Caspian Journal of Internal Medicine
Volume:10 Issue: 3, Summer 2019

Among the blistering (vesicant) chemical warfare agents (CWA), sulfur mustard is the most important since it is known as the “King of chemical warfare agents”. The use of sulfur mustard has caused serious damages in several organs, especially the eyes, skin, respiratory, central and peripheral nervous systems after short and long term exposure, incapacitating and even killing people and troops. In this review, chemical properties, mechanism of actions and their effects on each organ, clinical manifestations, diagnostic evaluation of the actions triage, and treatment of injuries have been described.

With the growing population of the elderly, the prevalence of disabilities and chronic diseases will also likely increase. Muscle weakness leads to low amounts of physical activity in elderly diabetic patients and makes them susceptible to falls. In this study, we aimed to compare the muscle strength between diabetic and non-diabetic elderly individuals.
The present study is part of the the Amirkola Health and Ageing Project (AHAP) cohort performed on 1320 elderly individuals. Diabetic and non-diabetic subjects were considered as case and control groups, respectively. A diagnosis of diabetes was assigned to patients who were previously diagnosed and those with repeated fasting blood sugar FBS≥126mg/dl. Digi Hand Dynamometer device and manual muscle testing (MMT) grading systems were used to assess muscle force in the upper and lower extremities, respectively. Data were then analyzed and p<0.05 was considered significant.
29.8% of the total participants (n=393) were diabetics. In the case group, 143 (36.4% of all diabetics) had weak upper extremity muscles. The number was 314 (33.9%) among non-diabetics (P=0.38). We saw decreased lower extremity muscle force in 134 (34.1%) diabetic individuals and 292 (31.5%) non-diabetics (P=0.35). Statistical analysis showed no significant difference in any of the lower or upper extremity muscle forces between diabetics and non-diabetics (p>0.05).
Our findings indicate that diabetes mellitus (DM) affects neither the upper nor the lower extremity muscle force in the elderly.

Given the fact that various studies have reported the positive effects of hydroxyethyl starch therapy in controlling shock, this study aimed to compare the effects of hydroxyethyl starch on modifying acidosis and treating patients with aluminum phosphide poisoning.
This was a randomized clinical trial that was conducted on 60 patients with aluminum phosphide poisoning. We compared the two groups of patients treated with hydroxyethyl starch and normal saline. Base excess and serum pH of arterial blood gases (ABG) were measured before and after the treatment and compared by t-test.
Results showed that arterial pH in the starch group and normal saline group increased by 0.13 and 0.18, respectively, and the difference between the two groups was not statistically significant. The difference in the base excess before and after treatment in the starch group and normal saline group was 6.41 and 5.39, respectively, and the difference between the two groups was not statistically significant. Changes in mean values of arterial pH after the intervention in comparison with before treatment were statistically significant (p<0.05).
Overall, the results of the present study show that starch is at least as effective as normal saline in treating acidosis in patients poisoned with aluminum phosphide and can be used instead of normal saline, and both of the two treatments could be equally effective.

Recent evidence has indicated that beta-secretase 1 (BACE1) is involved in the production of amyloid beta (Aβ) in patients affected with Alzheimer’s disease (AD). Therefore; the purpose of this study was to measure mRNA and plasma levels of BACE1 in AD patients, as an early diagnosis biomarker for such individuals.
A total number of thirty AD patients and thirty normal subjects as controls were recriuted in the present study. Plasma levels of BACE1 were then examined via enzyme-linked immunosorbent assay (ELISA) and also mRNA expression of BACE1 in total blood was measured using real-time PCR technique.
The findings revealed a significant difference in gene expression of BACE1 in the peripheral blood of AD patients compared with that in controls (p<0.0001). Additionally, elevated plasma levels of BACE1 were found in AD patients compared with those in normal subjects (p<0.01). Statistical analyses also demonstrated no correlation between expression (mRNA and protein) of BACE1 in both AD patients and controls and age or the results of Mini-Mental State Examination (MMSE) scale (p>0.05).
Given the importance of early diagnosis of AD patients, it was suggested that the measurement of plasma levels and also mRNA expression of BACE1 might be a valuable blood-based biomarker used in preference to other invasive diagnostic methods such as cerebrospinal fluid (CSF) analysis.

There is conflicting data about prognostic implication of electrocardiographic (ECG) left ventricular hypertrophy (LVH) in patients with first non- ST-segment elevation myocardial infarction (NSTEMI). We aimed to examine the association of left ventricular hypertrophy (LVH) on admission electrocardiogram with adverse outcomes in patients with NSTEMI.
In the present study, 460 patients (77.5% males with mean age of 65.44±13.15 years) with first NSTEMI were evaluated. ECG left ventricular hypertrophy (LVH) was diagnosed based on Sokolow-Lyon voltage criteria. Baseline laboratory and clinical results, angiographic data, as well as in- hospital adverse events were compared between the patients with and without LVH.
Electrocardiographic LVH was observed in 74 (16.1%) patients. Patients with LVH had higher admission systolic blood pressure (132.91±21.08 vs 125.80±21.78; P=0.01) and higher peak troponin (6.42±1.03 vs 4.41±0.28; P=0.004), but less likely to undergo coronary angiography (54.1% vs 66.8%; P=0.03) .Patients with electrocardiographic LVH had similar in-hospital mortality (5.4% vs 3.6%, P=0.5) and heart failure/ pulmonary edema (2.7% vs 2.07%, P=0.6) compared to patients without LVH.
The present study showed that among the patients with first NSTEMI, electrocardiographic LVH was not associated with increased in-hospital adverse events.

Type 2 diabetes mellitus (DM) and chronic periodontitis (CP) show common pathophysiological features. We investigated the serum levels of IL-23 and IL-35 in people with type 2 DM and CP.
In a cross-sectional study, 72 patients were divided into four equal groups: group A, participants without type 2 DM and CP; group B, patients with type 2 DM without CP; group C, patients with CP and without type 2 DM; and group D, patients with type 2 DM and CP. Demographic data were obtained and periodontal conditions including clinical attachment loss, bleeding on probing, plaque index, gingival index, and probing depth was evaluated on all existing teeth. Fasting blood sugar (FBS) levels, hemoglobin (Hb) A1c, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were assessed. In addition, serum levels of IL-23 and 35 were measured using enzyme-linked immunosorbent assay.
The serum levels of IL-23 and 35 showed no significant differences between all groups (P>0.05). A significant positive correlation between the serum concentration of IL-23 and clinical attachment loss in the control group (r: 0.548, P=0.019) was detected. A significant negative correlation between IL-35 and the plaque index in group B (r: -0.578, P=0.012), plus significant negative correlations between IL-23 with ESR (r: -0.487, P=0.040) and CRP (r: -0.498, P=0.035) in groups C and D were also detected.
Despite significant associations of serum concentration of IL-23 and 35 with certain periodontal and inflammatory indices, neither type 2 DM nor CP differentially affects serum levels of these two cytokines.

As populations of elderly grow, the prevalence of type 2 diabetes and hypertension increases. These diseases can be asymptomatic for a long time and cause irreversible damages to organs. Therefore the aim of this study was to evaluate the prevalence of undiagnosed hypertension and diabetes among the elderly in Amirkola.
This is a descriptive/analytical cross-sectional study and a part of the first phase of a cohort study on the health status of the elderly in Amirkola (a city in the North of Iran) which has been conducted on all people aged 60 and over since 2011. The demographic information was collected using a questionnaire, the hypertension was diagnosed by measuring blood pressure in lying down- position and the diabetes was diagnosed by measuring fasting blood glucose level.
This study was conducted on 1568 elderly participants including 703 (44.8%) females and 865 (55.2%) males. The overall prevalence of diabetes was 30.6% of which, 23.3% was diagnosed and 7.4% was undiagnosed. Nearly one-fourth (24.1%) of the participants with diabetes were unaware of their disease. Thirty-one percent of the people with undiagnosed diabetes also had undiagnosed hypertension. The overall prevalence of hypertension in this study was 62.8%, including 41.2% diagnosed and 21.5% undiagnosed hypertension.
Regarding the results of this study and the high prevalence of undiagnosed diabetes and hypertension in elderly, improving the individual’s general awareness and screening in older adults for timely management are necessary.

Distal radius fractures constitute 17% of all fractures and 75% of forearm fractures in adults. Due to the vital role of the hands in a wide range of daily tasks, quick recovery and fewer complications for the patients are important. The purpose of this study was to compare the two common treatments of distal radius fractures namely, percutaneous pinning and pin-in-plaster.
An observational analytical cohort study was conducted on 74 patients with distal radius fracture treated with percutaneous pinning fixation and pin-in-plaster techniques. The patients, aged more than or equal to 18 years with unilateral, closed and unstable distal radius fractures were treated in Shahid Beheshti Hospital during 2007 to 2010.The data were entered into the SPSS Version 20 statistical software and analyzed by student’s t-test, one-way ANOVA and repeated measures test.
Randomly, 31 patients were in pin-in-plaster group and 43 patients in percutaneous pinning group. The patients’ age range was 18-74 years. The average of radial inclination and palmar tilt after 6 weeks was significant (P=0.02, p<0.0001) in patients with percutaneous pinning. The performance of the patients after 3 and 12 months in both groups was significant (p=<0.0001).
This study revealed that in approach to unstable DRF in adults, PCP method shows better improvement compared to PP technique.

Irisin is a myokine that regulates energy metabolism by inducing browning of adipose tissue. The aim of this study was to evaluate the relationship between irisin level and biochemical parameters of chronic kidney disease (CKD) patients in stage 2 and stage 4.
The research was a cross-sectional study; the study population included patients with CKD who were over 18 years of age, included 90 individuals with CKD, of these participants, 45 were in the second stage of the CKD while the other 45 subjects were in the fourth stage. Serum irisin concentration plus the level of glucose (Glu), urea, creatinine (Cr) and hemoglobin (Hb) were measured.
In the present study, the serum irisin level of patients in stage 4 was significantly reduced (13.00 ng / ml) compared with patients in stage 2(21.41 ng / ml).
With the progression of CKD from stage 2 to stage 4, parameters such as serum Cr, TG, LDL, FBS, BUN and urea levels significantly increased. Inversely, factors such as irisin, GFR, Alb, HDL and Hb levels significantly decreased. These findings suggest that irisin may be involved in the regulation of biochemical factor levels in CKD patients through the progression from stage 2 to stage 4.

Neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR) and platelet-lymphocyte ratio (PLR) have a prognostic value in several types of diseases such as cancers and they vary in different races. So, we aimed to evaluate the normal range of these markers among healthy people to determine the normal value in Iranian population.
In the present study, cross-sectional data of population-based cohort study named “Tabari cohort study” was utilized. In the first phase of Tabari cohort, 10255 participants aged 35-70 years from urban and rural areas of Sari, Mazandaran, Iran entered into the study. The study included a questionnaire survey and blood collection. Blood samples were collected after 12 hours fasting from all participants during the study. Hematological indices were measured for all samples using Celltac Alpha MEK-6510 K (Tokyo, Japan).
After sample exclusion, 2212 healthy subjects of Tabari's normal cohort population were investigated. The mean age of the samples was 47.9±9.29 years. The mean of NLR, LMR, PLR were 1.70±0.70, 11.15±3.14 and 117.05±47.73, respectively.
Our investigation provides preliminary reference values for NLR, LMR, and PMR among Iranian population that can be used for disease progress in various clinical procedures.

Hepatitis C virus (HCV) is a blood-borne virus. It is a major global public health problem and can cause both acute and chronic hepatitis. The aim of this study was to report the epidemiological features of HCV infection and risk factors based on the data from Azar Cohort, East Azerbaijan province, Iran.
The population of this study comprised the people in the age range of 35-70 years from Azar Cohort, East Azerbaijan province, Iran. The study was conducted between 2015 and 2016. Based on cluster sampling, 4, 949 people were selected and invited to complete the questionnaire and perform the tests. Blood samples collected in this study were analyzed to detect the presence of antibodies against HCV using enzyme immunoassay (ELISA) Kit. The positive samples were re-tested by qualitative HCV-RNA polymerase chain reaction. All data were analyzed using SPSS version 19.0 software.
The mean age of the participants was 49.15±9.02 years. Of these participants, 54.3% (n=2686) were females. Seven people (0.14%) were detected as HCV positive and the highest frequency was seen in the age range of 40-50 (0.16%). There was a statistical significant relationship between history of hospitalization (P=0.02) and history of abnormal urine (P=0.01) with the frequency of HCV infection.
The findings of this study indicated that the frequency of hepatitis C virus infection is 0.14% in the general population of Azar Cohort.

Because of the importance of thyroid function and its effect on different organs, such as the heart, this study was aimed to evaluate the effect of levothyroxine on cardiac function in children with subclinical hypothyroidism.
This quasi-experimental study was performed on children aged 4-12 years old with diagnosis of subclinical hypothyroidism in Amirkola Children's Hospital during 2018-2019. Cardiac functional parameters, including ejection fraction (EF), fractional shortening (FS), ratio of early filling velocity to early diastolic mitral annulus velocity (E/E'), myocardial performance index (MPI), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-systolic diameter (LVESD), were measured by echocardiography at baseline and 6 months after levothyroxine treatment.
Out of the 30 subjects, 19 (63.3%) were boys and 11 (36.7%) were girls. The mean age was 6.60±2.13 years old. The mean EF index was 63.13±3.01 percent before treatment, which increased to 69.07±4.50 percent after treatment (p<0.001). Also, the mean FS was 31.83±1.62 percent before treatment, which improved to 35.10±1.13 percent after treatment (p<0.001). The mean MPI was 0.28±0.02 before treatment, which increased to 0.33±0.03 after treatment (p<0.001). On the other hand, no significant difference was found in the mean E/E' before and after treatment. The mean LVEDD decreased from 3.47±0.46 cm before treatment to 3.05±0.40 cm after treatment (p<0.001), whereas LVESD non-significantly decreased after treatment versus before treatment.
The results showed that treatment with levothyroxine may improve cardiac functional parameters in children with subclinical hypothyroidism.

Libman-Sacks endocarditis (LSE) is characterized by sterile lesions that commonly affect the aortic and mitral heart valves. Antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) have been associated with LSE. Cardiac manifestations including LSE could be interrelated with other manifestations and early diagnosis could help in preventing further complications. Here, we report three cases of LSE in SLE patients with secondary APS. All patients presented with neurological manifestations and LSE was diagnosed by Transesophageal echocardiography (TEE). All three patients were treated for the underlying disease and also received anticoagulant therapy. In all patients with SLE and secondary APS, LSE should be considered if a patient manifests any evidence of neurologic involvement.

Wegener granulomatosis or granulomatosis with polyangiitis is a pauci-immune small vessel vasculitis which is usually associated with anti-neutrophil cytoplasmic antibodies (ANCA) mainly in old men. This small vessel vasculitis is usually characterized by necrotizing granulomatous inflammation with multiorgan involvement. Kidneys could be involved as the main and life-threatening condition in Wegener granulomatosis.  Oral or ocular lesions may occur as the first and uncommon presentations before internal organ involvement in these patients and could be misdiagnosed with other diseases. We present a 24-year-old man with erosions and ulcerations on palatal mucosa and a strawberry-like gingival hypertrophy associated with nasal congestion and epistaxis which two stated months ago. Also he had an episode of unilateral blepharitis and upper eyelid edema five months ago. Mucosal biopsy showed perivascular infiltrations of mainly neutrophils, some eosinophils and rare giant cells. He had elevated level of proteinase 3–ANCA or C-ANCA with microscopic hematuria without significant kidney involvement in kidney biopsy. Mucosal lesions and hematuria improved after two months of treatment with oral prednisolone. Unilateral eyelid edema and mucosal erosions in a young man could be the uncommon presentations of Wegener granulomatosis.

Primary hypothyroidism is a common medical condition. It can lead to pituitary adenoma which is usually asymptomatic, but it can also lead to symptomatic macroadenomas which are hard to diagnose due to different clinical presentations. A 16-year-old girl presented for endocrinology consultation prior to neurosurgical operation. She had galactorrhea which was accompanied by vertigo & low grade blurred vision without a headache and was diagnosed with pituitary macroadenoma and was planned for a surgery. She had TSH level of more than 100 mU/L, free thyroxine of 1.9 pmol/L. Her thyroid peroxidase (TPO) antibody level was 13.3 IU/mL, insulin growth factor-1 392 µ/l and serum prolactin level 42 ng/ml. During physical exam and with the laboratory findings, we suspected for a primary hypothyroidism as the leading cause of pituitary macroadenoma. As the result, we cancel the surgery and start levothyroxine therapy 100µg daily for her. In the follow-up it revealed that our diagnosis was correct and she went into remission with pituitary gland shrinking and decreasing TSH and prolactin levels. It is important to understand the different presentation of primary hypothyroidism to decrease the unnecessary risk of maltreatment in patients.

Metastatic carcinomas to the upper jaw region are very rare and unfortunately occur in advanced stages of malignancies. Pancoast tumor is a challenging subset of lung carcinoma commonly followed by distant metastasis. Since the metastatic lesion of our patient was very huge and unusual, we decided to report the case. Our patient was a middle-aged heavy smoker male with a history of unresectable pancoast tumor. He was referred to the dental clinic with an expanded maxillary metastasis involving the bone and sinus region as well as oral soft tissues. To confirm the primary site of his malignancy, immunohistochemical staining was performed. Distant metastases of a pancoast tumor are more frequent when the primary tumor is unoperable and bone involvement is one of the early manifestations of disease.