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1.  Association of Mutations in the Basal Core Promoter and Pre-core Regions of the Hepatitis B Viral Genome and Longitudinal Changes in HBV Level in HBeAg Negative Individuals: Results From a Cohort Study in Northern Iran 
Hepatitis Monthly  2015;15(2):e23875.
Although certain HBV mutations are known to affect the expression of Hepatitis e antigen, their association with HBV viral level or clinical outcomes is less clear.
We evaluated associations between different mutations in the Basal Core promoter (BCP) and Pre-core (PC) regions of HBV genome and subsequent changes in HBV viral DNA level over seven years in a population of untreated HBeAg negative chronic hepatitis B (CHB) participants in Northeast of Iran.
Materials and Methods:
Participants in the current study were drawn from the Golestan Hepatitis B Cohort Study (GHBCS), a cohort of approximately 2590 HBsAg positive subjects (living in Gonbad city) embedded in the Golestan Cohort Study (GCS). At baseline, HBsAg was measured in all participants and revealed 2590 HBsAg positive cases. We randomly selected 304 participants who their blood sample were taken at both baseline and seven years later in follow-up and had not been treated for HBV during this time. HBV viral load were assessed at baseline and at year 7. The BCP and PC regions of the HBV DNA, at baseline, were amplified via hemi-nested PCR and sequenced by cycle sequencing. At year 7, liver stiffness was assessed by fibroscan; also, other parameters of liver disease were assessed following standard clinical protocols. Associations were assessed via tabulation, chi-square, t-tests and logistic regression. P values < 0.05 were considered statistically significant and all tests were two-sided.
Among 304 HBsAg positive participants, 99 had detectable HBV DNA at study baseline. Of these, 61.6% had PC mutations (48.5% A1896 and 25.2% G1899). In contrast to other mutations, A1896 was associated with a higher proportion of detectable HBV DNA at year 7 (39.6%) compared to patients with the wild type (13.7%) (OR: 4.36, CI95% = 1.63-11.70; P Value = 0.002). Although participants with the A1896 mutation had higher year-7 HBV viral load than participants with G1896 (2.30 ± 1.66 IU/mL vs. 1.76 ± 1 IU/mL among patients with detectable HBV; P value = 0.052), no association was observed with either serum level ALT or liver stiffness. Interestingly, mutations in the basal core promoter (BCP) region had no significant effect on virus DNA detection.
In this population with chronic HBeAg negative hepatitis B, an association was observed between the G1896A mutation in the Pre-core region of HBV and subsequent level of HBV DNA seven years later, which indicated that mutations in this region of HBV genome may contribute to disease progression in these patients and play an important role in HBV natural course of disease.
PMCID: PMC4350247  PMID: 25788956
Hepatitis B, Chronic; Mutation; Genome, Viral
2.  Correlation Between Low Bone Density and Disease Activity in Patients with Ulcerative Colitis 
Different clinical and epidemiological studies using dual-energy X-ray absorptiometry have shown an increased prevalence of low bone mineral density in patients with inflammatory bowel diseases. The aim of this study was to assess the correlation between bone density and the disease activity in patients with ulcerative colitis.
In this cross-sectional study, 52 patients with ulcerative colitis (duration of the disease less than 5 years) were invited to our research center, Golestan province, northeast of Iran, during February 2012 up to August 2012. A demographic checklist and Simple Clinical Colitis Activity Index was completed for each patients and 5 cc of blood sample was taken after obtaining the informed consent. We used colorimetry method for measuring serum calcium, UV method for serum phosphorus and ELISA for serum vitamin D. Dual-energy X-ray absorptiometry was done to evaluate the bone density. Data analysis was done using SPSS software version 16. Normality of data was assessed using Kolmogorov– Smirnov test. T and ANOVA tests were used if data had normal distribution. Mann-Whitney U or Kruskal-Wallis tests were used for the remaining data. Correlation between qualitative variables was evaluated by Chi-square test.
The mean (±SD) age and disease activity of the patients were 37.72 (±12.18) years and 4.78 (±1.98), respectively. There were no correlation between disease activity and mean age. Low bone density was seen in 30.8%, 11.5%, and 15.4% in spine, femur neck, and hip, respectively. There was no relationship between Z-score of total hip, spine, and femur neck with disease activity, age, and duration of disease (p>0.05).
Our results showed an acceptable rate of low bone density in patients with ulcerative colitis without any correlation with the disease activity index.
PMCID: PMC4293797  PMID: 25628850
Ulcerative colitis; Z-score; Bone densitometry; Low bone density
3.  Cohort Profile: Golestan Hepatitis B Cohort Study- A Prospective Long Term Study in Northern Iran ​  
Hepatitis B virus (HBV) infection is the most common cause of end stage liver disease in Iran and in Golestan province. Large-scale population-based prospective cohort studies with long term follow-up are the method of choice to accurately understand the natural course of HBV infection. To date, several studies of HBV epidemiology, natural history, progression to cirrhosis and association with HCC have been reported from other countries. However, few of these are prospective and fewer still are population-based. Moreover, the underlying molecular mechanisms and immunogenetic determinants of the outcome of HBV infection especially in low and middle income countries remains largely unknown. Therefore, the hepatitis B cohort study (HBCS), nested as part of the Golestan Cohort Study (GCS), Golestan, Iran was established in 2008 with the objective to prospectively investigate the natural course of chronic hepatitis B with reference to its epidemiology, viral/host genetic interactions, clinical features and outcome in the Middle East where genotype D HBV accounts for >90% of infections. In 2008, a baseline measurement of HBV surface antigen (HBsAg) was performed on stored serum samples of all GCS participants. A sub-cohort of 3,505 individuals were found to be HBsAg positive and were enrolled in the Golestan HBCS. In 2011, all first degree relatives of HBsAg positive subjects including their children and spouses were invited for HBV serology screening and those who were positive for HBsAg were also included in the Golestan HBCS.
PMCID: PMC4208926  PMID: 25349681
4.  Potential Mutations Associated With Occult Hepatitis B Virus Status 
Hepatitis Monthly  2014;14(5):e15275.
Occult hepatitis B virus (HBV) status (OHBS) is simply defined as the presence of HBV DNA in the liver (with or without detectable HBV DNA in the serum), in the absence of serum HBV surface antigen (HBsAg). Importance of OHBS is mostly clinical, related to its possible role in spreading through blood transfusion and liver transplantation; causing classic forms of HBV. Mechanisms underlying this entity are poorly defined. Several possibilities have been suggested, with major classification into two groups: defective host immune response and viral replication activity through mutations of HBV DNA sequence. Mutations are extensively investigated in all four overlapping open reading frames (ORFs) of HBV genome, to define their possible role in the pathogenesis of OHBS. Some of these mutations like S-escape mutants could not be detected by the routine available assays, making them difficult to diagnosis. Therefore, trying to detect this covert condition could be more helpful for defining better preventive and therapeutic strategies.
Evidence Acquisition:
In the present study we provided an in-depth review of the most important new data available on different mutations in HBV genome of patients with OHBS, which may play a role in the pathogenesis of OHBS. The data were collected through reviewing the full-text articles, identified by the PubMed search, using the following keywords and their different combinations: occult hepatitis B, HBV genome, "a" determinant, HBV open reading frames, S mutations, X mutations, P mutations and C mutations.
Variants within the major hydrophilic region (MHR) of the HBsAg, deletions in the pre-S1region, codon stop in the S open reading frames (ORF), sporadic non common mutations, some mutations affecting the posttranslational production of HBV proteins in the S ORF like deletion mutations, mutations in start codon and nucleotide changes in the X ORF, deletion and point mutations in P ORF and sometimes, nucleotide substitution in the C ORF are among the assumed mutations detected to have a role in OHBS appearance.
Studies mostly lacked a control group and the whole-length HBV sequencing was scant with conflicting results, suggesting that OHBS is often a result of multiple mechanisms. Additional studies on full-length HBV genomes from occult and non-occult HBV cases may shed more light on the interplay between different mechanisms involved in the pathogenesis of OHBS.
PMCID: PMC4013497  PMID: 24829588
Hepatitis B; Mutation; Virus Diseases
6.  Modifiable Risk of Breast Cancer in Northeast Iran: Hope for the Future. A Case-Control Study 
Breast Care  2011;6(6):453-456.
Breast cancer is the most common cancer in women. Its prevalence is increasing annually by 2%. The determination of modifiable risk factors has been the subject of various studies. The aim of this study was to determine risk factors of breast cancer in women in Golestan Province.
Patients and Methods
This case-control study was conducted among women with breast cancer recorded in the cancer registry system between 2004 and 2006 (n = 134), and their age-matched healthy neighbors (n = 133). Data were statistically analyzed.
Age at marriage, menarche and pregnancy, breast feeding, positive family history, marital status, and educational level were not significantly correlated with risk of breast cancer, but age at menopause (< 46.6 years) was significantly correlated (95% confidence interval 1.15–7.37; p = 0.021). Live births, still births, and infant deaths were not significantly different between the 2 groups. For other variables, such as smoking history, no odds ratio was calculated.
Results show that there is no significant correlation between variables and risk of breast cancer in our population, except for age at menopause. A large cohort study is recommended.
PMCID: PMC3290010  PMID: 22419899
Breast cancer; Risk factors; Golestan; Case-control study
7.  Hepatocellular Carcinoma in Pregnancy withUnusual Presentations 
Hepatocellular carcinoma (HCC) is very rare during pregnancy and has a worse prognosis in pregnant women compared to those who are not pregnant. We present a case of HCC in a 41- year-old pregnant patient who was referred to our academic hospital.The patient presented with chief complaints of abdominal pain, jaundice, edema and hypertension. Laboratory results were notable for elevated liver enzymes and features of microangiopathic hemolytic anemia with normal alpha fetoprotein (AFP) and elevated cancer antigen 125 (CA125). At laparotomy for termination of pregnancy, multiple massive lesions were detected in the liver. Histologic evaluation showed features of HCC.HCC must be included in the differential diagnosis of any pregnant patient who presents with elevated liver enzymes and hemolysis.
PMCID: PMC3990127  PMID: 24829662
Hepatocellular carcinoma (HCC); Pregnancy; Prognosis
8.  Frequency and Perception of Sexual Activity during Pregnancy in Iranian Couples 
Pregnancy stimulates partners to search for ways to preserve their mutual emotional relations and satisfy their sexual needs, with some limitations. This study evaluates the frequency and perception of sexual intercourse during pregnancy in a group of Iranian couples.
Materials and Methods
In this cross-sectional study, 155 pregnant women were recruited from two academic clinics in Tehran. The exclusion criteria were: any underlying disease, history of pelvic surgery or gynecologic and obstetric complications, abortion or sterility, and previous preterm labor. A checklist was administrated in the labor room, that included: demographic data, partus and their viewpoints about sexuality. Frequency of sexual activity in each trimester, vaginal intercourse, coitus position, orgasm, breast stimulation, condom usage, and pregnancy outcome were recorded. Data were analyzed with t- and chi-square tests.
Women and their husbands with sexual behaviors during pregnancy had a lower mean age; the majority were nulipara (p<0.05). The biggest reason for decreased intercourse in the first trimester was fear of abortion (39.45%). No significant relationship between sexual activity in pregnancy and preterm labor, gestational age, membrane rupture, and fetal outcome was shown. There was a significant negative relationship between intercourse in the 2nd and 3rd trimesters and need to induction.
Although our results showed that sexual intercourse had no adverse effect on the fetus and was a proper stimulus for the induction of delivery, its frequency was reduced during the gestational stage due to parents’ fear of adverse effects.
PMCID: PMC4258238  PMID: 25493167
Sexual Intercourse; Pregnancy Outcome; Adverse Effect
9.  Wild lettuce (Lactuca virosa) toxicity 
BMJ Case Reports  2009;2009:bcr06.2008.0134.
Wild lettuce (Lactuca virosa) can cause toxic effects when eaten. Wild lettuce grows in the north of Iran and some natives consume it unaware of its adverse side effects. We describe eight patients with manifestations of wild lettuce toxicity, admitted to a general hospital affiliated to the Golestan University of Medical Sciences. All the patients recovered (although one had to spend 48 h in the intensive care unit) and no chronic complications were reported. A clinical suspicion of toxicity caused by wild lettuce intake and an accurate history formed the basis of the diagnosis. Conservative treatment, vital sign monitoring, control of patient intake and output, and reducing patient agitation provided the basis for treatment.
PMCID: PMC3031874  PMID: 21686920
11.  Inoperable esophageal cancer and outcome of palliative care 
AIM: To determine the outcome of esophageal cancer patients referred for palliative care, in Gorgan and Gonbad gastrointestinal clinics, northeast of Iran.
METHODS: This cross-sectional study was done on inoperable esophageal cancer cases referred to gastrointestinal clinics in Gorgan and Gonbad city (2005-2006). Demographic data were collected during the procedure and cases were followed up every one month. Improvement proportion was calculated with 95% confidence interval, to determine the rate of improvement. Survival analysis and Kaplan-Meier methods were used to estimate the duration of palliative care effectiveness.
RESULTS: We recruited 39 cases into the study. Squamous cell carcinoma was the most prevalent (92.3%). The middle third of the esophagus was involved predominantly (51.3%). Dilation was the most preferred method (89.7%) and stenting was done in 4 cases. Decreasing dysphagia score was not related to palliation method or pathology type of carcinoma. Age of the patients was significantly related to the improvement of dysphagia score. Mean survival time was 137.6 d and median was 103 d.
CONCLUSION: Results of this study showed a low survival rate after palliative care in esophageal cancer cases despite dysphagia scores’ improvement after dilating or stenting.
PMCID: PMC2719235  PMID: 18595139
Esophageal cancer; Palliative care; Survival; Dysphagia; Iran
12.  Role of silis in esophageal cancer 
Association of silica with diseases like cancers has been determined previously. This study was designed to determine the quantity of silis in flour produced in Golestan Province, and its relation to esophageal cancer (EC). We took flour samples from all flour millings in Golestan Province. Base-melting method in nickel cruise was used at 550°C. The extract was reduced with acids. Different silis concentrations in various regions were compared. P < 0.05 was considered statistically significant. The median silis concentration was 0.0030 g, the mean silis concentration was 0.008760 ± 0.004265 g in each 100 g flour. The difference of mean silis concentrations in various regions was not significant. No high level of silica was found in the flour of Golestan Province. We could not find any significant difference in various areas between silica contaminations. Studies on the consumed bread and rice in various regions of Golestan Province can be helpful.
PMCID: PMC2712187  PMID: 18494071
Silis; Esophageal cancer; Flour; Miling; Iran

Results 1-12 (12)