross-sectional study at Vali-asr Hospital, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran, from March 2013 to 2014. The level of T4, FT4 and TSH hormones was measured in all natural childbirth, without any complications and with one-minute Apgar score above 7 while this study was underway.

Results: A group of 249 infants (male and female), including 35 (14.1%) aged between 0 and 4 days, 102 (41%) aged between 5 and 7 days and 112 (45%) aged between 7 and 30 days, were examined. The average TSH, T4 and FT4 amounts in infants, aged 0 to 30 days, were respectively 5.35 µU/ml, 10.77 µg/dl and 1.33 ng/dl. The interval was 4.76-6.01 µU/ml for TSH, 10.36-11.17 µg/dl for T4 and 1.29-1.37ng/dl for FT4. The difference between age groups with average TSH concentration is not meaningful (P=0.7) and the average T4 amount in different age groups was meaningfully different (P=0.05). The average FT4 in different age groups is meaningfully different (P=0.007). The thyroid hormone amounts calculated for males and females were not significantly different.

Conclusion: Given the difference in the reference range in race, population and geographical zones, it is necessary to determine a range for screening in Iran. According to the findings of the present study, lower cut-offs, compared with western countries, should be envisaged for TSH in congenital hypothyroidism screening programs that could speed up the diagnosis of minor cases of the disease and prevent complications.

---

Background: Infeliximab is a form of chimeric antibody which neutralizes the most important inflammatory cytokine, TNF-a, in inflammatory disorders. The aim of current study was to pilot expression of chimeric infliximab in Chinese Hamster ovary (CHO) cells.

Methods: In this research study, pVITRO2-neo-mcs vector that consist of infliximab light chain and heavy chain was used to transform into the E.coli by CaCl2 method. The plasmid was then purified and transfected to cultured CHO cells by Lipofectamine 2000® (Invitrogen GmbH, Germany). Transfected cells were selected upon G-418 treatment after 2 weeks and the level of expression, based on standard curve, was measured using IgG ELISA kit after 48 hours for each clone. High level expressed clone was then cultured in roller bottles and recombinant chimeric product was purified by protein A affinity chromatography. The purity of the product was analyzed by 10% gel SDS-PAGE from eluted samples. The efficacy of the purification was analyzed by ELISA before and after purification step. This article is a master's student thesis from February 2015 to August 2016 in pharmaceutical technology development center, Tehran University of Medical Sciences, Tehran, Iran.

Results: The purified plasmid was analyzed on 2% agarose gel. After selective pressure of G-418, 10 stable transfect clones were assessed for infliximab secretion by IgG ELISA kit at 450 nm. The maximum and minimum expression which detected by ELISA were 23 ng/ml and 6 ng/ml, respectively. The band width of infliximab fraction during purification procedure was observed at 0.7-0.8 min. The efficiency of the purification by ELISA was 70%. On SDS-PAGE analysis, two bands, 25 and 50 kDa, respect to light and heavy chains of Infliximab, was confirmed the expression of recombinant protein.

Conclusion: In the current study, the construct for infliximab monoclonal antibody production was designed using genetic engineering techniques and the expression was confirmed by conventional molecular biology methods. The high yield production was carried out in semi-industrial scale using roller bottles with a 70 percentage of purification efficiency.

---

Hemoglobinopathies are most common inherited disorders in the world; approximately 7 percent of the worldwide population and 5-6 percent of population of Iran are carriers. The hemoglobin disorders inherit as autosomal recessive and are very common in the Mediterranean area and much of the Asia and Africa. The control of this inherited disorders need to genetic counseling and accurate screening by more advanced and more accurate methods. This study explains features of current Iran hemoglobin disorders, nominates the accessible methods for screening them and introduces the capillary zone electrophoresis as a rapid and more accurate method. The required data were extracted of various articles and then for good explanation, current Iran hemoglobinopathies properties were showed in the tables and electropherograms of important hemoglobin disorders in Iran population were provided for help to interpretation results of blood tests by capillary zone electrophoresis method. Hemoglobin disorders are including thalassemias and hemoglobin variants; Disruption in the production and malfunction of globin chains cause types of hemoglobin disorders. We cannot introduce one of clinical laboratory tests as critical and basic method for screening and distinguishing types of inherited hemoglobin disorders as alone. For distinguishing the types of them must be prepared enough information and data of the hemoglobin disorders and for more accurate analysis must be used simultaneously different methods as gel electrophoresis, high performance liquid chromatography, isoelectric focusing, capillary zone electrophoresis or molecular tests. The capillary electrophoresis is an accurate and rapid method for screening types of the hemoglobin disorders. Other side this method cannot analyze all of them, so must be used biochemical, biophysical and molecular methods for confirmation the results. This review showed we can use the capillary electrophoresis and HPLC as two complementary methods for hemoglobinopathies screening. We can analyze by the methods more hemoglobin disorders and decrease more laboratory errors. Moreover, we must have patient history, hematological indices, information and data of types of hemoglobinopathies. The patient history and complete blood count results as red blood cell count, mean corpuscular volume, mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration can be useful and helpful in screening the hemoglobin disorders and then distinguishing all of hemoglobin disorders.

---

Background: The relationship between serum homocysteine levels and cardiovascular diseases has been elucidated since many years ago. In this study, the association between serum levels of homocysteine, folic acid, and vitamin B12 with the pulse wave velocity and Buckberg index or subendocardial viability ratio was assessed in individuals with diabetes and also non-diabetic subjects. Methods: In this cross-sectional study, 58 individuals with type 2 diabetes and 36 non-diabetic people, from April to October 2013 were enrolled in Dr. Shariati Hospital affiliated to Tehran University of Medical Sciences. Anthropometric and blood pressure measurements were performed with standard methods. Fasting serum glucose, total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, Triglyceide, A1C, vitamin B12, folic acid and serum homocysteine levels as well as, highly sensitive complement-reactive protein (hs-CRP) were measured. Artherial stiffness was assessed by calculating pulse wave velocity and aortic agumentation index via Sphygmocor. In addition, Buckberg index (Subendocardial viability ratio) was assessed by dividing myocardial oxygen supply to dimand expressed as percent. The normality of distributions was evaluated by Kolmogorov-Smirnov test and linear regression models were utilized to detect associations. Results: Diabetic and non-diabetic subjects differed in terms of age, history of hypertension, serum levels of homocysteine, and LDL-C (P< 0.05). The pulse wave velocity in subjects with diabetes and without diabetes were 60.91 m/s and 41.91 m/s, respectively (P= 0.01). After adjustment for confounding factors in multivariate regression analysis pulse wave velocity was associated with age and homocysteine levels in non-diabetic group, (β equal to 0.441 and 0.345, respectively), and it was related to age, diastolic blood pressure and serum levels of c-reactive protein in subject with diabetes (β= 0.417, 0.302, and 0.262, respectively). Conclusion: Homocysteine levels in non-diabetic individuals were associated to sub-clinical atherosclerosis markers but we could not find this association in diabetic participants.

---

Background: Swyer syndrome is a type of hypogonadism with 46,XY karyotype. This syndrome was named by Gerald Swyer, an endocrinologist. It leads to a female with normal internal genitalia (uterus, fallopian tubes, cervix, vagina), but instead of ovaries, they have non functional ovary (streak gonads). Also, they have absence of puberty because of gonadal  digenesis. The current practice is to proceed gonadectomy once the diagnosis is made due to the fact that the risk of malignant transformation is high in dysgenetic gonad. In addition, hormonal replacement therapy after surgery is acceptable.

Case Presentation: We present a case of gonadoblastom in right ovary in a Swyer syndrome who referred to the department of Gynecology Oncology at Ghaem Hospital, Mashhad University, Iran in 2015 for evaluation of abdomino-pelvic distention. She was a 18-year-old female with 46, XY karyotype and poor secondary sexual character and normal external genitalia. She suffered of abdominal pain. In palpation of the abdomen, an irregular mobile mass was detected in left lower quadrant. The ultrasound revealed uterine size approximate dimensions 3×2 cm (infantile) and a 19 cm pelvic mass heterogeneous and multi-loculated in left side of the pelvic cavity with possible origin of the left ovary. In addition, in right pelvic fossa, a mass about 6 cm was detected. CT-Scan showed a pelvic mass with overall dimensions of 10 cm with vicinity to the left iliac vessels, modest amounts of ascities along with evidence of peritoneal dissemination (seeding). In laparotomy we observed massive ascities and a 20 cm solid mass in left ovary and a small mass in right ovary and involvement para aortic lymph node. Pathological report indicated as stage III of dysgerminoma in left ovary and gonadoblastom in right ovary.

Conclusion: This case is presented because it could have excellent prognosis if not missed opportunities of early recognizing and furthermore adequate treatment with gonadectomy.

---

Background: Human leukocyte antigen E is a member of non-classical HLA class I. Interaction between HLA-E molecule on the target cells and inhibitory CD94/NKG2A receptor on the cell surface of natural killer (NK) cells has an important role in the regulation of immune system against pathogens; therefore different cell surface expression of HLA-E molecule plays an important role in host resistance against viral infections as well as host response to treatment. Considering this fact, we analyzed the frequency of different HLA-E genotypes (HLA-E*01010101, HLA-E*01030103, HLA-E*01010103) in major thalassemic patients who underwent frequent transfusion therapy and are thus more susceptible to infectious diseases.

Methods: This study was a cross-sectional study of 104 major thalassemic patients who referred to Tehran Thalassemia Clinic between the years 2015 to 2016. Blood DNA was extracted and proliferated by sequence-specific primer polymerase chain reaction (SSP PCR). The PCR product was subjected to electrophoresis on 1.5 percent agarose gel then DNA fragment bands on the gel were detected by exposing to UV light. Furthermore, PCR products were also subjected to sequencing analysis for further confirmation.

Results: From 104 patients in this study, 49 (47.1%) were man and 55 (52.9%) were women. These patients were in the age range of 16 to 43 years (mean+SD; 31.03±4.7 year). The frequency of HLA-E*01010103 genotype (64.4 percent) was significantly (P= 0.001) higher than the genotypes of HLA-E*01010101 (15.4%) and HLA-E*01030103 (20.2%) whereas there was no difference between the frequency of HLA-E*0103 allele (52.4%) and HLA-E*0101 (47.6%).

Conclusion: This is the first study that examined the HLA-E polymorphisms in Iranian thalassemic patients referred to Tehran Thalassemia Clinic. This study has shown that the frequency of HLA-E*01010103 genotype was significantly higher than other genotypes of HLA-E whereas there was no difference between the frequency of HLA-E*0103 allele and HLA-E*0101 allele. Whether different frequencies of HLA-E genotype may affect thalassemic patients’ susceptibility to blood-borne infections will be of interest for future studies.

---

Background: Surgical staging is the standard treatment of ovarian cancer. Pelvic and para-aortic lymphadenectomy is the important part of the surgery. The aim of this study was to evaluate the effect of para aortic lymph node dissection in early stage of patients with ovarian cancer. Methods: This descriptive cross-sectional cohort study was performed on all stage I of ovarian cancer patients admitted in department of gynecology oncology of Ghaem Hospital, Mashhad University of Medical Sciences in November 2012 to March 2014. Every patient with clinical early stage of ovarian cancer candidate to surgical treatment selected. All cases underwent surgical staging surgery with concurrent systematic pelvic and para-aortic lymphadenectomy. In laparotomy after identification of left and right iliac artery, all lymph nodes have been properly exposed and dissected as a part of a staging laparotomy. The dissection was continued up to the nodal tissues surrounding the aorta, and inferior vena cava, until inferior mesenteric artery lymphadenectomy level. The procedure performed only by gynecologist oncologist. In addition, we assessed other parameters such as operation time, estimated blood loss, associated mortality and morbidity and vascular injuries. Finally, the effect of para aortic lymph node dissection in early stage of ovarian cancer evaluated. Results: Among a total of 57 ovarian cancer patients, 27 of them apparent stage I disease cases were selected. Surgical staging surgery with concurrent systematic pelvic and para-aortic lymphadenectomy was carried for all of them. Positive para-aortic lymph node was found only in one case. The average number removed para-aortic lymph nodes in the pelvis was 9 and in para aortic was 7, respectively. In addition, 20 minutes increase in total length of operation time was observed duo to para-aortic lymphadenectomy. Also the rate increase in intra-abdominal hemorrhage rate was estimated 60 ml. Conclusion: Lymph node dissection will produce a significant benefit in accurate and complete surgical staging. Staging surgery in addition to systematic pelvic and para aortic lymph adenoctomy in early stage ovarian cancer is preferred in gynecologic oncology centers.

---

Background: The most common symptom of patients with gestational trophoblastic neoplasia is abnormal vaginal bleeding. Despite repeated visits of patients with postpartum choriocarcinoma and abnormal postpartum hemorrhage, delayed diagnosis leads to advanced disease with widespread metastasis. Therefore, occurrence of choriocarcinoma with variable patterns in different diagnosis of late onset postpartum hemorrhage should be considered. Early diagnosis of choriocarcinoma after term pregnancy is important that resulted in decrease of maternal morbidity. Therefor late onset postpartum hemorrhage should have an awareness. The aim of this study was to report a case of choriocarcinoma after caesarian section. Case Presentation: A 33-years-old woman one month after antecedent caesarian section in her second pregnancy admitted with abnormal vaginal bleeding. Based on raised titer concentration of β-hCG was 187000 u, with clinical suspicious of choriocarcinoma she was referred to oncology department of Ghaem Hospital, Mashhad University of Medical Sciences, Iran, in 2016. Vaginal exam revealed an enlarged uterus about 10 weeks of pregnancy. Transvaginal sonography showed an intracavitary heterogeneous mass with irregular surface in fundus without myometrium invasion. Extra pelvic metastasis excluded via vaginal exam, pulmonary X-ray and, ultrasonography and computed tomography scan. Due to early stage of gestational trophoblastic neoplasia and diagnosis of this condition, single agent chemotherapy (methotrexate) was recommended, but because of unresponsive disease, subsequently, she was treated with combination chemotherapy (etoposide, methotrexate, and actinomycin, followed by cyclophosphamide and vincristine) that led to remarkable response. After three courses of therapy, normal level of β-hCG was observed and now the patient is free of disease and under-serial follow-up visit for choriocarcinoma. Conclusion: Diagnosis of choriocarcinoma should be considered in any postpartum woman with abnormal vaginal bleeding.