Idiopathic granulomatous hypophysitis presenting with galactorrhea, headache, and nausea in a woman: a case report and review of the literature.

BACKGROUND: Inflammation of the pituitary gland can occur in a variety of primary or secondary disorders. Idiopathic granulomatous hypophysitis is a rare inflammatory disease of the pituitary gland that can closely mimic a pituitary adenoma clinicoradiologically. Most authorities agree on minimally invasive transsphenoidal surgery as the mainstay in diagnosis and treatment of this disorder. There is still some controversy regarding pure medical management of idiopathic granulomatous hypophysitis in the literature. CASE PRESENTATION: A 47-year-old Iranian woman of Azeri ethnicity with a history of benign breast cysts with a chief complaint of galactorrhea presented to our endocrinology clinic. Her past medical history was negative for any menstrual irregularities, hirsutism, visual complaints, diplopia, polyuria and polydipsia or seizures. She was taking 100 mcg of levothyroxine daily. Her familial history and physical examination were unremarkable. Her initial laboratory work-up revealed hyperprolactinemia (82.4 ng/mL) with otherwise normal pituitary axes. Brain magnetic resonance imaging showed a pituitary macroadenoma for which she was treated with 0.5 mg of cabergoline weekly. Although her serum prolactin level dropped to 1.7 ng/mL and her galactorrhea was resolved, she continued to complain of headaches and nausea. Repeated imaging showed no decrease in size of the macroadenoma. Therefore, she underwent transsphenoidal surgery of the macroadenoma which was reported as chronic granulomatous hypophysitis by expert pathologists. Tuberculosis, sarcoidosis, Wegener's granulomatosis, Langerhans cell histiocytosis, and syphilis were ruled out by appropriate tests and she was diagnosed as having idiopathic granulomatous hypophysitis. Fortunately, her condition was not complicated by hypopituitarism and she was symptom free 9 months after transsphenoidal surgery. CONCLUSIONS: Idiopathic granulomatous hypophysitis, a rare inflammatory disease of the pituitary gland, is a diagnosis of exclusion for which both medical and surgical management are reported in the literature. We present a case of idiopathic granulomatous hypophysitis who was symptom free with no complications of hypopituitarism following its transsphenoidal resection after 9 months of follow-up.

Leech Induced Pyoderma Gangrenosum in an Ulcerative Colitis Patient: A Case Report.

Pyoderma gangrenosum (PG) is a painful skin lesion that results from excessive inflammatory response to a host of traumatic, inflammatory, or neoplastic processes in susceptible individuals. A clear pathogenetic mechanism as well as an exhaustive list of potential triggers for PG is yet to be fully characterized. This case documents the occurrence of pyoderma gangrenosum following leech-therapy in a patient who is a known case of ulcerative colitis and it deserves attention because leeches have been part of medical armamentarium since ancient times and have re-emerged in the last century relying on their ancient charm and modern research revealing potential benefits of several bioactive substances in their saliva.

Clinical Clerkship Education Improves With Implementing a System of Internal Program Evaluation Using Medical Students' Feedbacks.

Quality of clinical education for medical students has always been a concern in academic medicine. This concern has increased in today's time-squeeze while faculty members have to fulfill their complementary roles as a teacher, researcher, and practitioner. One of the strategies for program evaluation is obtaining trainees' feedbacks since they are the main customers of educational programs; however, there are debates about the efficacy of student feedback as a reliable source for reforms. We gathered Likert scores on a 16-item questionnaire from 2,771 medical students participating in all clerkship programs in a multidisciplinary teaching hospital. An expert panel consisting of 8 attending physicians established content validity of the questionnaire while a high Cronbach's Alpha (0.93) proved its reliability. Summary reports of these feedbacks were presented to heads of departments, clerkship program directors, and hospital administrators, at the end of each semester. Analysis of variance was used for comparing hospital scores across different time periods and different departments. Significant changes (P<0.001) were observed in mean scores between different semesters (partial η2=0.090), different departments (partial η2=0.149) as well as the interaction term between departments and semesters (partial η2=0.111). A significant improvement in mean clinical education score is noticeable after three semesters from the beginning of the survey. Periodic, systematic trainee's feedback to program directors can lead to an improved educational performance in teaching hospitals.

Polypill for the prevention of cardiovascular disease (PolyIran): study design and rationale for a pragmatic cluster randomized controlled trial.

BACKGROUND: The complexity of treatment regimens, costs and pill burden decrease the medication adherence and contribute to shortfall in cardiovascular preventive drug coverage. The polypill, a fixed dose combination pill of established drugs, is expected to increase adherence and reduce the costs whilst preventing major cardiovascular events (MCVE). DESIGN AND METHODS: The PolyIran trial is a pragmatic cluster randomized trial nested within the Golestan Cohort Study (GCS). Subjects were randomized to either non-pharmacological preventive interventions alone (minimal care arm) or together with a polypill (polypill arm) comprising hydrochlorothiazide, aspirin, atorvastatin and either enalapril or valsartan. This study benefits from the infrastructure of the primary health care system in Iran and the interventions are delivered by the local auxiliary health workers (Behvarz) to the participants. The primary outcome of the study is the occurrence of first MCVE within five years defined as non-fatal and fatal myocardial infarction, unstable angina, sudden death, heart failure, coronary artery revascularization procedures, and non-fatal and fatal stroke. TRIAL STATUS: From February 2011 to April 2013, 8410 individuals (236 clusters) attended the eligibility assessment. Of those, 3421 in the polypill arm and 3417 in the minimal care arm were eligible. The study is ongoing. CONCLUSION: The infrastructure of GCS and the primary health care system in Iran enabled the conduct of this pragmatic large-scale trial. If the polypill strategy proves effective, it may be implemented to prevent cardiovascular disease in developing countries.

Prevalence, awareness and risk factors of hypertension in a large cohort of Iranian adult population.

BACKGROUND: There is considerable variation in hypertension prevalence and awareness, and their correlates, across different geographic locations and ethnic groups. We performed this cross-sectional analysis on data from the Golestan Cohort Study (GCS). METHODS: Enrollment in this study occurred in 2004-2008, and included 50,045 healthy individuals from Golestan Province in northeastern Iran. Hypertension was defined as a SBP at least 140 mmHg, a DBP at least 90 mmHg, a prior diagnosis of hypertension, or the use of antihypertensive drugs. Potential correlates of hypertension and its awareness were analyzed by logistic regression adjusted for sex, age, BMI, place of residence, literacy, ethnicity, physical activity, smoking, black and green tea consumption and wealth score. RESULTS: Of the total cohort participants, 21,350 (42.7%) were hypertensive. Age-standardized prevalence of hypertension, using the 2001 WHO standard world population, was 41.8% (95% confidence interval: 38.3-45.2%). Hypertension was directly associated with female sex, increased BMI, Turkmen ethnicity, and lack of physical activity, and inversely associated with drinking black tea and wealth score. Among hypertensive patients, 46.2% were aware of their disease, 17.6% were receiving antihypertensive medication, and 32.1% of the treated patients had controlled hypertension. Hypertension awareness was greater among women, the elderly, overweight and obese patients, and those with a higher wealth score. CONCLUSION: Hypertension is highly prevalent in rural Iran, many of the affected individuals are unaware of their disease, and the rate of control by antihypertensive medications is low. Increasing hypertension awareness and access to health services, especially among less privileged residents are recommended.

Hepatitis B Virus Infection during Pregnancy: Transmission and Prevention.

Hepatitis B virus (HBV) infection is a global public health problem. In endemic areas, HBV infection occurs mainly during infancy and early childhood, with mother to child transmission (MTCT) accounting for approximately half of the transmission routes of chronic HBV infections. Prevention of MTCT is an essential step in reducing the global burden of chronic HBV. Natal transmission accounts for most of MTCT, and providing immunoprophylaxis to newborns is an excellent way to block natal transmission. Prenatal transmission is responsible for the minority of MTCT not preventable by immunoprophylaxis. Because of the correlation between prenatal transmission and the level of maternal viremia, some authors find it sound to offer lamivudine in women who have a high viral load (more than 8 to 9 log 10 copies/mL). In addition to considerations regarding the transmission of HBV to the child, the combination of HBV infection and pregnancy raises several unique management issues. Chronic HBV infection during pregnancy is usually mild but may flare after delivery or with discontinuing therapy. Management of chronic HBV infection in pregnancy is mostly supportive with antiviral medications indicated in a small subset of HBV infected women with rapidly progressive chronic liver disease.