systematic review of environmental risk factors for pancreatic cancer

More than 250,000 people die annually of pancreatic cancer, worldwide. The highest incidence and mortality rates of pancreatic cancer are reported in developed countries. In developing countries the rate have been stabilizing over the past two decades but in countries which rates have been low for decades is now increasing. Recognizing pancreatic cancer's risk factors and its prevention are important roles in reducing pancreatic cancer mortality. Risk factors for pancreatic cancer are not well recognized. The aim of the study is to review the environmental risk factors of pancreas cancer. We performed a systematic review of the published literature to identify all studies that provided environmental risk factors in association with pancreatic cancer .we conducted MEDLINE search limited to last 5 years up to June 2011, for all relevant case -control, meta analysis, systematic review and cohort studies. Citations were limited to those published in the English language. Review and comment articles have been excluded. Sixty six independent studies met the predefined inclusion criteria. Seven studies out of 15 found positive association between cigarette smoking and pancreatic cancer. Five articles out of 10 reviewed articles found high alcohol intake as a risk factor for pancreas cancer and the other 5 articles found dose related association with pancreas cancer. Coffee: according to 2 reviewed studies coffee not only does not have a substantial impact on pancreatic cancer risk but also coffee drinking has been associated with a reduced risk of pancreatic cancer in men. Frequent intakes of red meat and well-cooked meat and Vitamin D deficiency have positive association with pancreatic cancer risk. Cigarette smoking is the most consistent risk factor for pancreas cancer in relevant studies about pancreas cancer risk factors

Gastroenterology and hepatology training in the Islamic Republic of Iran

Training in internal medicine has significantly evolved alongside the development of science, technology and new facilities during the past fifty years. After the specially of internal medicine, there are multiple subspecialty training programs which have started since 1985 in the Islamic Republic of Iran. In this manuscript we want to define the characteristics of the gastroenterology subspecialty training program in our country. The characteristics of approved gastroenterology training centers were gathered through a questionnaire. The questionnaire was consisted; the establishment date, the number and academic rank of trainers, the number of trainees, hospital beds, the number and types of diagnostic and therapeutic procedures in a year, the characteristics of training programs and their curriculum composition. The collected data was discussed and revised in a focused group of gastroenterologists from training centers and the board members of Iranian Association of Gastroenterology and Hepatology [IAGH]. There are 11 training centers with 94 trainers and 65 trainees, with a ratio of trainers to trainees of 1.36. Fifty four percent of trainers are assistant professor. Yearly, 36 new fellows are admitted. Four centers have adequate facilities for training in advanced gastroenterology, and in three centers there are facilities for liver transplantation. The duration of training in internal medicine is four years, whereas in gastroenterology it is two years. The admission for this subspecially is not university based and with other subspecialty programs, there is a national entrance examination. There are adequate well known training centers with a suitable ratio of trainer to trainee in the Islamic Republic of Iran. The duration of the GI fellowship is short and implementation of post subspecialty programs for completing the required capabilities of fellows is necessary. The capacity of fellowship admission should be revised according to needs of the country in the fields of health maintenance, research and medical education programs

Prevalence of non alcoholic steatohepatitis in Iran: a population based study

Non-alcoholic fatty liver disease/steatohepatitis [NAFLD/NASH] is the most common form of chronic liver disease woldwide and is no longer considered a benign disease. Its prevalence has not been determined in a large-scale population-based study in Iran. A total of 6583 individuals aged 18 to 65 were randomly selected from three geographically distinct provinces in Iran. Blood samples were obtained from each subject and a questionnaire was completed exploring data including self-admitted regular alcohol use. Serums were tested for anti-HCV antibody [anti-HCV], hepatitis B surface antigen and anti-hepatitis B core antibody. Positive samples for anti-HCV antibody were re-tested and those positive in a repeat ELISA were confirmed by a recombinant immunoblot assay [RIBA] test. Serums were also tested for ALT levels. Subjects with elevated ALT defined as serum ALT >/= 40 IU/L with no history of alcohol consumption and negative HBV and HCV infection were considered as [presumed NASH]. In this study 5589 subjects were analyzed. Two hundred and forty two individuals [4.3%] were diagnosed with elevated ALT levels. Among individuals with elevated ALT, 15 [6.2%] were diagnosed with either hepatitis B or hepatitis C. The overall weighted prevalence of presumed NASH was 2.9%. According to multivariate analysis, male sex, urban lifestyle, and being overweight or obese were significantly associated with [presumed NASH]. Obesity and metabolic syndrome, the most predictive factors of fatty liver disease, are increasing in Iran, therefore the prevalence of NAFLD/NASH and related complications are expected to increase in the future. This population based study gives a crude estimate of the prevalence of NASH around the country. Studies with more accurate surrogates of NASH need to be done. The disparity among different provinces merits special consideration

[Oral and dental health status in Northeastern Iran]

Esophageal cancer is one of the major malignancies around the world. It is the 8th high frequency cancer and the 6th leading cause of cancer death worldwide. The etiology of esophageal carcinoma is thought to be related to the exposure of smoking, alcohol, nitrate and low socioeconomic status. In this study, the status of oral health was evaluated in the population living in the north east of Iran. 45862 inhabitants of Gonbad and Kalaleh districts, aged 40-75 years, who had no esophageal cancer, were included in the study, which was part of Golestan Cohort. Oral health status and socioeconomic condition were evaluated by trained physicians. 19362 [42.2%] were male and 26490 [57.8%] were female [mean age was 52.1 +/- 9.1 years]. The mean number of existent teeth, missed teeth, decayed teeth and filling teeth were 13.3 +/- 9.4, 18.4 +/- 9, 4.7 +/- 6 and 0.23 +/- 1.1 respectively. There were significant relationship between male, low socioeconomic status and low educational level with poor oral health status. Oral health was poor among inhabitants of Gonbad and Kalaleh districts, especially in men and was related to low socioeconomic status and illiteracy

[Hepatitis A and E in the east of Golestan province]

Hepatitis A and E are among the most important etiological factors of acute hepatitis, which can lead to fulminant liver disease and death. The aim of this study was to determine the prevalence of hepatitis A and E in the east of Golestan Province, Iran. Eight hundred inhabitants of Gonbad City and Ghamar Ghozi Village from Kalale district were randomly selected for the study. Hepatitis A virus Antibody [Anti HAV] and Hepatitis E virus Antibody [Anti HEV] were checked by ELISA method. A total of 697 subjects [441 females] with a mean age of 43 +/- 15.1 years participated in this study. A total of 687 [98.6%] and 82 [11.8%] persons had positive Anti HAV and Anti HEV, respectively. This research is the first study on the prevalence of hepatitis A and E in the general population of Iran, which shows that HA V infection is pandemic and hepatitis E is common in the area

Irritable bowel syndrome and psychiatric disorders among university freshmen

Irritable Bowel Syndrome [IBS] is a very common disorder. Some researches have pointed to an interaction between psychiatric disorders and IBS. Present study aimed to determine psychiatric disorders in patients with IBS compared to normal controls among an Iranian population. All freshmen students [n=3012] of Tehran University invited to the study at 2001. A trained general practitioner interviewed the entire students for IBS based on Rome II criteria. A gastroenterologist visited the students who had Rome II criteria and ordered laboratory exams that are necessary for ruling out organic diseases. After confirming IBS patients, a matched control group by sex and age was selected. A psychologist who was blind to IBS diagnosis interviewed all cases and controls using a reliable 28- items General Heath Questionnaire. Chi-Square analysis used to compare psychiatric disorders in the cases and controls. P-value less than 0.05 determined as significant. A total of 3008 students [female; 1785, male; 1223] participated to the study and 143 had Rome II criteria for IBS [4.7%, 95% CI 4-5.6%]. Finally 46 [female; 31] with IBS and 97 [female; 62] controls underwent psychologic interview. Somatic symptoms, anxiety, depression, social dysfunction and mental disorder were reported by 41.3%, 34.8%, 15.2%, 43.5% and 41.3% respectively in IBS patients and 14.4%, 14.4%, 5.2%, 21.6% and 13.4% among control group respectively. All psychiatric disordoers were significantly more common among IBS patients than controls. Mental health in IBS patients is impaired. This fact could be primary or secondary. Control of psychiatric disorders may improve IBS symptoms

Assessment of inter-and intra-observer variability of the la classification for gerd

Los Angeles classification is widely adopted as a means of unifying endoscopic observation for GERD. We assessed the inter- and intra-observer variability of LA classification. Two-hundred fifty-four still images of the lower esophagus taken by an expert endoscopist [RM] were randomly selected and presented to 9 gastroenterologists [2 females, 6 experts, 3 trainees]. They were asked to report the images according to LA classification. After 2 weeks the images were re-ordered and the same people were asked to report them again. Kappa-statistics was calculated for intra- and inter-observer variability. Mean kappa for intra-observer agreement was 0.54 for experts and 0.55 for trainees [p = NS]. Mean intra-observer kappa was greater among females than males [0.70 vs 0.50 respectively, p=0.05]. Mean inter-observer kappa was 0.20 and 0.31 for experts and trainees respectively [p = NS]. Mean inter-observer weighted kappas were 0.25 and 0.07 [p = 0.007] for males and females respectively. Analyzing data for source of the discrepancy showed that the least reproducible reading was GERD-A both for intra- and inter-observer agreement calculations. According to our data, the LA classification, although a major advance in reporting GERD, has a poor to fair reproducibility. There was no difference between experts and trainees in using the LA classification. Females seem to be more consistent in their readings, but have less agreement with others. Despite the inherent short-comings of kappa statistics and the limitation caused by the possible quality of the still images, revision of the LA system seems to be advisable

[Determination of the normal range of the number of intraepithelial lymphocytes in the duodenal mucosa of healthy Iranian individuals]

An increase in the number of intraepithelial lymphocytes [IEL] in the duodenal mucosa is an important criterion for the histological diagnosis of celiac disease [CD]. We determined the normal range for intraepithelial lymphocytes [IEL] in the second part of duodenum in healthy Iranian population. Four biopsy samples of the endoscopically normal appearing mucosa at the second part of duodenum were obtained from 50 individuals referred to Shariati hospitals [48 for epigastric pain, 2 for esophageal varices]. They had no sign, symptoms and evidence for malabsorption or small intestinal disorders in history, physical examination, Laboratory tests and IgA anti tissue transglutaminase [t.T.G]. Four-micrometer thick sections were stained with Hematoxillineosine [H and E] and immunohistochemistry [IHC] for leukocyte common antigen [LCA]. At least 500-600 cells from the tip and body of villi were counted separately and the number of IEL was given as mean/ 100 epithelial cells. The mean for IEL count in total villi in IHC method was 21/100 [23/100 in tip, 21/100 in body, p = 0.058] and 19/100 in H and E method [19/100 in tip, 18/100 in body, p =0.035] [p = 0.006]. Considering total villi, the normal upper limit [Mean+2SD] was calculated to be 35/100 in IHC and 34/100 in H and E stained sections and normal upper limit of confidence interval [the 95 percentile] was 39/100 in IHC and 37/100 in H and E stained sections. The villus height to crypt depth ratio was 3/94 in average. Respectively in IHC and H and E methods, the amounts equal or less than 35/100 and 34/100 are considered as normal., values between 35-39/100 and 34-37/100 as border line and counts more than 39/100 and 37/100 represent a pathology. Although the difference between two staining methods was statistically significant, considering cost effectiveness, we recommend H and E staining for routine clinical practice

[Gastroesophageal reflux disease in Esfahan]

Gastroesophageal Reflux Disease [GERD] is a common disorder in the western population but detailed population-based data in Iran is limited. The aim of this study was to investigate the prevalence of GERD in Esfahan. A population-based study was conducted in 2004. Major GERD symptoms [heartburn and acid regurgitation] were assessed through an interview by six trained medical students based on a systematic clustering among adult inhabitants [n=2400] in Esfahan and included any family member between 20-70 years old. Existenxe of any major GERD symptoms in the past 12 months was used to diagnosis GERD. Prevalence of daily, weekly and monthly GERD symptoms were 12.1%,12.9% and 21.5% respectively. GERD symptoms occurred in 19.3% of men and 27.3% of women [p-value: 0.002]. Body Mass Index [BMI] was 24.71+/-3.04 in GERD group compared to normal population which was 24.1+/-3.11 [p = 0.001]. GERD symptoms are frequent among Esfahan population. The prevalence of GERD was affected by the gender category and BMI

[Hepatitis C in Golestan province-Iran]

Hepatitis C is one of the most important etiological factor in chronic liver disease which could lead to the progressive liver cirrhosis and hepatocellular carcinoma. The purpose of this study is to determine the prevalence of Hepatitis C in east of Golestan province [north-east of Iran]. 2123 inhabitants from north-east of Iran of general population have been studied using randomized selection. The taken samples were fresh serum searching for Hepatitis C Virus Antibody [HCV Ab] via ELISA method. A recombinant immunoblot assay [RIBA] was done for the positive HCV Ab samples tested with ELISA as the next step. A total of 2123 samples [female: 1387] with mean age of 41.3+/- 14.8 years and 960 rural and 1141 urban were studied. Fifty six samples [female:44] were HCVAb positive [ELISA], twenty of fifty six samples were also RIBA positive [female: 18 equal 81.8% and male: 4 equal 18.2%]. According to ELISA result the prevalence of HCVAb positive samples in female was 3.1% [44 of 1387 samples] and in male was 1.6 [12 of 714 samples]. As a total result we reached out that the prevalence of Hepatitis C through ELISA method was around 2.6%. This number reduced to 1% considering RIBA positive samples which is the definite test in Hepatitis C diagnosis. This study is the first Hepatitis C determination in general population in Iran. A comparison between the Hepatitis C prevalence in north east Iran and other part of the world showed that Iran relatively has a lower prevalence [Asia: 3.55% Africa: 5.17% America: 1.9%]. No other Hepatitis C evaluation study has been done in any other part of Iran

[Case report: a case of disseminated Burkitt's lymphoma with involvement of the stomach, breast and eye-lids]

Disseminated B cells Burkitt's lymphoma with stomach ,breast and eyelid involvement Burkitt's lymphoma in adult is rare and has a progressive pattern in advanced stages. The current case is a 19 year old lady who was admitted in a hospital due to GI bleeding shown as melena. An upper gastrointestinal Endoscopy report remarked a tomural mass lesion and also multiple masses in breast and abdomen Were found in computerized tomography escan. A B cells Burkitt's lymphoma diagnosis came up after biopsies of stomach and breast masses which was confirmed by immunophenotyping done with flowcytometry [CD[20], Ki[67] = 100%]

[Celiac disease in Gonbad-Kavoos]

Northeast Iran has one of the highest rates of esophageal cancer in the world which is mainly squamous cell carcinoma [E SCC]. Celiac disease [CD] has been identified as a risk factor for ESCC. The aim of this study is to determine the prevalence of CD in Gonbad at northeast Iran and probable relation between celiac and ESCC. fourteen hundred inhabitants of north eastern Iran were randomly selected. The subjects underwent blood sampling for determination of IgA antibodies against tissue transglutaminase [anti- TTG]. Subjects with positive anti-TTG underwent an interview, upper endoscopy and duodenal biopsy. The duodenal biopsies were classified according to Marsh criteria. A total of 1209 subjects [female: 699] with mean age of 50 +/- 11.7 years were studied. Twelve subjects [female: 9] had a positive anti-TTG [1%]. Four patients did not accept endoscopy. Eight cases underwent endoscopy and duodenal biopsy. Four, two and two subjects had Marsh III, II and I respectively. Flatulence and diarrhea [the most symptoms] were in five and four subjects and characteristic skin manifestation was reported in three subjects. One subject was already diagnosed as CD. although prevalence of ESCC in northeast Iran is significantly higher than central Iran, the prevalence of gluten sensitive enteropathy is the same [1%]. It dose not appear that CD has any impact on the prevalence of ESCC in Iran

[High exposure to polycyclic aromatic hydrocarbons may contribute to high risk of esophageal cancer in northeastern Iran]

The northeastern region of Iran has some of the highest rates of esophageal squamous cell carcinoma [ESCC] in the world. To investigate the role of polycyclic aromatic hydrocarbons [PAHs] in the etiology of ESCC in northeastern Iran, we measured urine 1-hydroxypyrene glucuronide [1-OHPG], a stable PAH metabolite, in 99 inhabitants of this area. Results: The median urine 1-OHPG in participants of this study was 4.2 pmol/ml. Forty-two subjects [42%] had levels ranging from 1 to 5 pmol/ml, indicative of moderate PAH exposure, and 41 [41%] had levels above 5 pmol/ml, indicative of very high exposure. Further analysis showed that 1-OHPG levels were high in all subgroups of our study subjects, including both sexes; rural and urban dwellers; and smokers and non-smokers. Only 15% of the variance in 1-OHPG was explained by age, sex, residence, smoking, nass, or opium consumption. This pattern of PAH exposure parallels with the ESCC incidence pattern seen in this area. We conclude that people in northeastern Iran are exposed to widespread and very high levels of PAH, largely from unknown sources, and this may contribute to the high rates of ESCC observed in this area

[TT virus infection among Iranian blood donors: its prevalence and relationship to serum alanine aminotransferase [ALT] leve]

TT virus [TTV] is a DNA virus and is proposed as a potential cause of non-A to E hepatitis. We aimed to investigate, for the first time, the prevalence of TTV in Iranian healthy blood donors. Three hundred and twelve healthy Iranian blood donors were randomly selected and tested for TTV DNA by the seminested polymerase chain reaction method. Serum alanine aminotransferase [ALT] levels were determined in those infected and uninfected individuals that adequate serum were available. HBsAg or HCV antibody-positive subjects were excluded. Results: TT virus DNA was detected in 70 [22.4%] of the 312 subjects under study. ALT was elevated in 8 [18.2%] of the 44 TTV positive blood donors and in 8 [10.9%] of the 73 TTV negative blood donors. There was no significant difference between these two groups. TTV viremia is common among Iranian blood donors. Its prevalence in Iran is higher than US [1%] and most West-European countries and is comparable to China [28%] but lower than Thailand [37%] and Italy [42.4%]. Our data do not support the correlation between TTV viremia and elevated ALT level

[Ecologic study of serum selenium and upper gastrointestinal cancers in Iran]

Both observational and experimental studies have shown that higher selenium status reduces the risk of upper gastrointestinal cancers in selenium deficient populations. Recent cancer registry data have shown very different rates of esophageal cancer [EC] and gastric cancer [GC] in four provinces of Iran, namely Ardabil, Mazandaran, Golestan, and Kerman. The aim of this study was to have a preliminary assessment of the hypothesis that high rates of EC in Golestan and high rates of GC in Ardabil may be partly attributable to selenium deficiency. We measured serum selenium in 300 healthy adults from Ardabil [n=100], Mazandaran [n=50], Golestan [n=100], and Kerman [n=50], using inductively coupled plasma, with dynamic reaction cell, mass spectrometry [ICP-DRC-MS] at the US Centers for Disease Control [Atlanta, Georgia]. The median serum selenium concentrations were very different in the four provinces. The medians [IQR] for selenium in Ardabil, Mazandaran, Golestan, and Kerman were 82 [75-94], 123 [111-132], 155 [141-173], and 119 [110 -128] micro g/L, respectively [p<0.001]. The results of linear regression showed that the province variable, by itself, explained 76% of the variance in log selenium [r2=0.76]. The proportion of the populations with a serum selenium more than 90 micro g/L [the concentration at which serum selenoproteins are saturated] was 100% in Golestan, Kerman, and Mazandaran but only 29% in Ardabil. Our findings suggest that selenium deficiency is not a major contributor to the high incidence of EC seen in northeastern Iran, but it may play a role in the high incidence of GC in Ardabil province