Does this patient have pheochromocytoma? A systematic review of clinical signs and symptoms
© Pourian et al. 2016
Received: 5 September 2015
Accepted: 2 March 2016
Published: 31 March 2016
Pheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly.
To determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease.
MEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles.
We included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally.
Two authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test.
The most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %.
Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR- 0.45), Palpitation (LR+ 1.9, LR- 0.52) and headache (LR+ 1.6, LR- 0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR- 0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease.
By available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings. Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.
KeywordsPheochromocytoma Likelihood ratio Clinical exam Sensitivity Specificity
A 35 year old woman was referred by her family physician because of recurrent spells of headache, dizziness, and sweating since 6 months ago. She had also experienced dyspnea and palpitation followed by chest discomfort. Each time, she was admitted to the hospital with high blood pressure and heart rate. But the physical exam between attacks was normal.
A 50 year-old man came to his family physician with moderate bitemporal headache. On physical exam, his blood pressure was 170/100 mmHg and pulse rate was 70. He had no chest pain, dyspnea or blurred vision. He had experienced such headaches in the last 6 months about once a month.
Pheochromocytoma is a rare tumor with an annual incidence of 1–4/106 population . It is popular for causing hypertension; however, It is an uncommon cause of hypertension, estimated to occur in approximately 0.1 to 1 % of hypertensive patients [1, 2, 4, 5]. It is suggested that most doctors meet only one patient with pheochromocytoma in their working lifetime and a large general hospital admits -on average- one such patient annually . Despite the low frequency, pheochromocytoma is fascinating and challenging to clinicians because it has lethal potential if untreated, and possible long term cure -in the majority- if diagnosed and treated surgically. Clinical awareness of this tumor should be stressed because 1) Surgical removal is curative in more than 90 % of patients (The 5-year patient survival after removal of benign pheochromocytoma has been ranged from 84 to 96 %) , 2) Tumor excision has significant effect on hypertension, the most important cause of pheochromocytoma related mortality and morbidity. In the follow up of surgeries, it has been shown that about 60 % of patients became normotensive [4, 7–9]. In patients with persistent hypertension after surgery, the mean arterial pressure decreased significantly  and was controlled better with anti-hypertensive drugs ; hypertensive crises disappeared after surgery [10, 11]; and hypertension-related complications regressed significantly , 3) Biochemical testing and imaging together have high accuracy in detection of the disease 4) Some drugs and in particular, anesthetic agents may potentiate the life-threatening effects on the heart and circulation of catecholamines secreted by this tumor, and 5) If it is left untreated, fatal complications often ensue, most of which are related to hypertension (In a series of autopsy from the Mayo Clinic that spanned 50 years, 75 % of the cases were undiagnosed during life, although they were symptomatic) . Thus, early clinical diagnosis of pheochromocytoma is imperative, to allow clinicians to efficiently complete further investigations and initiate appropriate treatment with the goal of minimizing morbidity and mortality.
P.F. Plouin studied 2585 hypertensive patients to find out the value of clinical triad –headache, palpitation and diaphoresis, in the diagnosis of pheochromocytoma . He found positive Likelihood ratio (LR) of 14.6 and negative likelihood ratio of 0.1 for the triad of symptoms. It showed that clinical picture can predict the probability of the pheochromocytoma to a good level. From that time, this triad became the base of clinical suspicion for endocrinologists to further work up to detect pheochromocytoma. But pheochromocytoma shows many other symptoms and signs which may have additional benefits for clinical diagnosis. We did a systematic review in order to define the value of each piece of the clinical picture to identify patients with pheochromocytoma whom further diagnostic tests are indicated.
Pathophysiology and clinical presentation of pheochromocytoma
First described in 1886 by Fränkel, pheochromocytomas are tumors derived from the chromaffin cells of the embryonic neural crest . Chromaffin cells are post-ganglionic sympathetic neurons which produce catecholamines. When fresh tissue samples are oxidized with certain fixatives, their catecholamine content is stained dark grey-brown (“peso” in Greek). These cells are mainly located in the adrenal medulla (in fact, approximately 85–95 % of pheochromocytomas are located in the adrenal medulla) [2, 3]. Tumors arising from extra-adrenal chromaffin cells are termed paragangliomas and they can be found along the paravertebral and para-aortic axes (sympathetic paraganglia have a neck-to-pelvis distribution, while parasympathetic paraganglia are found almost exclusively in the neck and skull base, along the branches of glossopharyngeal and vagus nerve).
In addition to the classic triad, patients often experience other symptoms such as anxiety, dyspnea, chest, abdominal or flank pain, nausea and vomiting, tremor, flushing, dizziness, visual symptoms such as blurred vision, and paresthesia. On the other hand, persistent vasoconstriction in patients with pheochromocytoma declines the blood volume leading to orthostatic hypotension . The sudden out-pouring of epinephrine has been postulated as causing an elevation in body temperature by a combination of inducing hypermetabolism and impairing heat dissipation as a consequence of cutaneous vasoconstriction  (the leading cause of pallor during attacks). Hypermetabolism caused by catecholamines can cause weakness, fatigue and weight loss. Paradoxically, some patients have diarrhea, whereas others may have constipation.
Although chronic hypertension can cause cardiovascular complications, catecholamines directly have toxic effect on myocardium as well. During attacks different ECG changes evolve, which are resolved after the surgery. However, chronic exposure to catecholamine can lead to irreversible myocardial fibrosis .
We reviewed Medline database from 1960 to February 2014 by the structured search strategy including both text word and MeSH term of the following keywords: pheochromocytoma, diagnosis, physical examination, medical history taking, sensitivity and specificity, reproducibility of results, observer variation and predictive value of tests; We limited the results to English language and humans1. The results were reviewed by two of the authors for relevance and quality. The aim was looking for original articles which reported the sensitivity and/or specificity of symptoms in patients with pheochromocytoma. Then, the results were discussed and the papers which the authors had disagreement, were given to the third author for decision about inclusion. We chose the papers which their method for disease-confirmation was based on histopathology and the data was extracted before diagnosis of the disease (in order to resolve recall bias). We excluded papers which studied a specific subtype of pheochromocytoma (e.g. malignant or familial), or just syndromes that pheochromocytoma was a part of them (e.g. MEN, Von Hippel Lindau disease). Also, we excluded the studies on only specific age/gender. Moreover, we reviewed the papers studying the value of biochemical testing in diagnosis of pheochromocytoma (we thought that these studies more possibly have specificity of symptoms beside their sensitivity, because of having control group); if they had clinical data of the patients, and if they had no clinical relevant data, we sent an email to the authors and asked for their clinical data if available. On the other hand, we tracked the references of review articles to find more original articles. In addition to electronic search, we did hand-searching using endocrinology textbooks.
We defined hypertension as blood pressure higher than 140/90 mmHg. As this definition was accepted in the fifth Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) in 1993 , we sent emails to the authors of articles published before this time with no definition for hypertension in the article and asked if their definition was the same, and if we got no response, we ommited the article from analysis. Orthostatic hypotension was defined as a drop in systolic (20 mmHg) or diastolic (10 mmHg) blood pressure within 3 min of standing. Finally, because the definitions were different among the studies which checked this sign, we separately discussed the articles in the result section.
After selection of articles for analysis, considering inclusion and exclusion criteria, we extracted the crude numbers of patients having symptoms or signs of possible pheochromocytoma. The symptoms consist of headache, palpitation and diaphoresis (three parts of the classic triad), total classic triad, flushing, palor, nausea/vomiting, weakness/fatigue, diarrhea, constipation, dizziness/vertigo, chest pain, abdominal pain, flank pain, dyspnea, paresthesias, anxiety, visual symptoms, and tremor. The signs we looked for, were hypertension and orthostatic hypotension. We filled the 2 × 2 tables for calculating LR for the symptoms that we could, and put the sensitivities together in a separate table. Meta-analysis was done if possible (number of studies more than one) for LR of symptoms and signs, and a meta-analysis was performed for sensitivities separately. Several factors affect distribution of symptoms and signs in studies, such as distribution of genders, malignant or benign disease and size of the tumor, but none of the studies had separated these factors (so we could not do subgroup analysis or meta-regression if the data was heterogeneous). We calculated heterogeneity by drawing Forest plot and I2 test. We considered heterogeneity as I2 > 50 %. Because our data was heterogeneous based on I2 (except one), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test. If the P value in Egger test is below 0.05, then we considered the data to have publication bias. Analysis of the sensitivity was done by Stats-direct software and analysis of the LRs was done by meta-disc software.
Studies Assessing Clinical Presentations: studies without control group
Clinical setting, Years
No. of Patients
Age, Mean (Range)
Gender (M, F)
Chung-Yau Lo et al., 2000
Queen Mary hospital, Hong Kong, China, 1981–1998
29 (24 diagnosed in life, 4 postmortem, 1 operated with an unexpected diagnosis
Median = 50 (18–75)
M. Mannelli et al., 1999
18 centers from all over Italy, 1978–1997
44 (8–84) in female
46(12–79) in male
Gennaro Favia et al., 1998
A university endocrine surgery unit, Italy, 1977-1996
Gunnar Stenstrom et al., 1988
A university hospital, Sweden, 1956–1982
J.W. Lance and Hinterberger, 1976
A University Hospital in Sydney, Australia
Patócs et al., 2004
Faculty of Medicine, Semmelweis University in Budapest, Hungary. 1995–2003
FC Hernandez et al., 2000
University Hospital “Virgen de la Arrixaca”, Murcia, Spain. 1994–1998
Laurence Amar et al., 2005
Referral to a Hypertension unit, France, 1975–2003
K.C. Loh et al. 1997
Endocrine clinics, Nova Scotia, Canada, 1986–1995
Charles AG Proye et al., 1994
3 medical centers, France, 1951–1992
P.F. Plouin et al., 1997
A hospital in Paris, France, 1975–1994
Roger R. Perry et al., 1990
Surgery branch of National cancer instate, Maryland, USA, 1982–1989
25 (extra-abdominal and 1 incidental discovery were excluded)
TD O’halloran et al., 2001
St. Vincent hospital Ireland, 1950–1997
Aguilo et al., 1991
University hospital, Puerto Rico, 1970–1990
24 (19 diagnosed clinically and 5 post-mortem)
J.E. Thomas et al., 1966
Mayo clinic, USA. 1945–1964
100 (97 in life and 3 autopsy)
Robert Kopetschke et al., 2009
4 endocrine centers, Germany, 1973–2007
C. Charles et al. 1984
A university hospital, Jamaica, 1963–1983
Wei-ber Liao et al., 2000
Chang Gung memorial hospital, Taiwan, 1993–1997
Joyce SY Yau et al. 2010
endocrine clinics of the Kowloon West Cluster hospitals, china. 1994–2003
17 (19 at first. 2 lost to follow up)
Van Duinen et al. 2010
Leiden university medical center, Netherland, 1975–2008
28 patients whom the pheochromocytoma was diagnosed based on signs and symptoms
Bernard Goldny et al., 2001
Department of General Surgery of the University of Munster Hospital, Germany. 1967–1998
I.M. Modlin et al. 1979
A number of hospitals, England, 1955–1976
72 (58 diagnosed in life)
E. J. Ross and Griffith 1989
3 hospitals, London, England, 1952–1982
Ulf Niemann et al., 2002
University hospital, Germany. 1974–2000
Takyo Noshiro et al., 2000
Tohoku University School of Medicine, Sendai, Japan. 1957–1995
95 (2 autopsy)
Richard E. Goldstein et al.,1999
2 medical centers, Tennessee, USA, 1950–1998
Khoram manes et al. 2005
Sahlgrenska University Hospital. western region of Sweden. 1950–1997
N. Sharma et al., 2001
Tertiary care hospital, Chandigarh, India, 1989–1996
Masky P et al. 2012
Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal. 2008–2011
Studies Assessing Clinical Presentations: studies with control group
Clinical setting, Years
No. of Patients
Age, Mean (Range)
Gender (M, F)
Plouin et al., 1981
Hypertension service, saint-Joseph hospital, Paris, France, from 1977
2585 hypertensive patients (11 of them were found to have pheochromocytoma)
All of the 2585 patients are considered control group as the proportion of pheochromocytoma is 0.4 %
Peter P. Stein et al. 1991
Yale university school of medicine, USA.
30 episodes (29 patients), 28 controls
Henry R. Black et al. 1984
11 new England hospitals, USA, 1962–1980
53 patients (60 first. 5 excluded because of finding based on predisposition genetic factor. 1 excluded because of being asymptomatic and tumor found at autopsy) 25 controls
P.F. Plouin et al., 1988
Hypertension departments of 2 hospitals, Paris, France, 1976–1985
Yes (21 patients with essential hypertension)
Václavík J et al. 2007
Sternberk Hospital, Sternberk, Czech Republic.
Run Yu et al. 2007
An academic hospital, Los Angeles, USA 1997–2007
Yes (patients with over-diagnosed pheochromocytoma)
Yu R et al. 2010
Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California. 2000–2008
Yes (24 patients with highly elevated biochemical tests but pheochromocytoma was ruled out)
Sensitivity of signs and symptoms
No. of studies report
Pooled sensitivity (Random effects) (%)
95 % CI
HTN (paroxysms on sustained)
Sensitivity of orthosthatic hypotension based on different definitions in studies
Study (number of patients)
Definition of OHa
M. Mannelli et al. (156)
falling SBP > 30 mmHg or falling DBP > 20 mmHg
N. Sharma et al. (30)
fall in SBP > 20 mmHg
Baguet et al.  (41)
fall in SBP > 20 or fall in DBP > 10 1 min after standing
Plouin et al. (39)
fall in SBP > 10 mmHg
Based on funnel plot and Egger test, paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias.
Pooled estimation of LR for symptoms and signs of pheochromocytoma
Number of studies
1.682 (1.093–2.589) fixed effect
The main purpose of this article was defining sensitivity and – if possible- LR of signs and symptoms in diagnosis of pheochromocytoma. We used the search strategy of “Rational Clinical Examination” for collecting articles in Medline from 1960 to 2014; and used reference tracking of review articles to find more relevant original articles. In addition to electronic search, we did hand-searching using endocrinology textbooks. The result of this search strategy was 37 articles. From 6 of these articles, we could fill the 2 × 2 table of LRs.
For evaluating the possibility of doing meta-analysis for our data, first we calculated heterogeneity of different symptoms, which all were heterogeneous according to definition of heterogeneity based on I2 (except negative LR of hypertension with I2 of 43.2 %). Because of heterogeneity of data, we used random effect model for meta-analysis. For evaluating publication bias we used Egger test, which the P-value < 0.05 was considered significant and so the data was considered to have publication bias. This was true for 4 of the symptoms: paroxysmal hypertension, chest pain, flushing and weakness.
The meta-analysis of positive and negative LRs for symptoms and signs was done. Therefore, palpitation with positive LR of 1.888 (95 % CI 1.161–3.073) and negative LR of 0.518 (0.333–0.806), diaphoresis with positive LR of 2.184 (1.411–3.382) and negative LR of 0.451(0.310–0.657) and headache with positive LR of 1.607 (1.124–2.297) and negative LR of 0.240 (0.094–0.613) were the symptoms useful in differentiating pheochromocytoma from other similar diseases. In addition, not having the classic triad had the LR of 0.139 (0.059–0.331) (Table 5). One was included in confidence interval of a number of LRs, but because of asymmetry of the intervals, the numbers could be considered clinically significant. These, include classic triad with the positive LR of 6.312 (0.217–183.217), hypertension with the positive LR of 0.762 (0.562–1.033), anxiety with the positive LR of 1.127 (0.500–2.541), and flushing with the negative LR of 1.466 (0.754–2.850). Among our data only one feature proved to be homogenous: negative LR of hypertension (LR- of 1.682 with 95 % confidence interval of 1.093–2.589).
Two studies of P.F. Plouin for evaluating classic triad in diagnosis of pheochromocytoma
Authors, number of patients and control group
P.F. Plouin et al. 1988, N = 39/21essential HTN
Plouin et al. 198l, N = 2585 HTN whose 11 patient had pheochromocytoma
As shown on the table, the most significant difference between 2 studies is the ratio of false negative results to all negative results (4/14 vs. 1/2414). An explanation can be the precedence of the first study (1981) with larger sample size . At that time thinking about the triad symptoms was not routine and evidence-based. So, it is possible that asking about them was not done in a series of patients and this group was classified as “not having the symptoms”. So, the ratio of patients that apparently didn’t have the symptoms and finally diagnosed as “having pheochromocytoma” was increased (As the study was retrospective and based on patients’ files).
Hypertension is the most famous sign among physicians for clinical suspicion of pheochromocytoma. What we found was somehow different. We found positive LR of 0.762 (0.562–1.033) with an asymmetry through below 1 (means that hypertension decreases the probability of pheochromocytoma), and negative LR of 1.682 (1.093–2.589) with heterogeneity below 50 % (means homogeneity of data and so fixed effect meta-analysis), which shows that normotension increases the probability of pheochromocytoma. Our explanation is that may be in patients without hypertension the threshold to think about and refer for further analysis of pheochromocytoma is higher for clinicians, and so more patients finally would be proved having pheochromocytoma.
Some of the symptoms were only reported in Stein’s article . Pallor, dyspnea, paresthesia, and orthostatic hypotension were the symptoms and signs which their presence increases the likelihood of pheochromocytoma; whereas diarrhea, constipation, dizziness, chest pain and tremor were the symptoms and signs which their presence decreases the likelihood of pheochromocytoma. Diarrhea and constipation are non-specific symptoms related to pheochromocytoma; so, their incidence is not valuable accordingly.
The LRs of orthostatic hypotension was studied in Plouin article . The control group were patients with essential hypertension and the definition of orthostatic hypotension was falling systolic blood pressure more than 10 mmHg after standing. The positive LR 1.885(0.710–5.003) and the negative LR 0.792(0.579–1.083) were calculated. The value of triad plus orthostatic hypotension was studied too. When considering this combination, the sensitivity was decreased from 89 % (considering triad alone) to 30 %, and the specificity was increased from 67 to 95 %. (LR + = 6.462(0.901-46.325), LR- = 0.727(0.578–0.915).
By drawing the Funnel plot for each sign/symptom and doing Egger test for assessing publication bias, paroxysmal hypertension, chest pain, flushing and weakness were the signs/symptoms which had publication bias based on our definition. So, these items reasonably should be excluded from our final report.
At last, when we look at the table of LRs, it seems that no single sign or symptom alone is helpful in diagnosis of pheochromocytoma. Rather, the combination (such as the classic triad) can be probably important for this aim. Despite flushing and pallor had significant positive LRs and headache had significant negative LR, these were evaluated in only one study and additional studies should be done for more accuracy. Studying the triad in hypertensive patients decrease the spectrum bias and approximates the LRs to reality in clinical setting. According to Plouin’s study (11 pheochromocytoma in 2585 hypertensive patients), the probability of pheochromocytoma in hypertensive patients with classic triad becomes 2.6 %, compared with 0.4 % in hypertensive patients . By experts’ consensus, this number could be high enough for continuation of evaluating the disease. On the other hand, the probability of pheochromocytoma in hypertensive patients without classic triad becomes 0.05 % (compared with 0.4 % in patients with classic triad). So it seems reasonable to clinically rule out the disease by this data.
The limitations of our study were looking for English articles only, and using only PubMed for our search. For compensation of this limitation, we used reference tracking for expanding the results. This was done till we reached the point that the articles we were finding became duplicated. Also we looked at articles which aimed to diagnose pheochromocytoma biochemically (we hoped to find control groups and therefore could calculate LR).
The other problem was verification bias. Patients with known signs/symptoms are usually referred for evaluation of pheochromocytoma. Patients with less common presentations are less evaluated and this overestimates sensitivity and underestimates specificity of the findings. Because most of the studies were done in referral centers, the verification bias would further increases. Doing the studies in tertiary referral centers also cause spectrum bias, because the prevalence of pheochromocytoma defers from the general population in this setting. In some of the studies found, the prevalence of pheochromocytoma in the population studied was reported. This, has a range of 1.5–6.7 % (compared to prevalence of 1−4 × 10−6 in the general population) [21–23].
An important point is the paucity of studies about value of clinical presentation regarding pheochromocytoma. Because of heterogeneity of most of the clinical studies and wide confidence interval of results, additional studies are recommended to narrow the confidence intervals and increase the precision of the results.
As the essential hypertension is most commonly seen in middle aged population, the presence of paroxysmal hypertension in a young patient leads us to pathological conditions such as pheochromocytoma. The presence of classic triad of headache, palpitation and sweating raises the clinical suspicion 6 times. The other symptoms (dizziness, chest pain, dyspnea) are not independent. So we cannot simply multiply them to calculate the final LR. By considering the value of signs and symptoms, we decided to move forward in our evaluation. The level of urine catecholamines was increased. Imaging showed a 3 cm mass in left adrenal gland. The patient was referred to surgeon for left adrenalectomy. The pathologist reported chromaffin cells and the diagnosis of pheochromocytoma was proved. The attacks of the patient subsided after surgery and the blood pressure became stable during 2 years of follow up.
The patient was a known hypertensive patient from 5 years ago on anti-hypertensive drugs. Symptoms of emergent hypertension were asked from the patient (chest pain, blurred vision, hematuria, and headache) and a complete physical exam was done. Then, he was given oral anti-hypertensive drugs and observed for 4 h. He was discharged from the Emergency department and was recommended to visit his family physician. The absence of classic triad and other parts of the history made pheochromocytoma less probable.
By available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, in order to specify the value of clinical findings –alone or in combination- in favor or against the diagnosis of pheochromocytoma more accurately, to help us distinguish patients who require more evaluation, from those who require no further testing. Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.
This strategy was selected based on the “search strategy for the rational clinical examination- David L. Simel, 1995”.
We thank Dr A. Keshtkar and Dr K. Heidari for their helpful comments about method of the study. And also Dr M. Zakeri for technical editing of the manuscript. And all the authors who had cooperation in sending us the full-texts of their studies.
This study was supported in part by a grant from Endocrinology and Metabolism Research Center (EMRC), Shariati hospital.
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