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Article
Thyroid Role in Threatened Abortion

Author: Thura jaafar kadhum
Journal: Karbala Journal of Medicine مجلة كربلاء الطبية ISSN: 19905483 Year: 2009 Volume: 2 no.8, 9 Issue: 5 Pages: 568-575
Publisher: Kerbala University جامعة كربلاء

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Abstract


Background: Mild impairment of thyroid function may contribute to disturbed reproductive function.
Objective: To evaluate the role of thyroid hormones in maintaining early pregnancy and their association with the outcome of the threatened abortion.
Materials and methods: The study was carried out in Maternity and pediatric Teaching Hospital in Al-Najaf during period between 1st April to 1st September 2008. The study included 80 pregnant women divided into two groups 50 women with threatened abortion and 30 women with normal pregnancy of comparable age, parity, gestational age and body mass index (BMI). Both groups were subjected to clinical examination, obstetric ultrasound examination and were investigated for hemoglobin, total thyroxine (TT4), total tri-iodothyronine (TT3) and thyroid stimulating hormone (TSH). The group of threatened abortion women divided into two groups where 31 women had a positive outcome (continuation of pregnancy to the third trimester) and 19 women had a negative outcome (pregnancy ended with spontaneous abortion).
Results: There was a significant difference in the level of TT3 and TSH between the control group and the women with threatened abortion (lower TT3 and higher TSH in threatened abortion women) with no significant difference in TT4 between the two groups while TT3and TT4 levels were significantly reduced in the women with negative outcome as compared with the women with a positive outcome while the TSH level was significantly increased in the women with negative outcome. Conclusion: reduced levels of thyroid hormones in early pregnancy may contribute to some cases of spontaneous abortion.
Key words: thyroid hormones, pregnancy, abortion.


Article
The Effect of Chronic Renal Failure on Thyroid Hormones

Author: Layla K. Ali
Journal: Iraqi Journal of Pharmaceutical Sciences المجلة العراقية للعلوم الصيدلانية ISSN: 16833597 Year: 2010 Volume: 19 Issue: 1 Pages: 65-68
Publisher: Baghdad University جامعة بغداد

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Chronic renal failure (CRF) affects thyroid function in multiple ways, including low circulating thyroid hormone concentration, altered peripheral hormone metabolism, disturbed binding to carrier proteins, possible reduction in tissue thyroid hormone content, and increased iodine store in thyroid glands.The target of study is to find a relationship between chronic renal failure and thyroid function.In addition, we tried to study the effect of CRF on serum creatinine dependent on the level of thyroid hormones (T3 and T4) and thyroid stimulating hormones(TSH). Forty patients with chronic renal failure (20 male, 20 female) were enrolled in this study in addition to forty healthy individual as control group (20 male, 20 female). The age ranged from (25 -65) years. T4, T3, TSH, urea, uric acid and creatinine were measured in each of the two groups. The results revealed statistically significant reduction in T3 and T4 while there is elevation in TSH, urea,uric acid and creatinine in the patients group compared to the control group.

يؤثر القصور الكلوي المزمن على فعالية الهرمونات الدرقية بطرق متعددة تتضمن قلة في تركيز هرمون الغدة الدرقية في الدم، تبدل أو تغير ايض الهرمون في الانسجة المحيطية، وإرتباطه بالبروتين الناقل، أحتمالية انخفاض مستوى الهرمونات الدرقية في الانسجة المحيطية والبلازما وكذلك زيادة خزن اليود في الغدة الدرقية. الهدف من الدراسة ايجاد علاقة بين القصورالكلوي المزمن والغدة الدرقية بالاضافة الى دراسة تاثير الفشل الكلوي المزمن اعتمادا على مستويات الهرمونات الدرقية والهرمون المحفز للدرقية. جمعت النمادج من 40 مريضا" مصابا" بالفشل الكلوي بالاضافة الى 40 شخصا" من الاصحاء كمجموعة سيطرة.اعمار المجاميع تتراوح بين (25- 65) سنة . تم قياس هرمونات الغدة الدرقية (ثلاثي يوديد الثايرونين والثايروكسين) ،الهرمون المحفز للدرقية،اليوريا ، حامض اليوريك والكرياتنين .بينت النتائج وجود انخفاض معنوي في كل من ثلاثي يوديد الثايرونين والثايروكسين في حين وجد ارتفاع ملحوظ في كل من الهرمون المحفز للدرقية ،اليوريا، حامض اليوريك والكرياتنين في مرضى القصور الكلوي مقارنة بالاصحاء.


Article
Association Between Chronic Renal Failure and Thyroid Hormone

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Abstract

The levels of serum urea , creatinine ,total thyroxin (TT4) , Tri-iodothyronine (TT3) , free T4 (fT4) , freeT3 (fT3) and Thyrotropin (TSH) were measured in the serum of 80 Patients with varying grades of chronic renal failure (CRF) ; and 40 healthy individuals . They were divided into 3 groups as : Group 1 Containing 40 healthy individuals as Control group; Group 2 containing 40 Patients on Conservative management ; and Group 3 Containing 40 Patients on Regular haemodialysis therapy. Groups 2 and 3 showed significant increased in urea and creatinine compared with control group ( P< 0.001) and significant decreased in TT4(P < 0.01) , TT3(P < 0.001) , fT4( P < 0.01) and fT3( P< 0.001) , whereas TSH values were not significantly altered . Conclusions: Uremia is accompanied with endocrine disorders , due to impaired degradation of hormones , because of failed kidney functions and to the interference of the uremic environment with extra renal degradation or synthesis and secretion of certain hormones . The aim of the study was to investigate the association between chronic renal failure and thyroid function. Key words: chronic renal failure , thyroid hormones

تم دراسة مستويات كل من اليوريا والكرياتينين والثايروكسين الكلي TT4 والثايروكسين الحرfT4 وثلاثي ايوديد الثايروكسين الكلي TT3 وثلاثي ايوديد الثايروكسين الحر fT3 وهرمون الثايروتروبين TSH الهرمون المحرض للدرقية وقياسها في مصل م 80 مريضا يعانون من درجات متفاوتة بالفشل الكلوي المزمن (CRF) ومقارنتهما بـ 40 شخصا من الاصحاء , حيث قسمت الدراسة الى ثلاث مجاميع : مجموعة (I) شملت 40 شخصا كمجموعة سيطرة, مجموعة (II) شملت 40 مريضا في مرحلة العلاج التحفظي ,مجموعة (III) شملت 40 مريضا في مرحلة الغسل الدموي.اظهرت المجموعة الثانية والثالثة ارتفاع معنوي في مستويات اليوريا والكرياتينين عند مقارنتهما بمجموعة السيطرة وبمستوى معنوية )0,001>(p, وانخفاضا معنوي في مستوى TT4 عند مستوى معنوية (0,01>p)، وانخفاضا في مستوى TT3 بمستوى معنوية(0,001>(p, وانخفاضا في مستوى fT4 عند مستوى معنوية (0,01>p) عند مجموعة العلاج التحفظي و(0,001>p) عند مجموعة الغسل الدموي, و انخفاض معنوي في مستوى fT3 عند مستوى معنوية (0,001>p), بيمنا قيم TSH لم تتغير معنويا . وكان الهدف من هذه الدراسة ايجاد العلاقة بين الفشل الكلوي المزمن و وظيفة الغدة الدرقية .


Article
Lipoxidative and Glycoxidative Modifications of Erythrocytes-Proteins in Relation to Thyroid Status
التبدلات في تفاعلات اكسدة الدهون واكاسيد السكر مع بروتينات كريات الدم الحمر وعلاقتها بنشاط الغدة الدرقية

Author: Shatha Hussein Ali د.شذى حسين علي خضر
Journal: IRAQI JOURNALOF COMMUNITY MEDICINE المجلة العراقية لطب المجتمع ISSN: 16845382 Year: 2005 Volume: 18 Issue: 2 Pages: 191-196
Publisher: Al-Mustansyriah University الجامعة المستنصرية

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Abstract :Objective : Different mechanisms for lipid peroxidation activation in patients presenting with thyroid hormone abundance or deficiency have been analyzed . However, changes in metabolism associated with thyroid dysfunction through the glycoxidative reactions and its contribution to such enhancement of lipid preoxidation is assessed in this study. Methods:The study included seventy –two patient with either , hyperthyroidism , hypothyroidism or euthyroidism, in addition to 25 control subjects for the estimation in their erythrocytes :-1-concentration of the end product of lipid peroxidation (malondialdehyde- MDA).2-susceptibility to oxidative challenge (H2O2- induced methaemoglobin- Met-Hb).3-glycosylation of proteins (glycated haemoglobin- GHb).Results : The hyperthyroid patients group were presented with significantly elevated MDA levels (p < 0.001) among other thyroid disorders. Elevated Met-Hb levels were detected in different thyroid diseases. Moreover, significant modulation of glycated haemoglobin values was observed in both hyper- and hypothyroid patients (7.8 ± 1.8 , 5.9 ± 1.7 , respectively Vs control 5.1± 0.82).Conclusion : The changes in lipoxidative and glycoxidative modification of proteins in patients with thyroid pathology may have some clinical and biological implications. Key words : thyroid hormones , MDA, Glycated- Hb

ملخص:هناك فرضيات عديدة لتفسير اسباب زيادة سرعة اكسدة الدهون في الحالات المرضية المصاحبة لزيادة او نقصان نشاط الغدة الدرقية موضوعة حاليا قيد البحث . احتمال وجود علاقة للتغيرات الحاصلة في الايض المرتبطة بنشاط الغدة الدرقية بالتغيرات في ايض السكر وبالتالي امكانية مساهمته في تفسير زيادة اكسدة الدهون. تضمنت الدراسة الحالية اثنان وسبعون مريضا بين مصاب بزيادة او نقصان او اعتدال في نشاط الغدة الدرقية ، اضافة الى 25 شخصا طبيعيا كمجموعة مقارنة وذلك لغرض دراسة :1-تراكيز اكاسيد الدهون (المالوندايلديهايد) في كريات الدم الحمر .2-القابيلة للاكسدة بمادة بيروكسيد الهيدروجين لتكوين الميتوهيموكلوبين.3-تركيز البروتينات المتفاعلة مع السكر.اظهرت نتائج الدراسة زيادة نسبة المالوندايلديهايد في كريات الدم الحمر لمرضى فعالية الغدة الدرقية الزائدة وكذلك زيادة في تكوين الميتهيموغلوبين يصاحب الانواع المختلفة من الاختلال في وظائف الغدة الدرقية ، مع زيادة ملحوظة في درجة تفاعلات السكريات مع بروتينات كريات الدم الحمر في حالتي زيادة ونقصان نشاط الغدة الدرقية .يمكن الاستنتاج من هذه النتائج ان هناك تغيرات في تفاعلات اكسدة الدهون واكاسيد السكر مع بروتينات كريات الدم الحمر في الامراض المصاحبة لأختلال نشاط الغدة الدرقية والتي قد يكون لها بعض التطبيقات السريرية والحيوية لتحسين حالة المريض.


Article
Metabolic and Hormonal Changes Associated with Menopause

Author: Hind Shakir Ahmed
Journal: Mustansiriya Medical Journal مجلة المستنصرية الطبية ISSN: 20701128 22274081 Year: 2017 Volume: 16 Issue: 3 Pages: 77-82
Publisher: Al-Mustansyriah University الجامعة المستنصرية

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Abstract

Background: Menopause is the perpetual cessation of menstruation due to defeat of ovarian follicular activity. Menopause in women leads to various physiological changes in the body.Objective: To study the metabolic and hormonal changes in postmenopausal women.Patients and Methods: Forty five postmenopausal women were articipated in the study and compared them with 45 premenopausal women who had aregular menstruation. They were attending the Medical City Hospital/Obstetrics and Gynecology Department during the period from July 2016 until the end of December 2016. Anthropometric and physiological parameters were taken. Biochemical and hormonal parameters were measured for all individuals.Results: In this study, there was a significant increase in serum apolipoprotein E levels, total cholesterol, triacylglycerol, low density lipoprotein cholesterol, urea, and thyroid stimulating hormone in postmenopausal group as compared to premenopausal group, (P ≤0.05). Serum total tri- and tetra-iodothyronine levels were decrease in postmenopausal group as compared to premenopausal group, but it was not significant. There was a significant increase in apolipoprotein E in postmenopausal women who had family history for dyslipidemia, (P =0.001). There was a significant positive correlation betweenapolipoprotein E and thyroid stimulating hormone. While there was a significant negative correlations among apolipoprotein E with high density lipoprotein cholesterol and estradiol, (P ≤ 0.01)Conclusions: The physiological basis and the complex interaction between thyroid hormones and apolipoprotein E and their relation with estradiol hormone among postmenopausal women trigger the lipids control mechanism.


Article
Thyroid Hormones and Cardiac Dilatation and Dysfunction In Iraqi Patients with Idiopathic Dilated Cardiomyopathy Biochemical and Echocardiographic Study

Author: Basil O.M. Saleh
Journal: Iraqi Academic Scientific Journal المجلة العراقية للاختصاصات الطبية ISSN: 16088360 Year: 2007 Volume: 6 Issue: 1 Pages: 41-44
Publisher: The Iraqi Borad for Medical Specialization المجلس العراقي للاختصاصات الطبية

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ABSTRACT:BACKGROUND:Serum thyroid hormone level can provide a quantitative index for evaluating the severity of chronic heart failure.OBJECTIVES:To assess the contributions of thyroid hormones [tri-iodothyronine] (T3) and thyroxine (T4)] to the left ventricular (LV) dilatation and myocardial dysfunction in patients with idiopathic dilated cardiomyopathy (IDC).METHODS:Forty patients with idiopathic dilated cardiomyopathy (IDC) aged 46.20 + 1.90 years, as (mean ± SEM) (11 females and 29 males) were studied. Serum total T3, total T4 and thyroid-stimulating hormone (TSH) were measured in these patients. Echocardiographic parameters including LV systolic diameter, septal thickness systolic diameter, LV diastolic diameter, septal thickness diastolic diameter and LV ejection fraction (LVEF) were also be assessed in all patients.RESULTS:This study showed that the serum T4 values were significantly directly correlated with the values of EF % (r = 0.34; p < 0.035) along with significant inverse relationship between serum levels of T3 and the diameter of LV systole (r = - 0.34; p< 0.032).CONCLUSION:This study revealed an important significant correlation between serum thyroid hormones levels and echocardiographic parameter values that may point to the role of these biochemical factors in the contribution to the LV dilatation and cardiac dysfunction (heart failure) .


Article
Homocysteine and Thyroid Hormones in Patients with Familial Dilated Cardiomyopathy

Author: Basil O.M. Saleh
Journal: Iraqi Academic Scientific Journal المجلة العراقية للاختصاصات الطبية ISSN: 16088360 Year: 2007 Volume: 6 Issue: 2 Pages: 88-91
Publisher: The Iraqi Borad for Medical Specialization المجلس العراقي للاختصاصات الطبية

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ABSTRACT:BACKGROUND:Familial linkage of primary dilated cardiomyopathy (DCM) occurs more commonly than often is appreciated. In 10-20 percent of patients, a first degree relative also shows evidence of primary DCM suggesting that familial transmission is relatively frequent.METHODS:this study included 7 patients aged 40-70 years (2 females and 5 males) with familial dilated cardiomyopathy (FDCM) and 17 healthy subjects aged 29-60 years (6 females and 11 males). Plasma fasting total homocysteine tHCY, serum folic acid (FA), vitamin B6, total triiodothyronine (T3), and total thyroxine (T4) were measured in these two groups.RESULTS:The mean value of plasma tHCY was significantly higher in patients with FDCM than in control (P<0.001). The mean (±SD) values of serum folic acid and vitamin B6 were significantly decreased in FDCM patients when compared with those of control group (P<0.05, P<0.01, respectively).A significant inverse relationship between plasma tHCY concentration and the values of serum FA was shown in the FDCM patients (r=-0.78, P<0.05). The mean values of serum T3 and T4 were insignificantly decreased in patients with FDCM than in controls.CONCLUSION:The level of plasma tHCY is significantly higher in FDCM patients than in healthy control. This severe hyperhomocyteinemia of FDCM patients may be related to evolution and development of myopathic state in such patients.


Article
ROLE OF ECTOPIC PROLACTIN ON THYROID HORMONES LEVEL IN A SAMPLE OF IRAQI INFERTILE WOMEN WITH UTERINE FIBROIDS

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Background :A large number of traditional investigations and bioassay of hormones have been practiced in the diagnosis and management of infertility for a long time. Measurements of prolactin and thyroid stimulating hormone have been considered important components of the evaluation of women presenting with infertility.Objectives:To study the effect of prolactin hormone produced from uterine fibroid(s) on thyroid hormones levels and role of these hormones.Methods:One hundred three women with uterine fibroid were entered to the Obstetrics and Gynecology Department in Al-Kadhimyia Teaching Hospital in Baghdad-Iraq from the 15th of June 2007 to December 30th 2010. Fasting serum prolactin, total T3, total T4, and thyroid stimulating hormone (TSH) were estimated using MiniVIDAS [ELFA (Enzyme Linked Fluorescent Assay)] kits.Results:Forty five out of 103 (43.69%) women were found with primary infertility and the rest 58 (56.31%) with secondary infertility. Serum thyroid hormones mean ± standard deviations were found normal before and after surgery in both primary and secondary infertile women. Level of serum prolactin was found elevated about 9 folds in primary infertile women and 8 folds in those with secondry infertility before surgery more than their levels after. No significant difference was found between thyroid hormones before and after surgery in both infertile groups, unlike their prolactin which was found highly significant with p value <0.001 in both groups.Conclusion:It can be concluded that, first, the increase in prolactin level was due to an ectopic production from uterine fibroid(s), and second, there is no effect or role of this prolactin on their thyroid hormones function. Third, their infertility could be due to the presence of prolactin secreting fibroid(s).Keywords:Infertility, Ectopic prolactin, Thyroid hormones, Uterine fibroids


Article
The correlation between thyroid hormones, reproductive hormones, body mass index (BMI) and hirsute in Iraqi women with polycystic ovary syndrome (PCOS).
العلاقة بين هرمونات الدرقية والتكاثر وكتلة الجسم و المشعرانية عند النساء العراقيات المصابات بمتلازمة تعدد الاكياس المبيضية.

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This research was conducted to study the relationship between the polycystic ovarysyndrome (PCOS) and thyroid disorders. The study includes 50 infertile Iraqi women with polycystic ovary syndrome (PCOS) and 20 healthy women. Blood samples were collected from the Infertility Center of AL-Yarmok Teaching Hospital in Baghdad, during the period from November, 2010 to May, 2011. The age of infertile and fertile women was ranged from 16 to 45 years. Hormonal study of Estradiol (E2), Luteinizing hormone (LH), Follicle stimulating hormone (FSH), Testosterone (T),Thyroid stimulating hormone (TSH) , Triiodothyronine (T3) and Thyroxin(T4) was done for each patient. The results showed that there is a significant (P <0.05) decrease in E2 and FSH levels in PCOS women comparing with fertile women. Also a significant (P <0.05) increase in LHFSH was detected in PCOS women and fertile women and non-significant (P <0.05) differences in testosterone,TSH,T3 and T4 levels between infertile and fertile women.The hormonal profile according to Body mass index -BMI was showed to be significantly (P <0.05) decreased in testosterone in obese and overweight PCOS women, significant (P <0.05) decrease in FSH level in obese PCOS women and no significant differences in E2 and LH levels.According to the hirsute in PCOS women the hormonal profile showed a significant (P <0.05) decrease in E2 and FSH levels in hirsute PCOS women, no significant differences in LH levels and elevated in testosterone levels but without significance in hirsute PCOS

هدفت الدراسة الى أيجاد العلاقة بين متلازمة تعدد الاكياس المبيضية و أختلال الهرمونات الدرقية. شملت الدراسة 50 من النساء غير الخصيبات مصابات بمتلازمة تعدد الاكياس المبيضية و 20 من النساء الخصيبات الطبيعيات. جمعت عينات الدم من المشمولات بالدراسة من مركز العقم في مستشفى اليرموك التعليمي في بغداد بين نوفمبر 2010 الى مي 2011. تراوح عمر المشمولات بالدراسة بين 16 و 45 سنة. حسب مستوى هرمونات الاسترادول و هرمونات التكاثر LH, FSH و التستوستيرون و هرمونات الدرقية T3,T4 و الهرمون المحفز TSH لهما ولجميع المشمولات بالدراسة. بينت النتائج وجود أنخفاض معنوي بأحتمالية 0.05 في مستوى هرموناتالاسترادول و FSHوزيادةمعنويةفيمستوىLHFSHعند النساء المريضات مقارنة مع الطبيعيات.كما بينت النتائج عدم وجود فروق معنوية في مستويات هرمونات التستوستيرون و الهرمونات الدرقية T3, T4و TSH بين النساء المريضات و الطبيعيات. قياس مقدار كتلة الجسم BMI و المشعرانية تم أيضا في هذه الدراسة. بينت النتائج وجود انخفاض معنوي في مستوى التستوستيرون في النساء المريضات بمتلازمة تعدد الاكياس المبيضية والسمينات و زائدات الوزن و انخفاض معنوي في مستوى هرمون FSH و عدم وجود فروق معنوية في مستوى هرمونات الاسترادول و LH في المريضات السمينات. وبينت نتائج المشعرانية ان هناك انخفاض معنوي في مستوى هرمونات الاسترادول و FSH و عدم وجود فروق معنوية في مستوى هرمون LH و أرتفاع غير معنوي في مستوى التستوستيرون عند النساء المشعرات المريضات بالمتلازمة.


Article
Study the Changes of Thyroid Hormones Levels Following Major Urological Surgery
دراسة التغيرات في مستويات هورمونات الدرقية المتزامن مع الجراحات الكبرى

Authors: Noor N. Oda نور نايف عوده --- Ihsan A. AL-Shammari احسان علي الشمري --- Fayhaa M. Khaleel فيحاء مقداد خليل
Journal: Baghdad Science Journal مجلة بغداد للعلوم ISSN: 20788665 24117986 Year: 2014 Volume: 11 Issue: 4 Pages: 1542-1548
Publisher: Baghdad University جامعة بغداد

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Abstract

This study was designed to evaluate the effect of major surgery on thyroid hormones and thyrotropin in patient undergoing major lower abdominal surgery. The study included fifty patients scheduled for elective major lower abdominal surgery, the serum levels of T3, T4 and TSH were determined one day preoperatively, intraoperative, one day postoperatively, two days postoperatively, and rT3 was determined one day preoperatively, and one day postoperatively. We observed that the levels of (T3, T4, TSH) increased significantly (P<0.05) intraoperatively, one day postoperatively the levels of T3 and T4 reduced significantly (P<0.05), while TSH reduced not significantly (P>0.05), and two days postoperatively T4 and TSH returned to increase significantly but T3 not significantly (P>0.05). rT3 increased not significant (P>0.05) in one day postoperatively. It has been proposed these changes due to surgical stress that inhibits peripheral conversion of T4 to T3 by inhibiting peripheral 5'-deiodinase activity, also The absence of pituitary response to changes in serum levels of T3 and T4.According to the results of this study there is a transient abnormality in thyroid function tests in patient undergoing elective major surgery and this abnormality due to surgical stress.

أجريت هذه الدراسة لتقييم تأثير العمليات الجراحية الكبرى على هورمونات الدرقية والهورمون المحفز للدرقية . ضمت الدراسة ( (50مريضا خضعوا لعمليات جراحية كبرى اختيارية (غير طارئة) للجزء البطني السفلي ,حيث تم قياس مستويات هورمونات الدرقية((T3, T4 والهورمون المحفز للدرقية(TSH) قبل يوم من اجراء الجراحة,و اثناء الجراحة,بعد يوم من الجراحة,وبعد يومين من اجراء الجراحة.وتم قياس هرمون الدرقية الانعكاسي (rT3) قبل يوم من اجراء الجراحة,و بعد يوم من الجراحة.توصلت الدراسة الى ان مستويات كل من (T3, T4, TSH)تزداد معنويا ب( P<0.05)داخل الجراحة ,و بعد يوم من الجراحة ينخفض(T3,T4) معنويا ( (P<0.05 بينما ينخفض ( TSH) غير معنوي (P>0.05),ثم تعود لترتفع(,T4 TSH ) بعد يومين من الجراحة ارتفاعا معنويا ( (P<0.05و غير معنوي لمستوى(T3) (P>0.05).كما لوحظ ان مستوى (rT3)يزداد غير معنويا(P>0.05) بعد يوم من اجراء الجراحة.ان هذه التغيرات تعود الى تأثير الجراحة الذي يثبط تحويل T4 الى T3 وذلك بتثبيط فعالية الانزيم (5'-deiodinase) ,وكذلك يعود لغياب استجابة الغدة النخامية للتغيرات في مستويات((T3, T4.وفقا لهذه النتائج تم التوصل الى ان هنالك تغير وجيز في اختبار وظائف الدرقية في المرضى الخاضعين لعمليات جراحية اختيارية كبرى وهذا التغير يعود الى الاجهاد الجراحي.

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