مجله غدد درون ریز و متابولیسم ایران
سال ششم شماره 2 (پیاپی 22، تابستان 1383)

Postpartum thyroiditis (PPT) is an autoimmune disorder that occurs during the first months after delivery in approximately 5-10 percent of women. Although it usually has a transient course, because of the autoimmune pathogenesis, long term follow up reveals permanent hypothyroidism in 20-30 percent of patients. In this survey, we tried to determine the prevalence of permanent hypothyroidism and its prognostic factors 3-5 years after PPT. For this study, 1040 questionnaires from our previous study (Prevalence of PPT in Tehran 1998-1999) were reviewed and 54 women were invited 3-5 years after PPT as cases, and 50 healthy women were selected as controls. At the time of the visit, a questionnaire containing demographic information, signs and symptoms of thyroid disorders and physical examination was completed. Venous samples for T3, T4, T3RU (RIA), TSH (IMA) and anti-TPO and anti-Tg antibodies (ELISA) were obtained. Twenty-two percent of cases and four percent of controls had permanent hypothyroidism (p< 0.01). Comparison of mean anti-TPO antibody titers between hypothyroid and euthyroid women in case group showed statistical significance (436.9±283 vs. 126.2±221 IU/mL, p<0.001), but not for anti-Tg antibody. The difference in mean peak postpartum TSH level between hypothyroid and euthyroid women in case group was significant (55.8±24 vs. 23.1±28 mU/L, p<0.001), and also for mean peak postpartum anti-TPO antibody titer (1959±1270 vs. 640±959I U/mL, p< 0.001). The result of this survey, like other studies, shows high prevalence of permanent hypothyroidism (22.2%) after PPT in Iran. High titer of anti-TPO antibody and TSH level during postpartum period are prognostic factors for occurrence of permanent hypothyroidism and we recommend long term follow up for women with PPT after recovery from thyroiditis.

Thyroid nodules are important because of the risk of malignancy. Fine needle aspiration (FNA), the first diagnostic method in assessment of cytology of thyroid nodules, is a simple, available and cost-effective technique. The aim of this study was to compare the quality of cytomorphology sample, number of cells, the quality of architecture of thyroid papillae and follicles in FNA and fine needle non-aspiration (FNNA) techniques.

200 patients of Shariati hospital, with palpable thyroid nodules, 1 to 4 cm in size, were recruited. FNA and FNNA techniques were applied to each patient. In a single-blind setting, all specimens were examined by the same cytopathologist. The specimens were scored (0, 1 or 2) on the basis of background blood or clot, number of obtained cells, preserved architecture of papillae and follicles and cellular degeneration. Nonparametric methods were used to compare scores of the two techniques.

200 patients (162 female, 38 male) were entered the study. Specimens from 43 patients were inadequate. In the remaining 157 patients there was no statistically significant difference between average scores in the quality of cytomorphology sample, number of cells, quality of architecture of thyroid papillae and follicles and cellular degeneration in FNNA and FNA.

It seems that FNNA is not superior to FNA in the cytopathologic studies of thyroid nodules and there is an agreement between two methods.

The incidence of permanent and transient congenital hypothyroidism (CH) has been previously reported. This report illustrates the causes of transient CH. From February 1998 to August 2002, cord spot samples were collected on filter papers in Tehran and Damavand hospitals and TSH  20 mU/L (two-site IRMA) were recalled. Between 7-14 days of life or thereafter, serum values of TSH > 10 mU/L and T4 < 6.5 g/dL were considered as CH. After taking the history of maternal ingestion of thyroid affecting drugs and goitrogens during pregnancy and perinatal period, CH-affected newborns were underwent thyroid scanning (99mTC) and eutopic cases were followed up until May 2003. Discontinuation of L-T4 for four weeks and normal serum TSH and T4 values determined transient CH. Maternal and neonatal serum were assayed for thyrotropin receptor autoantibodies (TRAb) and their urine samples were assayed for iodine concentrations. Of 35067 neonates, 373 were recalled (1.06%), 35 had CH (1:1002 births), and 6 had transient CH (1:5845 births). Median urinary iodine concentration in CH neonates (n=26) and their mothers (n=25) was 363 (range 70-500) and 200 (72-410) g/L, respectively. The history of maternal ingestion of thyroid affecting drugs was negative and of goitrogens was minimal. Serum TRAb levels were normal. All mothers were exposed to iodinated disinfectants during perinatal period. Iodine excess (410-500 g/L) was detected in three cases with transient CH. Undue usage of iodinated disinfectants during perinatal period can result in transient CH in the offspring and should be prevented.

The purpose of the present study was to assess the impact of Mg+Zn, vitamin C+E, and combination of these micronutrients on serum lipid and lipoprotein profiles in type 2 diabetic patients. In a randomized, double blind, placebo controlled clinical trial, 69 type 2 diabetic patients under diet and hypoglycemic drugs were randomly divided into four groups. Each group received one of the following daily supplement for 3 months group M: 200 mg Mg and 30 mg Zn (n=16), group V: 200 mg vitamin C and 150 mg vitamin E (n=18), group MV: minerals plus vitamins (n=17), group P: placebo (n=18). Results indicate that after 3 months of supplementation mean serum levels of HDL-c and apolipoprotein A1 increased significantly in the MV group by 24% (50.4±19.3 vs. 40.6±10.8 mg/dL) and 9% (170±34 vs. 156±24 mg/dL), respectively (p<0.01). There were no significant changes in the levels of these parameters in the other 3 groups. Serum levels of total cholesterol, LDL-c, triglyceride, and apolipoprotein B were not altered after supplementation in all 4 groups. It is concluded that since co-supplementation of Mg, Zn, vitamin C and E significantly increases HDL-c and apolipoprotein A1, supplementation of these micronutrients should be recommended for type 2 diabetic patients based on their daily requirements.

Cerebral edema has long been recognized as a complication of treatment of diabetic ketoacidosis, particularly in children, with a poor outcome. The most reported feature is the use of hypotonic fluids with failure in rising sodium and a rapid decrease in serum osmolality. This prospective study was designed to determine the changes in sodium, potassium, glucose, PH and bicarbonate during the first eight hours of treatment in patients with diabetic ketoacidosis. Eighty-three patients under 20 years with documented diagnosis of diabetic ketoacidosis (DKA) were invited in order to determine the changes of serum sodium, potassium and glucose as well as the changes of blood gases during the first 8 hrs of treatment with normal saline and insulin infusion. Overall 63.9% of the patients were female and 36.1% were male. The mean patients’ age on presentation was 11.67±5.37 years and at the time of diabetes onset was 10.38±5.16 years. Past history of DKA attack was seen in 12% of cases and DKA was the first manifestation of diabetes in 37.3% of cases. During the first 8 hours of treatment, the means of potassium and glucose reduction were 0/83 meq/L and 316/23 mg/dL respectively. The means of sodium and bicarbonate increase were 7/79 and 4/75 meq/L respectively and the mean of PH increase was %16. Results of this study show that cerebral edema is rarely if ever seen if isotonic saline is used as the primary rehydration solution and during treatment sodium increment is helpful to prevent rapid fall in extra cellular fluid osmolality, so it seems isotonic saline is the appropriate initial replacement fluid.

Growht hormone (GH) and Insulin-like growth factor-1 (IGF-1) may be related to the secretion of gonadal hormones. Some reports show that GH therapy promoted puberty. It seems that GH and its related factors such as IGF-1 enhance the promotion of puberty by increasing leydig cells’ ability to secret testosterone. With regard to the high percentage of people with gonadal hormonal disease in the present study, the effects of GH and IGF-1 on the stimulation of gonads for testosterone production in premature male rats were observed. Premature wistar rats in 10 separate groups were studied. GH, IGF-1 and HCG were injected intraperitoneally together as separately. On the other hand, one mL of leydig cell suspensions that had been extracted from the testis of the four groups of the rats was incubated with GH, IGF-1 and HCG together or separately. Blood samples were collected from the treated rats and testosterone concentrations were estimated in the serums. Testosterone concentrations in treated leydig cell suspensions were also measured. GH administration increased the testosterone production (p=0.001) but GH together with IGF-1 and HCG did not significantly increase the secretion of testosterone in the rats. Injection of IGF-1 and hCG reduced the testosterone production compared with those received hCG alone (p=0.02). Leydig cells incubated with GH secreted more testosterone (p<0.0001). Testosterone secreted by the cells incubated with IGF-1 or GH and IGF-1 was increased but was not different (p<0.001). It seems that the direct effect of GH on testosterone production is more than its indirect effect through hypothalamus. LH (or HCG) is a major hormone in testosterone production and promotion of puberty, conversely, IGF-1 has no significant effect on the testosterone secretion.

Osteoporosis is one of the most common diseases among elderly adults and old people and it is associated with some risk factors. The aim of this study is to determine the osteoporosis risk factors among 40-60 year women in Tehran. This study was conducted on 749 non – pregnant women aged 40-60 years selected by cluster random sampling from urban population of Tehran. Related demographic and risk factors data were collected by a questionnaire. Dietary data was obtained by means of 3 days consecutive recalls and a calcium- rich food frequency questionnaire for one week. Data on physical activity and depression were obtained by standard questionnaires. Anthropometrical indicators and blood pressure were measured according to standard protocols. Bone mineral densities (BMD) of hip and spine were evaluated. Age (p<0. 001), menopausal status and its duration (p<0. 001), using estrogen and progesterone (p<0. 01), using supplements of multivitamin (p<0. 05) and calcium (p<0. 01) were associated with osteoporosis in both hip and spine. Drugs reducing bone density (p<0. 01) and body mass index (p<0. 001) were correlated with hip osteoporosis. Central obesity and systolic blood pressure were related to spine osteoporosis. No relationship was observed between depression, duration of sun light exposure, menarche age, period of reproducibility, history of osteoporosis in family and physical activity level with BMD in either hip or spine. As osteoporosis could lead to disability and death, it is recommended to consider risk factors in its prevention.

Localization of the parathyroid gland (PTG) is often a challenge even to the experienced surgeons. While preoperative gland localization studies can improve the chance of success, their expense, limited availability and questionable reliability have generally relegated their use to instances where unilateral exploration alone is desired or, reexploration is required. Selective staining of the PTG by intraoperative methylene blue (MB) dye is rapidly available, simple, and effective adjunct to intraoperative gland identification. The purpose of this study was to evaluate the effect of variation in the rate of dye infusion.

Ten dogs underwent parathyroid gland exploration under general anesthesia (Halothane-Oxygen). Following the identification and exposure of at least one parathyroid gland in each animal intravenous infusion of MB was initiated at a dose of 5-7. 5 mg/kg mix with 200 cc D/W 5%. In Group A (5 dogs) a rapid infusion over a period of 3 to 5 minutes and in Group B (5 dogs) a slow infusion over a period of 20 to 30 minutes was done. The patterns of dye uptake (early, maximum, and diminution time) were recorded. Several digital photography was taken. After identification, the glands were removed and confirmed as parathyroid tissue histologically.

All animals tolerated infusion of dye without any obvious adverse effect intaoperatively. Twenty glands were identified with 3 intrathyroidal glands. Mean time for early uptake, maximum uptake, and diminution time in Group A was 8. 2,17. 2,and 32 minute respectively and in Group B was 10. 8, 17. 4, and 40. 6. This study showed the rate of infusion does not affect staining and the staining was seen much earlier as mentioned before. The time to initial dye uptake occurred between 6 and 15 minutes following dye infusion in both groups.

This investigation has demonstrated that the time of infusion is an important variable, with gland up taken occurring at a point much earlier than previously described. The uptake of dye shortly after infusion suggests reserving its use for those instances when standard PTG exploration fails to identify the glands.

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders accounting for the majority of cases of unovulatory infertilities. It also predisposes the individuals to specific conditions including diabetes mellitus, cardiovascular disease, and breast and endometrial cancer. Regarding the geographic and racial variations of the clinical and para clinical features of this disorder, the present study was carried out to find the prevalence of these characteristics and their interrelationship in Kerman. One hundred and thirty patients with clinical diagnosis of polycystic ovarian syndrome underwent pelvic ultrasound and endocrine evaluation. Cases of late onset adrenal hyperplasia, hypothyroidism and pituitary prolactinoma were excluded. Oligomenorrhea and hirsutism were the most frequent complaints (78 and 59.2 percent, respectively). Acne was present in 25.2% of patients and 39.2% of the individuals had a normal body mass index. 81.5% (106) of cases revealed the characteristic ultrasonic picture of PCOS and in the remaining cases it was normal. There was a significant relationship between LH/FSH>2 and hirsutism. Hyperprolactinemia was significantly related to galactorrhea. There was a significant positive correlation between dehydroepiandrostrone sulfate level and LH/FSH>2. Elevated levels of 17-hydroxy progesterone were significantly more frequent in obese cases. No significant relationships were found between hormonal status and ultrasound or clinical features. it can be concluded that oligomenorrhea and hirsutism are the most prevalent clinical symptoms of PCOS in Kerman. Obesity is not a prominent feature of the disease and many cases have a normal body mass index. Some of the clinical and laboratory parameters of hyperandrogenism become more prevalent as the LH level rise. The prevalence of clinical and Para clinical characteristic of PCOS in Kerman is different from other parts of the world and this may reflect the effect of geographic and ethnic factors.

The purpose of this study is finding the importance of hCG, estradiol, and progesterone serum level changes in prediction of spontaneous abortion. In a prospective study of 34 women with threatened abortion between 5 and 12 weeks gestation, serum levels of human chorionic gonadotropin (hCG), progesterone and estradiol (E2) were measured by radioimmunoassay. The same hormones were also determined in a control group of 44 women with normal intrauterine pregnancy of corresponding gestational age. HCG was determined consecutively in two serum samples obtained at 2- to 4- day intervals progesterone and E2 measurements were performed in the first serum sample. Pregnancy continued in the normal controls and in 18 patients with threatened abortion beyond 20 weeks gestation (viable pregnancies) and 16 patients aborted spontaneously before this time. In this investigation we have used forion radioimmunoassy kits of Amersham company (Kavoshyar agency in Iran) with an acceptable specificity and sensitivity in Reference Laboratory in Iran. There was no significant difference in the mean maternal ages or gravidity between these groups (p>0.05). The doubling time of hCG in abortions were lower than those in normal pregnancies and viable threatened abortions, although statistical analysis was not possible due to small numbers of abortions with rising hCG titers. The levels of all three hormones were significantly lower (p<0.05 –p<0.0001) in abortions than those in normal pregnancies and viable threatened abortions of the same gestational age except the hCG in the fifth and sixth gestational weeks. Regardless of the levels of two other hormones, the doubling time of hCG concentration for the second time on fifth and sixth weeks of gestation can differentiate between abortion and viability. However, after the 7th gestational week serial determinations of hCG generally did not add much information to that obtained from its single measurement. Statistical analysis revealed no significant difference between normal pregnancies and viable threatened abortions in the means of any of the biochemical markers (P> 0.05). The best discriminatory progesterone concentration that predicted abnormal pregnancies was 10 ng/mL. No pregnancies continued normally when progesterone was 10 ng/mL. An E2 level above 200 pg/mL indicated a normal intrauterine pregnancy and therefore ruled out an abnormal pregnancy with a specificity of 95% and a sensitivity of 87.5%. Progesterone with a positive predictive value of 100% was by far the best predictor of abortion and hCG with a negative predictive value of 98.4% was the best estimator of viable pregnancy, although their efficiency was the same (97.4%). Like hCG, estradiol was also a better predictor of viable pregnancy than abortion (a negative predictive value of 97.6% versus a positive predictive value of 82%) but with less efficiency (93.6%). If paired values of hCG+estradioal, hCG+ progesterone, or progesterone + estradiol were low, abortion followed in 94,100, and 100% of cases, respectively. The combination that comprised low levels of all three hormones was unavoidably followed by abortion.