فهرست مطالب rokhsareh aghili

Mortality has been indicated to be high in patients with underlying diseases. This study aimed to examine the comorbidities is associated with a higher risk of death during the hospital course.   

We retrospectively evaluated the risk of in-hospital death in 1368 patients with COVID-19 admitted to 5 academic hospitals in Tehran between February 20 and June 13, 2020.  We also assessed the composite end-point of intensive care unit admission, invasive ventilation, and death. The Cox proportional survival model determined the potential comorbidities associated with deaths and serious outcomes.   

The retrospective follow-up of patients with COVID-19 over 5 months indicated 280 in-hospital deaths. Patients with diabetes (risk ratio (RR), 1.47 (95% CI, 1.10-1.95); P = 0.008) and chronic kidney disease (RR, 1.72 (95% CI, 1.16-2.56); P = 0.007) showed higher in-hospital mortality. Upon stratifying data by age, patients aged ˂65 years showed a greater risk of in-hospital death in the presence of 2 (hazard ratio (HR), 2.68 (95% CI, 1.46-4.95); P = 0.002) or more (HR, 3.47 (95% CI, 1.69-7.12); P = 0.001) comorbidities, compared with those aged ≥ 65 years.   

Having ≥ 2 comorbidities in nonelderly patients is associated with a greater risk of death during hospitalization. To reduce the mortality of COVID-19 infection, younger patients with underlying diseases should be the focus of attention for prevention strategies.

The aim of this study was to assess the performance of the Framingham, UK Prospective Diabetes Study (UKPDS)[1], and the Action in Diabetes and Vascular disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE)[2] risk equations in prediction of 4-year cardiovascular events in an Iranian people with type 2 diabetes.

The 4-year risks of cardiovascular disease (CVD)[3] were estimated using the three equations in a community of 557 patients with type 2 diabetes and free of CVD at baseline. A trained physician evaluated all of the participants regarding occurrence of CVD event during follow up. CVD was defined as major events including fatal/ non-fatal myocardial infarction as well as fatal/non-fatal stroke, minor events including treated coronary heart disease (CHD)[4], and established peripheral arterial disease (PAD)[5].

During 4 years of follow-up, 64 CVD events were observed (66% minor CVD events). Despite having a good calibration (estimated to observed ratio ranging from 91.37 to 98.2 percent, Hosmer–Lemeshow χ2 (HLχ2)[6] values <15), both general (Framingham) and diabetes specific (UKPDS and ADVANCE) equations did not have adequate discriminative ability (AUC[7] ranging from 0.48 to 0.56).

Framingham, UKPDS, and ADVANCE risk equations, regardless of being general or diabetes specific, could not precisely predict 4-year risk of CVD in Iranian individuals with type 2 diabetes.

The prevalence of diabetes makes considerable costs for health‑care organizations. The increase of patient’s self‑care abilities by use of personalizing health information prescription can reduce these costs. This study was conducted to explore the benefits and challenges related to personalizing health information prescription in diabetes clinical settings.

The samples included diabetes education officials working in specialized diabetes clinics and Diabetes Research Centre managers of Iran and Tehran Universities of Medical Sciences. They were 21 cases and selected through purposeful sampling method. Semi‑structured interview and focus discussion groups were used to collect the viewpoints of specialists. Interview guide, based on literature review and the documents of diabetes, was used in interviews and focus groups. Their validity was affirmed by specialists. The interview texts were coded in MAXQDA10 software and analyzed through content analysis method.

The most important benefits of personalizing health information prescription were classified into five themes as follows: medical services improvement, facilitation of consumers to information resources, improvement in patients’ knowledge and awareness, increase in self‑care ability and disease management, reinforcing the relation between physician and patient and keeping physician in the information prescription cycle. The challenges of personalizing of health information prescription were revealed as follows: Recognition of patients’ personal characteristics at the turn of entering the system, systems’ functional modifiers especially bilateral interaction and relation to patient’s health file, content recognition, and creating suitable protocol.

This study showed that diabetes clinical settings face different organizational and process challenges for establishing the personalization of health information prescription. The most important challenges which should be considered in designing information prescription in diabetes clinical environments are as follows: reinforcing physicians’ recognition of information prescription benefits, lack of integrative electronic health information system, and patient primary assessment in the first stage of entering the patient into the system in respect of clinical and personal aspects in information needs of consumer.

Non-alcoholic fatty liver disease (NAFLD) is common in people with type 2 diabetes mellitus (T2DM). We aimed to explore predictive factors of NAFLD in T2DM and identify high risk subgroups.

This was a cross-sectional study including 100 individuals with T2DM and 100 without diabetes matched for age, sex, and body mass index (BMI). Hepatic steatosis grades (calculated by controlled attenuation parameters-CAP score-3), and liver fibrosis stages (F0-F4) were determined using transient elastography.

The frequency of NAFLD was comparable between the two study groups. However, CAP scores were significantly higher in individuals with diabetes (294.90 ± 53.12 vs. 269.78 ± 45.05 dB/m; P < 0.001). Fifty percent of individuals with diabetes had severe steatosis (S3), while this figure was 31.6% in those without diabetes (P < 0.05). Significant fibrosis (F2-F4) was more frequent in individuals with T2DM (13% vs. 4.1%, P = 0.02). Individuals with T2DM and advanced fibrosis had significantly higher BMI, waist circumference (WC), waist-hip ratio (WHR), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and CAP score compared to those without fibrosis (P < 0.05). In the regression analysis, a model including BMI, WHR, AST and female gender explained 50% of the variation in CAP score in patients with diabetes (all P < 0.05, adjusted R2 : 0.508). CAP scores were also the major determinant of liver fibrosis in this group (OR: 1.04; CI: 1.017–1.063; P = 0.001).

Individuals with diabetes are more likely to have severe fibrosis. Obesity (especially central obesity), the female gender, elevated liver enzymes, and higher degree of insulin resistance are associated with more advanced liver disease in individuals with T2DM.

The Corona Virus Disease 2019 (COVID-19) outbreak is becoming pandemic with the highest mortality in patients with associated comorbidities. These RNA viruses containing 4 structural proteins usually use spike protein to enter the host cell. Angiotensin-converting enzyme 2 (ACE2) acts as a host receptor for the virus. Therefore, medications acting on renin-angiotensin-aldosterone system can lead to serious complications, especially in patients with diabetes and hypertension. To avoid this, other potential treatment modalities should be used in COVID-19 patients with associated comorbidities.

A 27-year-old man came to our emergency department with chief complaints of abdominal pain, nausea and vomiting, colicky pain in all area of abdomen without any radiation and generalized myalgia. In his background, he had no previous medical problem. In his social history he had worked in an automobile battery-reclaiming factory for 5 years. During his physical examination, his appearance was pale with perioral priority, ill and agitated but not toxic with a blood pressure of 127/85 mmHg and a pulse of 80 beats/min, respiratory rate of 14 breaths/min and oral temperature of 37.3 °C, mild generalized abdominal tenderness without rebound. No obvious signs of sensory and motor neuropathy were found. In the head and neck examination, we found lead-lined teeth.
Learning points: The most common cause of chronic metal poisoning is lead. Exposure occurs through inhalation or ingestion. Both inorganic and organic forms of lead that exist naturally produce clinical toxicity. Gastrointestinal manifestations occur more frequently with acute rather than with chronic poisoning, and concurrent hemolysis may cause the colicky abdominal pains. Patients may have complained of a metallic taste and, with long-term exposure, have bluish-gray gingival lead lines. In addition, constitutional symptoms, including arthralgia, generalized weakness, and weight loss raises the possibility of lead toxicity.

A 58-year-old man presented to the emergency department with abdominal pain, nausea and loss of appetite for the last 8 hours. He reported diffuse pain that had been localized to the right lower quadrant (RLQ). Physical examination revealed muscular defense and tenderness in the RLQ. Computed tomography (CT) of the abdomen and pelvis confirmed luminal distension with a thickened enhancing wall with an appendicolith.
Learning points: Appendicitis may be developed by an appendicolith, a calcified deposit within the appendix. It may be an incidental finding on an abdominal radiograph, ultrasound (US) examination or CT. It appears as echogenic focus and casts an acoustic shadow on US examination and manifests as a calcified mass on plain radiograph or CT. The incidence of appendicolith is higher among patients with a retrocaecal appendix. In our patient, a clinical diagnosis of acute appendicitis was made and the patient was immediately transferred to the operating room and an appendectomy was performed.

This sub-analysis of the Iran-AFECT study was to determine the baseline characteristics are predicting the likelihood of attainment of HbA1c goal and changing in HbA1c after initiation of basal insulin glargine in insulin naïve people with type 2 diabetes not adequately controlled with oral glucose-lowering drugs. Iran-AFECT was a 24-week, prospective, multicenter, observational study of people with type 2 diabetes initiated or switched to insulin glargine. In this sub-analysis, we included all insulin naïve people. Glycemic response was defined as HbA1c≤7.0% and/or change in HbA1c at week 24. Data on 433 participants were included. The mean HbA1c was 8.9%±0.9% at baseline which decreased to 7.6%±1.2% (P

Hypoglycemia is associated with adverse health outcomes and can result in vascular events in diabetic patients. The impact of hypoglycemia on cardiovascular outcomes in non-critically ill people with diabetes is not well-determined. So, we examined short-term cardiovascular outcomes of hypoglycemic events in people with type 2 diabetes treated with insulin during routine clinical care.
This study was conducted in Tehran, Iran from January 2012 to January 2013. One hundred and twenty non-critically ill people with type 2 diabetes on oral glucose lowering drugs were enrolled. Insulin therapy was initiated for uncontrolled diabetes. The patients were educated to perform self-monitoring of blood glucose on a daily basis. Furthermore, they were asked to record the results if they experienced any symptom indicative of hypoglycemia during the 24 weeks of the study. The occurrence of any major cardiovascular event including unstable angina, fatal or non-fatal myocardial infarction, fatal and non-fatal stroke, or death from cardiovascular cause was also evaluated based on the patients’ hospital records.
There were 210 hypoglycemic episodes and 31 major cardiovascular events. Forty four percent of patients with documented hypoglycemic episodes developed cardiovascular events compared to 15.6% of those who did not experience any hypoglycemia (P = 0.001). The odds ratio for occurrence of major cardiovascular events related to hypoglycemia was 7.41 (CI = 2.15–25.47) with a risk ratio of 2.66.
Hypoglycemia is a major risk factor for occurrence of the first major cardiovascular event in non-critically ill people with type 2 diabetes initiating insulin therapy.

To obtain information related to the knowledge and clinical practice of general practitioners (GPs) in management of people with type 2 diabetes, and to explore the impact of formal continuous medical education (CME) programs. A total of 1104 GPs participated in a cross sectional survey related to diabetes management considering ADA/EASD consensus 2011 focused on demographic and background characteristics, diabetes related knowledge, and patient care. Fisher’s Exact and Chi-square tests were used in the analysis of contingency tables. The majority of the participants (83.9%) worked in large cities and 39.8% had taken part in CME programs in diabetes management. Overall, 52% of the GPs knew the treatment goal for HbA1c. The rate was slightly higher for those taken part in CME (P = 0.003). Considering patient care, slightly more than half of the participants answered correctly to the questions on duration and distribution of physical activity, with no difference by taking part in CME programs. On average, 41.5% of the physicians selected metformin as the first OGLD for treatment of type 2 diabetes, and only 27.9% stated that they add basal insulin to OGLD if treatment failed. The results of this study provide the evidence that the knowledge and clinical practice of Iranian GPs in management of type 2 diabetes were not satisfactory. Furthermore, traditional CME programs in diabetes management were not effective in changing the GPs’ clinical practice. Consequently, designing and implementing more effective strategies are necessary for improving patient health related outcomes.

This study was to estimate the frequency of prehypertension and to characterize patient awareness and associated cardiovascular risk factors in an urban population in Iran. During a hypertensive awareness program, a cross-sectional study was conducted on 2036 people. All participants completed a questionnaire about their demographic and anthropometric indices and were asked about symptoms, risk factors and preventive measures of hypertension. Data were compared between prehypertensive and non-hypertensive groups. Prehypertension was detected in 30% (n=611) of the subjects. Previous CHD, diabetes, and hyperlipidemia were more prevalent in low prehypertension group compared to high normal blood pressure. The male sex, increasing age and body weight were positively associated with the rate of prehypertension. Only 8% of participants with prehypertension were aware about the symptoms of hypertension, 12% correctly mentioned at least three risk factors of hypertension, and 48% explained appropriate preventive measures. Prehypertension was prevalent in this population. Age, body weight, male sex, and previous CHD were the major determinants. Furthermore, hypertension awareness was alarmingly poor. Therefore, hypertension prevention programs focused on increasing public awareness are essential.

For the treatment of pain, opioids are the main analgesic approaches. Opioid therapy involves the use of either weak or strong opiates, and both are often prescribed in conjunction to adequately control acute pain. Strong opiates often have additional routes beyond oral administration. Poor understanding of opioids and concerns about governmental retaliation for prescribing opioids can lead to treatment failure. Desired goal in handling of patients with chronic pain is achieving and sustaining an acceptable quality-of-life. In this narrative review, we discuss classifying and clinical use of opioids.

Emergency medicine is a relatively new specialty in Iran. Therefore, the general public and the medical community do not have enough information on its duties, capabilities, its nature, and its work schedule or its degree of occupational difficulty compared to other specialties. Hence, an insight from the early group of residents who selected this specialty can help identify the strengths and weaknesses of this field in order to promote the scientific quality of this field, and attract medical students. It can also help to alleviate deficiencies and strengthen positive aspects of emergency medicine. The aim of this study was to identify the reasons behind choosing emergency medicine as a specialty. A qualitative study was conducted using semi-structured interviews. Maximum variation opportunistic sampling was done, and face-to-face interviews were held with 23 emergency medicine residents and fellows (4 faculty members and 19 residents). Data were analyzed through thematic analysis, and categories and themes were extracted. The main levels extracted were: 1) Individual priorities, 2) the nature of work and the field of study, and 3) professional future. The themes of each main level were extracted and encoded. This study showed that the majority of residents choose emergency medicine specialty to achieve a better social and professional status in one of the most challenging fields of medicine.

medicine, there is a rapid development of a knowledge base. Medical professionals need to sustain and advance their competence to practice in response to these varieties. So, there is increased interest in self-directed learning methods. Study guides can make a major contribution to self-directed learning. This study was carried out to evaluate the effect of study guides on improving self-learning skills of medical students in the Iran University of Medical Sciences (IUMS). In this quasi-experimental study, 46 medical students were randomly assigned into two groups; the intervention group and the control group. Both groups participated in a diagnostic test at the beginning of the course (pre-test). The same test was taken at the end of the course (post-test). The intervention group was provided with study guides on thyroid disorders and diabetes. Meanwhile, they continued their routine clinical training. The control group was only involved in the conventional training program. Students in the intervention group were also asked to complete a designed questionnaire in regard to their attitude toward the study guides. At enrollment, there was no statistically significant difference between the two groups. The mean scores of the pre-test for the control group and the intervention group were 6.18 and 6.13 respectively (P=0.9). In the post-test, the mean score of the students in the intervention group was considerably higher: 9.25 vs. 12 (P=0.002). The students in the intervention group found the study guides useful. The study guides were potentially effective in motivating self-learning in this group of medical students and had a remarkable effect on their final score.

The prevalence of Metabolic syndrome (MetS) has been increased in Asian countries. It represents a cluster of cardiovascular risk factors including obesity, insulin resistance, lipid abnormality and hypertension.. The purpose of this study was to assess the association between MetS and outcome in patients undergoing coronary artery bypass grafting surgery (CABG)..Patients and This prospective study was performed on patients scheduled for coronary artery bypass grafting surgery (CABG). All the patients were followed up in hospital and three months afterward. Patients were excluded if they were younger than 18 years or had severe comorbidities, a history of valvular heart disease, and low ejection fraction.. A total of 235 patients (135 women) with a mean age of 59 ± 9.3 years were included. MetS was more prevalent in women (P < 0.001). The most prevalent complications were bleeding [20 (8.5%)] and dysrhythmia [18 (7.7%)]. At three months follow-up, the frequency rates of readmission [24 (10.2%)] and mediastinitis [9 (3.8%)] were higher than other complications. Diabetes and MetS were risk factors for a long ICU stay (> 5 days) and atelectasia (P < 0.05). Significant associations were observed between diabetes and pulmonary embolism (P = 0.025) and mediastinitis (P = 0.051).. Identification of MetS before CABG can predict the surgery outcome. Patients with MetS have increased risks for longer ICU stay and atelectasia..

Clinical assessment of distal symmetric polyneuropathy (DPN) involves the evaluation of symptoms and signs. Although there are numerous tools to evaluate DPN, there is still a need to determine the most sensitive, specific, and accurate tests to detect DPN in a busy outpatient clinical setting. A total of 107 patients with type 2 diabetes were examined using Michigan Neuropathy Screening Instrument (MNSI). Total score of the instrument was used as a standard to calculate sensitivity, specificity and diagnostic accuracy of every single item of MNSI to find the most accurate and applicable test for evaluation of DPN. In patients’ history, the most sensitive (99.4%) and accurate (78%) symptoms were muscle cramp and weakness. Numbness and prickling had lower sensitivity (72.6% and 67.9%, respectively) but greater specificity (65.2% and 47.8%). In physical assessment, the most accurate signs were appearance of feet (81.3%), ankle reflexes (67.2%), and vibration perception (63.5%). Monofilament test had a sensitivity of 16.7%, accuracy of 31.7% with specificity of 87%. Findings show that symptoms such as a muscle cramp, weakness, numbness, and prickling, as well as signs such as ankle reflexes, appearance of feet, and vibration could be used as the most accurate tests for rapid diagnosis of DPN. In addition, the results suggest that monofilament examination may not be the optimum test to detect high risk patients.

Autoimmune thyroid diseases (ATD) are multifactorial conditions that result from genetic predisposition in combination with environmental risk factors. Helicobacter pylori infection as an environmental risk factor has been proposed to imitate the antigenic components of the thyroid cell membrane and may play a leading role in the onset of the autoimmune diseases, such as Hashimoto thyroiditis. The aim of this study was to investigate the association between Helicobacter pylori (HP) infection and Hashimoto''s thyroiditis (HT). The participants in this case-control study included 43 patients affected by Hashimoto''s thyroiditis, and 40 healthy individuals without history of autoimmune disease as the control group. Anti HP IgG and anti-TPO antibodies were determined using ELISA method. Results were considered positive when the IgG anti-HP value was higher than 30 IU/ml and the anti-TPO autoantibody value was higher than 75 IU/ml. The mean TSH level was 18.3±16.8 IU/ml for patients and 2.8±1.2 IU/ml for the control group (P<0.001). 46.5% of the patient group and 10.8% of the control group were infected with HP. The association between HP and Hashimoto''s thyroiditis was statistically significant (Odds Ratio=7.2, 95%, Confidence Interval: 2.0- 28.8, P<0.001). The findings show that, there is an association between HP and Hashimoto''s thyroiditis. To establish a definite correlation between them, more detailed studies with a more specialized examination and precise consideration regarding species of HP, genetic polymorphism of the host and investigation of environmental factors are needed.

Chronic obstructive pulmonary diseases (COPD) have been defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as irreversible conditions which are diagnosed by fixed cut-off points of FEV1/FVC.. The aim of this study was to determine the cut-off points for FEV1/FEV6 ratio and FEV6 as alternatives for FEV1/FVC and FVC in detection of airway obstruction and lung restriction, respectively.. A total of 318 Spiro metric examinations of subjects referred to Shariati hospital were analyzed. A subject was considered to have obstruction if FEV1/FVC was lower than 70%. The restriction was defined as FVC < 80% in the absence of obstruction. The Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of FEV1/FEV6 and FEV6 were calculated.. This study shows that the current cut-off points used to detect obstruction and restriction can be replaced by FEV1/FEV6 < 71% and FEV6 < 83%, respectively. FEV1/FEV6 had sensitivity of 95.5% and specificity of 99.4%; the PPV and NPVs were 99.3% and 96.3%. The prevalence of obstruction was 49.4%. For restrictive pattern, FEV6 had sensitivity of 93%, specificity of 79.5% with PPV of 18% and NPV of 99.5%. The prevalence of restriction was 6.3%.. The FEV1/FEV6 ratio can be used as a valid surrogate for FEV1/FVC in the diagnosis of airway obstruction, especially for screening purposes in high-risk populations for COPD. Moreover, FEV6 is an acceptable alternative for FVC in detection of restrictive pattern..

The aim of this study was to determine the frequency of distal symmetric polyneuropathy (DSP) and the role of physical examination for neuropathy diagnosis in subjects with type 2 diabetes mellitus.

A cross-sectional study was carried out from 2009 to 2010. A total of 107 patients with type 2 diabetes were evaluated using the Michigan Neuropathy Screening Instrument (MNSI). MNSI consists of two parts: History and physical assessment. History was focused on positive (burning, tingling) and negative (numbness) sensory symptoms, cramps and muscle weakness, foots ulcers or cracks, and prior diagnoses of diabetic neuropathy by a physician. Physical assessment was determined from foot appearance, ulceration, ankle reflexes, vibratory perception and monofilament testing.

A total of 72 women and 35 men were participated in this study. The frequency of neuropathy diagnosed based on physical assessment was 78.5%. The mean age was 57.6 (± 10.2) and the mean duration of diabetes was 10.2 (± 7.3) years. Ankle reflexes were not observed in both both foot in 67% of patients. Vibration perception was absent in 25% of patients. Monofilament testing was normal in 86% of patients in both feet.

The results showed a key role of physical examination in diagnosis of DSP in diabetic patients. The high frequency of DSP among diabetic patients demonstrated the importance of annual screening, further evaluations, planning and management of patients in diabetic foot clinics. However, considering the results of this study, the sensitivity of monofilament test in screening of DSP is questionable.

Several investigations have been conducted on the effects of Islamic Ramadan fasting on blood glucose levels and lipid profile of type two diabetic subjects. However، this matter remained to be controversial. This study was designed to investigate the effect of Ramadan fasting and structured SMBG on blood glucose control in this group of subjects. Forty type two diabetic subjects on oral agent were selected. These subjects were randomly divided into two equal groups and matched based on their age and sex. Group A monitored their blood glucose level using structured SMBG method and group B monitored their blood glucose level in a traditional way. Fructosamine level، total cholesterol، LDL، HDL and TG were measured in all subjects before and after Ramadan. Fructosamine level raised from 363 (±53. 55) to 400. 29 (±73. 25) (P < 0. 003) in group A and from 388. 52 (±61. 89) to 411. 10 (±68. 37) (P < 0. 04) in group B. Total chol، LDL and TG levels were increased and HDL level was decreased in both groups; however، these changes were not statistically significant. Poor metabolic control despite structured SMBG method is observed in this study. This might be due to have high caloric diet and less physical activity during Ramadan in order to prevent hypoglycemic attacks.

Self-Monitoring of Blood Glucose (SMBG) is considered as a key factor in management of people with diabetes which is a growing and cost demanding health problem. The purpose of this study was to investigate the effect of comprehensive patient management using structured SMBG on metabolic control as well as its cost consequence analysis. Sixty subjects were recruited in an observational study for a period of 6 months. They were provided with the ACCU-CHEK 360° View tool to fill in the values of the 7-point blood glucose profiles in three consecutive days during the study on a monthly basis. Changes in metabolic control were assessed by HbA1c and lipid profile measurement at the beginning and at the end of the study. In addition, cost consequence analysis was done considering different level of health care professionals with or without insurance coverage. The Average Cost Effectiveness Ratio (ACER) as well as Cost saving analysis were calculated and compared. The analysis showed significant reduction in HbA1c during the 6-month period in all subjects (P = 0.000). Furthermore, a positive effect was observed on lipid profile. The cost of endocrinologist’s visit in private sector was estimated to be 265.76 USD while this figure was149.15 USD for general practitioner in public sector with insurance coverage. Total complications and mortality cost saving was 154.8 USD. The lowest ACER was calculated for intervention with general practitioner in public sector with insurance coverage. Structured SMBG results in significant improvement of glycemic status. Moreover, it is more cost saving in public sector with insurance coverage. It seems that general practitioner visits with insurance coverage is the most affordable option for people with type 2 diabetes.

Diabetic retinopathy is a chronic complication of diabetes that can result in blindness. Generally, there are two stages of diabetic retinopathy, non-proliferative and proliferative. The longer a person has diabetes and the poorer metabolic control, the higher the chance of developing diabetic retinopathy. The majority of people with type 2 diabetes will ultimately develop diabetic retinopathy. Multifactorial therapy targeted to lifestyle modification and optional glycemic control reduces the risk. However, diabetic retinopathy develops or progresses with time. Primary (preventive) strategies include glycemic, lipid, and blood pressure control. Glycemic control effectively reduces the incidence of diabetic retinopathy. In additional, its effect on progression of diabetic retinopathy has been demonstrated in randomized clinical trials. Furthermore, tight control of blood pressure significantly reduces the progression of retinopathy and visual loss. However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study Group has shown that intensive blood pressure control has no beneficial effect on reducing the rate of diabetic retinopathy in subjects with type 2 diabetes. Elevated serum lipids and dyslipidemias are associated with a higher risk of diabetic retinopathy. The beneficial effects of lipid-lowering agents on the progression of retinopathy have been reported. Intensive combination therapy for dyslipidemia has been shown to effectively reduce the rate of progression of diabetic retinopathy in type 2 diabetes. Secondary strategies are focused on various pathophysiologic approaches such as blockade of the renin angiotensin system (RAS), anti-vascular endothelial growth factor agents, somatostatin analogues, protein kinase inhibitors, and anti-inflammatory agents. The purpose of the current overview is to look into the medical management of diabetic retinopathy, and to explore the primary (preventive) measures as well as secondary strategies proposed to be effective in its medical management.

Verbal memory and executive function might be disturbed in subclinical hypothyroidism. The aim of this study was to explore the effect of levothyroxine treatment on the memory quotient of Anti-TPO-Ab positive subjects with subclinical hypothyroidism. Sixty Anti-Tpo-Ab positive subjects (51 female, 9 male) with subclinical hypothyroidism with a mean age of 34 were enrolled in this randomized double blind placebo controlled trial. Subjects were randomized into two groups, i.e. the case (26 females- 4 males) and the controls (25 females, 5 males) groups. Using the Weschler memory test, memory quotient was assessed at the beginning and three months after initiation of levothyroxine treatment. The mean age of subjects was 34.22±10.75 y and the mean TSH level was 8.25±3.64 mIU/l. There was no difference between two groups in relation to the memory quotient at the beginning of the study (10.5.70±11.66 vs 105.87±11.49, P=0.83). Following treatment the mean for the memory quotient rose by 9.9±8.01 in the cases and 3.23±7.63 in the controls (P=0.002). In this study we observed an increase in the memory quotient after treatment with levothyroxine in individuals with subclinical hypothyroidism, demonstrating that levothyroxine treatment could be recommended to improve verbal memory and executive function in this group of subjects.