Endocrinology and Metabolism Research Institute from inception to maturity: an overview of 25-year activity

Endocrinology and Metabolism Research Institute (EMRI) was founded in 1993. EMRI progressed step by step from inception and reached to its maturation during the past 25 years. EMRI has expanded and progressed in different aspects including human resources and infrastructures (laboratories and new technologies) and has obtained the first rank in the country in endocrinology research. It has also collaborated with regional and international organizations such as World Health Organization (WHO), International Osteoporosis Foundation (IOF), and American Association of Clinical Endocrinologists (AACE). This article provides an overview of EMRI activities during a quarter of a century.

Unusual Ectopic Parathyroid Adenoma: A Case Report

An ectopically placed parathyroid in the mediastinum is a rare cause of persistent or recurrent primary hyperparathyroidism. They are rarely in a huge size. We report a case of a 70-year-old man with a history of total parathyroidectomy and thymectomy presented with a lack of appetite, nausea, and generalized bone pain, polydipsia and a calcium level of 14.4 mg/dl. 99mTc-sestamibi scintigraphy with single-photon emission computerized tomography (SPECT) showed a focal zone of radiotracer accumulation in the midline of anterior chest wall (xiphoid level). The mass excised from our patient surgically was 75 grams. This weight and location of the tumor is a very rare finding in parathyroid adenomas.

Elevated serum levels of pregnancy-associated plasma protein-A in type 2 diabetics compared to healthy controls: associations with subclinical atherosclerosis parameters

Type 2 diabetes mellitus is associated with increased inflammation and accelerated atherosclerosis. The association of the pro-inflammatory and potentially pro-atherosclerotic molecule, pregnancy associated plasma protein-A (PAPP-A) with diabetes and vascular diseases remains to be further established. A total of 107 patients with type 2 diabetes and 101 healthy controls participated in this study. Serum levels of PAPP-A was measured by Enzyme-linked Immunosorbent Assay (ELISA). We also evaluated the lipid profile, aortic augmentation index, coronary calcium score, ankle brachial index, flow mediated dilation, and carotid intima media thickness. Serum level of PAPP-A was significantly higher in patients with diabetes compared to controls (P<0.001). In the multivariable regression analysis, PAPP-A was positively correlated with diabetes (P<0.001), aortic augmentation index (P=0.021) and was negatively associated with coronary calcification (P=0.050). In conclusion, serum levels of PAPP-A were significantly higher in diabetics compared to healthy controls and correlated with aortic augmentation index and coronary calcification. Our study results suggest that PAPP-A can be a marker of subclinical atherosclerosis in patients with diabetes.

Who are diabetic foot patients? A descriptive study on 873 patients

Background

Diabetic foot ulcer (DFU) as the leading cause of lower limb amputation is one of the most important complications of diabetes mellitus (DM). Patient and physician’s education plays a significant role in DFU prevention. While effective treatment and formulation of prevention guidelines for DFU require a thorough understanding of characteristics of DFU patients and their ulcers, there are reports that not only patients’ but also physicians’ information about these characteristics is inadequate. So we conducted this study to investigate these characteristics.

Methods

Necessary data was collected from medical archives of DFU patients admitted between 2002 and 2008 in two university hospitals.

Results

873 patients were included. Mean age was 59.3 ± 11.2 years and most of the patients developed DFU in 5th and 6th decades of their life. 58.1% were men. 28.8% had family history of DM. Mean duration of DM was 172.2 months. Mean duration of DFU was 79.8 days. Only 14.4% of the patients had Hemoglobin A1C < 7%. 69.6% of the patients had history of previous hospitalization due to DM complications. The most prevalent co-morbidities were renal, cardiovascular and ophthalmic ones. Most patients had “ischemic DFU” and DFU in their “right” limb. The most prevalent location of DFU was patients’ toes, with most of them being in the big toe. 28.2% of the patients underwent lower-limb amputations. The amputation rate in the hospital where the “multidisciplinary approach” has been used was lower (23.7% vs. 30.1%).

Conclusions

Number of patients with DFU is increasing. DFU is most likely to develop in middle-aged diabetic patients with a long duration of DM and poor blood sugar control who have other co-morbidities of DM. Male patients are at more risk. Recurrence of DFU is a major point of concern which underscores the importance of patient education to prevent secondary ulcers. As a result, educating medical and nursing personnel, applying screening and prevention guidelines, and allocating more resources are of great importance regarding treatment of DFU patients. Application of the “multidisciplinary approach” can reduce the rate of amputations. Primary care physicians might be furnished with the information presented in the present study.

Investigation The Role of Gender on The HLA-DRB1 and -DQB1 Association with Type 1 Diabetes Mellitus in Iranian Patients

OBJECTIVE

Type 1 diabetes mellitus (T1D) is an autoimmune and multifactorial disorder. Subsequent analysis on human leukocyte antigen ( HLA) region shows that HLA-DRB1 and -DQB1 genes have the strongest association with T1D. In this study, for the first time, we investigated the influence of gender on the HLA-DRB1 and -DQB1 association with type 1 diabetes mellitus in Iranian patients in order to determine gender dependent HLA heterogeneity in Iranian T1D patients.

MATERIALS AND METHODS

In this case control study, the HLA-DRB1 and -DQB1 typing were performed on 105 Iranian T1D patients and 100 healthy controls. The data were evaluated by using Fisher exact test.

RESULTS

Our results indicate that DRB1*04:01, DQB1*03:02 alleles and DRB1*04:01- DQB1*03:02 haplotype were significantly more frequent in male T1D patients than females. Also, DRB1*03:01, DRB1*15:01, DQB1*06:01 alleles, DQB1*03:01/05:01 genotype, DRB1*03:01-DQB1*02:01 and DRB1*15:01-DQB1*06:01 haplotypes were significantly higher in female T1D group than males. Furthermore, our results showed that DRB1*04:01 and DQB1*03:02 alleles were significantly more frequent in male T1D patients 1-5 years old at onset than females with similar condition. The DRB1*03:01 allele and DRB1*03:01- DQB1*02:01 haplotype were significantly higher in female T1D patients 6-10 years old at onset than males with similar condition. The DRB1*15:01 allele and DRB1*15:01-DQB1*06:01 haplotype were significantly more frequent in female T1D patients 16-20 years old at onset than males with similar condition.

CONCLUSION

Our findings suggest that gender has a significant influence on the distribution of HLA-DR and -DQ alleles, genotypes and haplotypes. Also, distribution of the HLA-DRB1 and -DQB1 alleles, genotypes and haplotypes vary based on the gender of T1D patients in different age at onset.

The importance of hypoglycemia in diabetic patients

Hypoglycemia is one of the most important complications of diabetes treatment. The risk of severe hypoglycemia is higher in elderly patients, those having comorbidities such as vascular disease or renal failure, pregnant women and in children with type 1diabetes. Moreover, in type 2 diabetes, progressive insulin deficiency, longer duration of diabetes, and tight glycemic control increase the risk of hypoglycemia as much as type 1 diabetes.Episodes hypoglycemia may lead to impairment of counter-regulatory system, with the potential of development of hypoglycemia unawareness. So, hypoglycemia may increase the vascular events even death in addition to other possible detrimental effects. Glycemic control should be individualized based on patient characteristics with some degree of safety. Recognition of hypoglycemia risk factors, blood glucose monitoring, selection of appropriate regimens and educational programs for healthcare professionals and patients with diabetes are the major issues to maintain good glycemic control, minimize the risk of hypoglycemia, and prevent long- term complications.

The influence of the HLA-DRB, HLA-DQB and polymorphic positions of the HLA-DRβ1 and HLA-DQβ1 molecules on risk of Iranian type 1 diabetes mellitus patients

Type 1 Diabetes mellitus (T1D) is an autoimmune and multifactorial disease. HLA-DRB1 and DQB1 loci have the strongest association with T1D. This study aimed at investigating (i) susceptibility or protection of alleles, genotypes and haplotypes of HLA-DRB1 and DQB1 loci; and (ii) highly polymorphic amino acid residues of HLA-DRβ1 and DQβ1 in 105 Iranian T1D patients and 100 controls. The results indicated that DRB1*04:01, 03:01, DQB1*03:02, 02:01 alleles, DRB1*03:01/04:01, 03:01/13:03, DQB1*02:01/03:02 genotypes, DRB1*04:01-DQB1*03:02, DRB1*03:01-DQB1*02:01, DRB1*07:01-DQB1*03:03 haplotypes had positive association with T1D. In contrast, HLA-DRB1*15:01, 13:01, DQB1*03:01, 06:01 alleles, DRB1*11:01/15:01, DQB1*03:01/06:01, 03:01/05:01 genotypes and DRB1*15:01-DQB1*06:01, DRB1*11:01-DQB1*03:01 haplotypes had negative association with T1D. Analysis of amino acid sequence of HLA-DRβ1 and DQβ1 revealed that DRβ1(Lys71+) and DQβ1(Asp57-) were significantly more frequent in patients than in controls and had a positive effect in the development of T1D. Haplotype analysis demonstrated that HLA-DRB1(Lys71+) allele provided major susceptibility for T1D, and DQβ1(Asp57-) had an additive effect. We designed an allele-specific primer to develop an easy, quick and cost-benefit method to detect the DRβ1(Lys71+) . This method can identify all 114 DRB1 alleles encoding DRβ1(Lys71+) by three PCR reactions. The PcPPV and PcNPV were also calculated to determine the impact of HLA genotype testing at amino acid positions. It showed that the DRβ1(Lys71+/+) genotype carrier had 1% absolute risk of developing T1D.

Association study of the -866G/A UCP2 gene promoter polymorphism with type 2 diabetes and obesity in a Tehran population: a case control study

BACKGROUND

A functional polymorphism in the uncoupling protein 2 (UCP2) gene promoter has been associated with obesity and type 2 diabetes (T2D) in some populations. The impact of UCP2 polymorphisms on diabetes and obesity is still under debate. Contradictory results have been reported in different populations world-wide. To clarify the contribution of the UCP2 gene -866 G/A polymorphism in the Iranian population, we studied its association with obesity and T2D.

METHODS

A total of 225 unrelated subjects were studied: 75 T2D patients without obesity, 75 obese patients without diabetes and 75 control subjects. The UCP2 -866 G/A polymorphism was determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

In the normal Iranian population, GG polymorphism was significantly associated with an increased HDL-C level (P=0.027). G/A polymorphism was not associated with obesity and T2D in our study population, but the odds ratio (OR) between GG and G/A polymorphism was 0.61 with a confidence interval (CI) range of 0.34 - 1.08 in obese patients. Subjects with AA genotypes in all of the studied groups showed a lower body mass index (BMI) than subjects with the GG genotype.

CONCLUSION

Although the data in our study population is not statistically significant, the A allele in the UCP2 gene promoter seems to be protective against obesity. This may suggest the possibility of UCP2 as a target molecule for studies on the etiology and treatment of obesity.

The common -866G/A polymorphism of the UCP2 gene in healthy Iranians compared with world populations

Uncoupling protein 2 (UCP2) is a member of the mitochondrial transporter superfamily. It is proposed as a candidate gene for obesity. A common G/A polymorphism in the promoter region of this gene is associated with enhanced adipose tissue mRNA expression in vivo. Using a PCR-RFLP method, we genotyped the UCP2 -866G/A polymorphism in 75 unrelated nonobese nondiabetic Iranians. The frequencies of the UCP2 -866G/A genotypes in 75 Iranian normal subjects were 7 (9.4%) for AA, 41 (54.6%) for GA, and 27 (36%) for GG. Significantly higher HDL cholesterol was detected in people with the GG genotype (p = 0.02) compared to individuals with the GA and AA genotypes. The frequency distribution results were compared with data from Japanese, Italians, Germans, Austrians, and Danes. Our allele frequencies were significantly different from the Japanese data from two different reports (P < 0.025) but not from the others. The Japanese data showed a higher frequency of the AA genotype, which is associated with a low prevalence of obesity, than the Caucasian individuals' data did. In conclusion, a single nucleotide polymorphism in the promoter region of the UCP2 gene has a significant association with HDL cholesterol level in Iranian nonobese nondiabetic subjects. Also, our allele-frequency distribution for this single nucleotide polymorphism is closer to European Caucasians than to Japanese in nonobese nondiabetic individuals.

Are biochemical values predictive of adenoma's weight in primary hyperparathyroidism?

BACKGROUND

Preoperative laboratory findings may carry some predictive value about the size of the abnormal parathyroid tissue that needs to be removed in primary hyperparathyroidism.

METHODS

In a retrospective study from 1988 to 2003, records of 71 patients with parathyroid adenoma were reviewed. The correlation between preoperative serum calcium, phosphate and parathyroid hormone (PTH) with adenoma's weight was analysed separately.

RESULTS

There was a significant correlation between preoperative serum PTH and calcium with adenoma's weight (P < 0.001 and P = 0.03, respectively). The correlation between preoperative serum phosphate and adenoma's weight was not significant (P = 0.1).

CONCLUSION

Preoperative PTH level cannot be used as a definite guide to the parathyroid adenoma's weight. Large parathyroid adenomas seem to secrete less PTH per unit weight than small adenomas. Calcium and phosphate do not seem to be of much value in predicting adenoma's weight in primary hyperparathyroidism.

The status of biochemical parameters in varying degrees of vitamin D deficiency

Vitamin D (Vit D) is an essential element for the regulation of serum calcium, phosphate, and alkaline phosphatase (Alk Ph). Because the Vit D serum level is not usually measured directly, Vit D deficiency is diagnosed indirectly by changes in serum calcium, phosphate, and Alk Ph leves. The current study assessed the status of these biochemical parameters in subjects with different degrees of Vit D deficiency. We selected 1,210 subjects, between 20 and 69 years old, randomly from the Tehran population. Subjects with diseases or medications that modified bone metabolism were excluded from the study. Serum 25(OH) D, calcium, phosphate, Alk Ph, and parathyroid hormone (PTH) levels were measured and the status of these biochemical parameters was compared in subjects with different degrees of Vit D deficiency. Vit D deficiency was diagnosed in 79.6% of the subjects. Different degrees of Vit D deficiency were classified as follows: group 1, severe; group 2, moderate; and group 3, mild. Serum PTH levels in the Vit D-deficient groups were significantly higher than that in group 4 (normal Vit D). Serum calcium and phosphate levels in groups 1 and 2 were significantly lower than those in groups 3 and 4. No significant difference was seen in serum Alk Ph in the groups with different degrees of Vit D deficiency. The sensivity for at least one biochemical variable (calcium, phosphorus, or Alk Ph) for the detection of severe, moderate, and mild Vit D deficiency was 24.2%, 13.8%, and 6%, respectively. When the serum 25(OH) D level was reduced to less than 25 nmol/l (groups 1 and 2), the effects of Vit D deficiency on calcium and phosphate levels were obvious. Therefore, the usual biochemical parameters (calcium, phosphate, Alk Ph) alone do not have sufficient sensitivity to detect mild deficiency of Vit D.

Potential risk factors for diabetic neuropathy: a case control study

Background

Diabetes mellitus type II afflicts at least 2 million people in Iran. Neuropathy is one of the most common complications of diabetes and lowers the patient's quality of life. Since neuropathy often leads to ulceration and amputation, we have tried to elucidate the factors that can affect its progression.

Methods

In this case-control study, 110 diabetic patients were selected from the Shariati Hospital diabetes clinic. Michigan Neuropathic Diabetic Scoring (MNDS) was used to differentiate cases from controls. The diagnosis of neuropathy was confirmed by nerve conduction studies (nerve conduction velocity and electromyography). The multiple factors compared between the two groups included consumption of angiotensin converting enzyme inhibitors (ACEI), blood pressure, serum lipid level, sex, smoking, method of diabetes control and its quality.

Results

Statistically significant relationships were found between neuropathy and age, gender, quality of diabetes control and duration of disease (P values in the order: 0.04, 0.04, < 0.001 and 0.005). No correlation was found with any atherosclerosis risk factor (high BP, hyperlipidemia, cigarette smoking).

Conclusion

In this study, hyperglycemia was the only modifiable risk factor for diabetic neuropathy. Glycemic control reduces the incidence of neuropathy, slows its progression and improves the diabetic patient's quality of life. More attention must be paid to elderly male diabetic patients with poor diabetes control with regard to regular foot examinations and more practical education.

Insulinoma in Iran: a 20-year review

BACKGROUND

The time between onset of symptoms of insulinoma to diagnosis ranges from 10 days to more than 20 years. To help physicians make an earlier diagnosis, we defined the clinical, imaging and paraclinical characteristics of insulinoma in cases from seven referral hospitals in Iran over two decades.

METHODS

The medical records of 68 cases with biochemical or histological evidences of insulinoma were reviewed.

RESULTS

More males were affected (53%). The mean age at diagnosis was 39 +/- 15.3 years. The mean duration of symptoms was 39.9 +/- 59.3 months. Eighty-four percent of patients had been initially misdiagnosed as cereberovascular accident (CVA), epilepsy, conversion disorder, and others). Neuroadrenergic symptoms were observed in 89.6% and and neuroglycopenic symptoms in 97% of patients. Mean diameter of tumours was 2.9 cm (range, 1 cm to 8.5 cm). Of 52 pathologically confirmed cases of insulinoma, 43 tumours (87.8%) were single and 49 (94.2%) were benign. Fifty-five patients had undergone surgery, with a successful outcome in 44 (80%).

CONCLUSION

The high incidence of neuroglycopenic symptoms suggest the clinical impression of insulinoma when patients present with a suggestive clinical syndrome. The clinical impression is essential to decrease the frequent delay in the diagnosis of insulinoma.

Assessment of Bone Structure in Renal Transplant Recipients: Comparison of Phalangeal Qualitative Ultrasound and Dual X-Ray Absorptiometry

According to the WHO criteria many renal transplant patients display osteopenia or osteoporosis. Dual-energy X-ray absorptiometry (DXA), the standard method to assess bone mineral density (BMD), is not always available. Quantitative ultrasound (QUS) of the phalanx is an inexpensive, mobile, and radiation-free diagnostic alternative. Few data address the correlation of this method with DXA in renal transplant patients. This study assessed the value of QUS compared with DXA to detect changes in bone structure among renal transplant recipients. This cross-sectional study of 42 patients (22 women), of mean age 40.2 +/- 11.9 years, mean time since transplantation of 2.8 +/- 2.9 years, and mean dialysis time of 8.55 +/- 10.26 months, included. DXA for bone mineral densitometry of the hip (neck and total femur) and spine as well as QUS to measure the amplitude-dependent speed of sound (Ad-SOS) in the phalanx. Using DXA, osteoporosis was observed in 19% of all patients: 9.5% in femoral neck, 9.5% in total region of the femur, and 9.5% in the spinal region. The sensitivity of Ad-SOS for osteoporosis diagnosis in the above regions were 100%, 75%, and 25%, respectively; its specificity was 45%, 43%, and 37%, respectively. There was no significant relation between the two methods for diagnosis of osteoporosis in any region. QUS of phalanx can be recommended for osteoporosis screening in renal transplant patients. Those suspected of osteoporosis should be examined by additional DXA measurements in order to establish the diagnosis.

Normative data of bone Mineral Density in healthy population of Tehran, Iran: a cross sectional study

Background

Osteoporosis is a major problem and is a hidden epidemic disease in the world. Early diagnosis by measurement of Bone Mineral Density (BMD) and treatment can prevent and reduce disease complications, especially fractures. As there is no comprehensive study in Iran, this study designed to assess BMD discrepancy in 20–69 yr Tehran population as well as prevalence of osteoporosis and osteopenia.

Methods

553 people (34% men, 66%women) from 50 Blocks in Tehran randomly selected. The assessment of BMD in spine and femur region performed through DXA method. All subjects clinically examined and their BMIs determined.

Results

The average spinal BMD score in men were more than in women. The peak bone mass of spine bone both in men and women occurred during 20–29 yr and reduction began from the age of 40. At the age of 60 to 69, loose of bone density was 19.6% in lumbar spine and 18.5% in femur of women and also 7.9% in lumbar spine and 14.6% in femur of men. Prevalence of osteoporosis in this age group in lumbar spine and femur was 32.4% and 5.9% in women and 9.4% and 3.1% in men respectively.

Conclusion

In all age groups, peak bone mass was lower than European or American population, whereas the rate of bone loss was as much as the some population and actually this process justifies the prevalence of osteoporosis and osteopenia in Tehran population.

Evaluation of suppressive therapy for cold thyroid nodules with levothyroxine: double-blind placebo-controlled clinical trial

OBJECTIVE

To study the efficacy of levothyroxine suppressive therapy in the management of benign thyroid nodules.

METHODS

We performed a double-blind clinical trial comparing levothyroxine treatment (1.5 to 2.0 mg/kg of body weight daily) (N = 32) with placebo (N = 30) for a 1-year period in patients with a benign, cold thyroid nodule confirmed by biopsy and 99mTc-pertechnetate scanning, who were randomly assigned to the treatment or control group. High-resolution sonography was used to measure the size of the nodules before and after the treatment. Suppression of thyrotropin was evaluated by the administration of thyrotropin-releasing hormone to 10 patients randomly in each group.

RESULTS

The mean volume of the thyroid nodules decreased significantly after 6 months in both the levothyroxine group (from 12.8 +/- 11.9 mL to 9.4 +/- 9.8 mL; P = 0.003) and the placebo group (from 13.2 +/- 10.2 mL to 11.5 +/- 8.0 mL; P = 0.003). After 12 months, however, the volume of the nodules had increased. Thus, no significant decrease was found in the mean nodule volume in either study group at 1 year in comparison with the mean volume at baseline (final mean volume: 12.4 +/- 16.7 mL in the levothyroxine group and 11.7 +/- 13.6 mL in the placebo group).

CONCLUSION

Suppressive therapy with levothyroxine for a period of 12 months proved to be ineffective in significantly reducing the size of the thyroid nodules in our patients despite effective suppression of the thyrotropin level.

Vitamin D deficiency and causative factors in the population of Tehran

BACKGROUND

There are multiple studies in different countries regarding the prevalence of vitamin D deficiency. These studies showed high prevalence of vitamin D deficiency in Asian countries. This study tries to elucidate the prevalence of vitamin D deficiency and its influencing factors in population of Tehran.

METHODS

1210 subjects 20-64 years old were randomly selected. 25 (OH) D serum levels were measured. Duration of exposure to sunlight, the type of clothing and level of calcium intake and BMI were quantified based on a questionnaire.

RESULTS

A high percentage of vitamin D deficiency was defined in the study population. Prevalence of severe, moderate and mild Vitamin D deficiency was 9.5%, 57.6% and 14.2% respectively. Vitamin D serum levels had no significant statistical relation with the duration of exposure to sunlight, kind of clothing and BMI. Calcium intake in the normal vitamin D group was significantly higher than the other groups (714.67 +/- 330.8 mg/day vs 503.39 +/- 303.1, 577.93 +/- 304.9,595.84 +/- 313.6). Vitamin D serum levels in young and middle aged females were significantly lower than the older group.

CONCLUSIONS

Vitamin D deficiency has a high prevalence in Tehran. In order to avoid complications of vitamin D deficiency, supplemental dietary intake seems essential.

Presentation and outcome of 93 cases of craniopharyngioma

We studied a series of 93 patients diagnosed with craniopharyngioma during a 15-year period with respect to presenting symptom, clinical course and management. The majority (62%) of patients were men, and had presented with neurological symptoms (75%), with headaches (82%) being the most common presenting symptom. The incidence of certain endocrine and ophthalmic symptoms varied little from that in the literature, on the other hand, the incidence of certain other symptoms did differ markedly from the literature. For example, loss of libido and amenorrhoea were seen at a much lower frequency than that stated in the literature. Hypertension, sensorimotor symptoms and urinary incontinence were not seen at all in our patients. In most cases diagnosis was made by a cranial CT scan, which is more sensitive than plain radiography for detection of enlarged sella turcica (69% vs. 24%; P < 0.001). In over 90% of cases, therapy consisted of removal of a variable portion of the tumour, with or without radiotherapy. Post-operative mortality was substantially reduced in cases treated by radiotherapy (P < 0.05). The most common post-operative complications in all cases were recurrence of disease, panhypopituitarism and diabetes insipidus.

Effects of levothyroxine suppressive therapy on bone mineral density in premenopausal women

BACKGROUND

Levothyroxine (L-T4) is widely prescribed for treating thyroid disorders, but its effect on bone mineral density (BMD), is being debated.

OBJECTIVES

We studied the effect of supraphysiologic doses of L-T4 on BMD in a group of premenopausal women.

PATIENTS AND METHODS

We included 50 women (mean age=36.8 +/- 7.6 years) receiving L-T4 for at least 1 year for treating their benign cold thyroid nodules. Serum T3, T4, thyroid-stimulating hormone (TSH), parathyroid hormone (PTH), calcium, and phosphate and urine calcium and sodium levels of all patients were measured. Bone density at femoral neck and lumbar (L1-L4) regions was measured, using dual energy X-ray absorptiometry (DXA).

RESULTS

No significant decrease was detected in the bone density of the subjects treated with L-T4 compared with the control group.

CONCLUSION

L-T4 treatment for 1 year is not associated with increased risk of osteoporosis in premenopausal women but other potential adverse effects still need to be monitored in women receiving L-T4 especially long-term.

Metabolic and clinical effects of Ramadan fasting in patients with type II diabetes

OBJECTIVE

To evaluate the effects of fasting on anthropometric indices and carbohydrate and lipid metabolism in patients with type II diabetes.

DESIGN

Observational non-interventional study.

PLACE AND DURATION OF STUDY

: Diabetes clinic, Shariati Hospital, Tehran, Iran during Ramadan 1419 (winter 1998-99).

PATIENTS AND METHODS

Fifty-seven volunteers with type II diabetes underwent anthropometric and biochemical evaluation before and on the 14th and 28th days of Ramadan. Biochemical markers were measured by standard laboratory methods and anthropometric indices by WHO criteria. Statistical analysis was done by ANOVA for repeated measurements and Friedman's two-way ANOVA using SPSSv6 software.

RESULTS

Daily cholesterol intake increased in all subjects (p<0.03). Body mass index increased in women (p<0.03), but BMI and waist-hip ratio both decreased in men (p<0.01). Blood pressure, fasting blood glucose and serum fructosamine did not change during the study. Plasma insulin (p<0.05), C-peptide (p<0.01) and insulin resistance (p<0.01) decreased only in men. Total and LDL cholesterol increased significantly in all subjects during the study.

CONCLUSION

Ramadan fasting does not alter carbohydrate metabolism or tissue insulin sensitivity in patients with type II diabetes given appropriate dietary education and rescheduling of oral hypoglycaemic medication. Lipid profile is unfavourably altered due to changes in both diet and biochemical response to starvation.

Treatment of hyperfunctioning thyroid nodules by percutaneous ethanol injection

BACKGROUND: Autonomous thyroid nodules can be treated by a variety of methods. We assessed the efficacy of percutaneous ethanol injection in treating autonomous thyroid nodules. METHODS: 35 patients diagnosed by technetium-99 scanning with hyperfunctioning nodules and suppressed sensitive TSH (sTSH) were given sterile ethanol injections under ultrasound guidance. 29 patients had clinical and biochemical hyperthyroidism. The other 6 had sub-clinical hyperthyroidism with suppressed sTSH levels (<0.24 &mgr;IU/ml) and normal thyroid hormone levels. Ethanol injections were performed once every 1-4 weeks. Ethanol injections were stopped when serum T3, T4 and sTSH levels had returned to normal, or else injections could no longer be performed because significant side effects. Patients were followed up at 3, 6 and, in 15 patients, 24 months after the last injection. RESULTS: Average pre-treatment nodule volume [18.2 PlusMinus; 12.7 ml] decreased to 5.7 PlusMinus; 4.6 ml at 6 months follow-up [P < 0.001]. All patients had normal thyroid hormone levels at 3 and 6 months follow-up [P < 0.001 relative to baseline]. sTSH levels increased from 0.09 PlusMinus; 0.02 &mgr;IU/ml to 0.65 PlusMinus; 0.8 &mgr;IU/ml at the end of therapy [P < 0.05]. Only 3 patients had persistent sTSH suppression at 6 months post-therapy. T4 and sTSH did not change significantly between 6 months and 2 years [P > 0.05]. Ethanol injections were well tolerated by the patients, with only 2 cases of transient dysphonia. CONCLUSION: Our findings indicate that ethanol injection is an alternative to surgery or radioactive iodine in the treatment of autonomous thyroid nodules.

Sustainable control of iodinedeficiency in Iran: beneficial results of the implementation of the mandatory law on salt iodization

Iodine deficiency disorders (IDD) were prevalent in the Islamic Republic (IR) of IRAN before 1989, when the national salt iodization program with 40 mg l/k of salt was initiated. Despite a comprehensive IDD control program, less than 50% of the households in rural areas consumed iodized salt by 1994. A law for the mandatory production of iodized salt for households was passed in 1994. The purpose of this study was to evaluate goiter status and urinary iodine excretion 2 yr after this law was implemented. In each of 26 provinces, 30 groups of 40 schoolchildren, total 36,178, were examined for goiter and classified according to World Health Organization (WHO) classification. Urinary iodine excretion was measured in 2,917 children by digestion method. Goiter was endemic in all provinces, but the majority were small (grade 1) goiter. Median urinary iodine was 20.5 microg/dl 85.1% had urinary iodine > or =10 microg/dl. Median urinary iodine was above 13 microg/dl in all 26 provinces. In all provinces the percentage of schoolchildren with urinary iodine <5 microg/dl was less than 16%. In nine provinces the median urinary iodine was between 13 to 20 microg/dl; urinary iodine of their schoolchildren was <5 microg/dl in 10.8% and <2 microg/dl in 6-9%. No significant difference was observed between boys and girls or children of rural and urban regions in urinary iodine excretion. We conclude that 7 yr after the beginning of salt iodization and 2 yr following mandatory iodized salt consumption, urinary iodine excretion is adequate in schoolchildren; considering the data of the percent of households consuming iodized salt and programmatic setting of the IDD program, The IR of Iran has reached a sustainable control program for iodine deficiency.

Dermopathy of Graves disease (pretibial myxedema). Review of 150 cases

Pretibial myxedema is an uncommon manifestation of Graves disease, and little information is available regarding its natural course and its relation to other manifestations of Graves disease. We reviewed 150 consecutive cases with the diagnosis of pretibial myxedema over a 20-year period in a referral center. Only 1 patient in this group did not have ophthalmopathy, whereas 88% had significant proptosis and 30% required orbital decompression surgery. Dermopathy was a late manifestation of Graves disease, and its onset usually followed the diagnosis of hyperthyroidism and ophthalmopathy. In a few patients, dermopathy preceded diagnosis of hyperthyroidism or onset of ophthalmopathy. Fourteen patients were never clinically hyperthyroid; spontaneous hypothyroidism had developed in 11 in this group. All cases involved the lower extremities, with only 1 patient having combined upper and lower extremity involvement. The most common form of thyroid dermopathy was nonpitting edema, followed by nodular and plaque forms, which occurred with equal frequency. The polypoid form occurred in 1 patient and the elephantiasic form in another; 7.3% had thyroid acropachy. Follow-up was available for 120 patients (range, 3 mo to 19 yr; mean, 3.2 yr), and complete remission was observed in only 12 patients. Topically applied corticosteroid therapy was used in 76 patients, and in this group 38% had sustained long-term partial remission, as opposed to 18% in the group receiving no corticosteroid therapy.