ARCHIVES OF IRANIAN MEDICINE
Year:2005 | Volume:8 | Issue:2|Papers Count:15

Hepatitis C infection has come to the top of virus-induced liver diseases in many parts of the world. In Iran, it seems that its prevalence in general population is less than 1%, which is much lower than in most of the regional countries. However, the infection is emerging mostly due to problem of intravenous drug abuse and needle-sharing in the country. On the other hand, an increase in number of centers providing hemodialysis and transfusion facilities for hemoglobinopathies generated new sources and susceptible populations in Iran. This article aims to summarize available data of Iran and to compare them with those of similar countries to find better preventive means.

Background: Little evidence exists on the diagnostic accuracy of clinical presentation in distinguishing the type of herniation in patients with lumbar disc disease. This study was undertaken to examine the correlation between clinical features and herniation type in lumbar disc hernia. Methods: One hundred and fifty consecutive candidates for lumbar discectomy were examined. The initial assessments, including location and duration of pain, neurological examination, and straight leg-raising (SLR) tests were performed by an independent observer who was unaware of the final diagnosis. Intraoperatively, all patients were assessed by a single neurosurgeon for the presence of disc protrusion or extrusion. Results: Among 90 men and 60 women (mean age: 41.4, range: 18 – 75 year), 85 patients had disc protrusion and 65 had extruded disc. Patients with radicular pain alone and those who experienced a resolution of low back pain followed by an increased severity of radicular pain were 6.5 (P < 0.002) and 10.2 (P < 0.000) times more likely to have an extruded disc, respectively. The mean preoperative duration among the group of patients with extruded disc (11 weeks) was significantly shorter than the protruded ones (18.6 weeks) (P < 0.005). Among all subjects, 103 patients showed neurological abnormalities. There was no association between the presence of neurological deficits and the type of herniation (P > 0.005). In patients with positive crossed straight leg-raising (N = 43), 33 had extruded disc and 10 had protruded disc. The positive crossed SLR test correlated significantly with the type of herniation (relative risk = 2.56, P < 0.000, and X2 = 27.4). Conclusion: In the lumbar disc disease, there were three groups of patients: a) those with radicular pain alone, b) those who experienced an increased severity of radicular pain followed by resolution of back pain, and c) patients with positive crossed SLR test who had a high probability of harboring an extruded disc. There was no significant association between the neurological abnormalities and the type of herniation.

Background: Various classification criteria of brain infarct are used in clinical trials and stroke registries. The practical Iranian criteria (PIC) is designed for clinical practice. Methods: From March 2001 through March 2003, all consecutive stroke patients admitted to Vali-e- Asr Hospital, Birjand, Khorasan, Iran were included in this prospective observational study. Patients underwent a standard battery of diagnostic investigations by a stroke neurologist. Data on patients, demographics, clinical presentations, and diagnostic work-up were kept in a database. Two stroke neurologists and a general practitioner independently reviewed the data of 20 randomly selected patients and classified patients according to the PIC classification of stroke topography and etiology. The PIC is designed by stroke neurologists and approved in the University of Alberta, Canada. The degrees of interrater agreement were measured with unweighted k-statistics. Results: Among 302 stroke patients, 20 patients (11 females, 9 males) were randomly selected. The three interrater agreement for topographic subtyping of the patients was 0.95%, k = 0.915 (0.662 – 1), P < 0.0001 and for etiologic diagnosis was 0.90 %; k = 0.9022 (0.753 – 1), P < 0.0001. Stroke neurologists agreed in topographic diagnosis for 20 out of the 20 cases (100%; k= 1; 95% CI, 1.0 to 1.0; P < 0.0001). The general practitioner arrived at the same topographic diagnosis for 19 out of the 20 cases (0.95%; k = 0.875; 95% CI, 0.638 to 1.0; P < 0.0001). Stroke neurologists agreed in etiologic diagnosis for 18 out of the 20 cases (0.90%; k = 0.855; 95% CI, 0.66 to 1.0; P < 0.0001). The general practitioner arrived at the same etiologic diagnosis for 18 out of the 18 cases that the two stroke neurologists agreed (100%; k = 0.875; 95% CI, 1.0 to 1.0; P < 0.0001). Conclusion: The interrater agreement of PIC for topographic and etiologic classification of brain infarct is much higher than the other classification systems. The PIC could be useful in stroke practice.

Background: Vancomycin has been widely used in the treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). The emergence of vancomycin-intermediate and -resistant Staphylococcus aureus (VISA and VRSA, respectively) in various parts of the world has been of great concern in clinical settings. This study was performed to evaluate the possible presence of VISA and VRSA in Tehran, Iran. Methods: The minimum inhibitory concentration (MIC) of vancomycin for 139 Staphylococcus aureus strains isolated between April and August 2003 was carried out according to the standards of the National Committee for Clinical Laboratory Standards (NCCLS) using the agar dilution method. Resistance of VRSA to vancomycin was checked by E-test. Disk diffusion method was also used to determine the susceptibility of strains to common antibiotics. Determination of oxacillin MIC was performed for VRSA with the agar dilution method according to the guidelines of NCCLS and the E-test. Results: Using the disk diffusion test, most isolates (91.7%) were resistant to penicillin while the lowest resistance (10.9%) was to imipenem. Five of the 139 isolates had a vancomycin MIC of . 128 by agar dilution and E-test methods. All VRSA isolates were MRSA (MIC . 256) and the majority were also highly resistant to other examined antibiotics. Conclusion: This is the first report of isolation of VRSA in Tehran, which calls for confirmation by reference laboratories and further epidemiological studies.

Background: Mutations in the gene that encodes the gap-junction protein connexin 26 (GJB2) at the DFNB1 locus on chromosome 13q12 are the major cause of autosomal recessive nonsyndromic sensorineural deafness (ARNSD) in many different populations. A fraction of patients with GJB2 mutations have only one mutant allele, and in some familial cases with linkage to the DFNB1 locus, no mutations in GJB2 are reported. Recently, a large deletion involving the GJB6 gene encoding connexin 30, which is also located at the DFNB1 locus delta(GJB6-D13S1830), has been reported to cause ARNSD in homozygotes for this mutation and in compound heterozygotescarrying deafness-causing allele variants of GJB2 on the opposite allele. To date, different papers have been published reporting the presence or absence of this deletion in various populations. Methods: Three hundred eighty-five probands segregating presumed autosomal recessive nonsyndromic deafness were screened for GJB2 mutations using an allele-specific polymerase chain reaction (PCR) assay to detect 35delG mutation. Direct sequencing was performed following DHPLC analysis of all patients except 35delG homozygotes. Screening for ∆ (GJB6-D13S1830) was completed using PCR primers that amplified the breakpoint junction of this deletion in all patients heterozygous for only one GJB2 mutation and 116 probands with normal GJB2 alleles. Results: GJB2-related deafness was diagnosed in 70 probands (18.2%). Sixteen patients were found to carry only one GJB2 mutant allele. Additionally, we found three novel GJB2 allele variants. ∆ (GJB6-D13S1830) was not detected in the subjects screened for this mutation. Conclusion: Our finding indicates that ∆ (GJB6-D13S1830) is not a common cause of deafness in Iran and suggests that this mutation is not widespread in the world.

Background: Maintenance treatment of schizophrenia reduces relapse rates of this disease. This treatment is carried out for long periods of time and occasionally for lifelong. Dose reduction strategies are designed to maintain the benefits of antipsychotic drug therapy, while reducing the side effects. The authors tested a new dose reduction approach by increasing the interval between administration of intramuscular (IM) injections of fluphenazine decanoate. Methods: Fifty outpatients with schizophrenia or schizoaffective disorder were randomly assigned to receive 25mg of fluphenazine decanoate intramuscularly, either every 2 weeks or every 6 weeks, for 54 weeks in a double-blind design. Results: The two-dose regimens did not differ significantly in the number of relapses or returning of symptoms, but the 1-year extrapyramidal symptom and dyskinesia scores, adjusted for baseline, were higher for the “every 2 weeks” than the “every 6 weeks” group. Conclusion: The use of injections of fluphenazine, every 6 weeks instead of every 2 weeks, may increase compliance and improve patient’s comfort as well as decreasing cumulative antipsychotic exposure, without increasing relapse rates or symptoms.

Background: The opioid withdrawal syndrome can vary greatly in intensity. Depression is proposed to be one of the contributing factors in withdrawal intensity of opioid dependents. Methods: Fifty-one male heroin dependents were enrolled in this study. All of them were admitted to Beheshti Psychiatric Hospital in Kerman, Iran for detoxification of heroin dependence. Existence of depression was evaluated by means of Beck Depression Inventory (BDI), and DSM IV criteria for major depressive disorders before the start of withdrawal complaints. The opiate withdrawal questionnaire was used for evaluating withdrawal signs and symptoms, 24 and 72 hours after the start of withdrawal. Results: The mean age of subjects was 33.67 ± 8.36 years. By means of BDI, 28 (54.9%) and by means of DSM IV criteria 11 (21.57%) subjects were ranked as depressed. Scores of withdrawal signs and symptoms were higher in the depressed patients, 24 hours after beginning of withdrawal, but were only higher in patients with major depressive disorder 72 hours after the start of withdrawal. Conclusion: Existence of depression, especially in the form of major depressive disorder, could intensify withdrawal signs and symptoms. This should be taken into account by the treating physicians, during the detoxification period and further treatment plans.

Background: Understanding the epidemiology of suicide will increase awareness of suicide as a major public health problem. The epidemiology of suicide is described for the first time in Ilam, Iran. To describe the incidence of and factors associated with completed and attempted suicide in Ilam (western part of Iran), a longitudinal prospective case-register study was conducted from 1995 to 2002. Methods: In the province of Ilam, Iran, all individual contacts concerning parasuicidal behavior were registered by the participating facilities. Demographic and case-related information were recorded. Two thousand five hundred twelve people committed suicide from the year 1995 to 2002. Cases were selected on the basis of information from the scene of crime, police inquest, office of welfare organization, autopsy findings, emergency medical services, mental health clinics and hospital records, Ilam Central Bureau of Statistics, and interview with the acquaintances of the victims and suicide attempted persons. Results: The overall annual completed suicide rate (95% confidence interval [CI]) was 10.0 (8.5 to 11.5) and 26.4 (23.9 to 28.9) per 100,000 men and women. The attempted suicide rate was 41.8 (38.7 to 44.8) and 64.5 (60.7 to 68.4) per 100,000 men and women. More women than men completed (relative risk = 2.7 [95% CI: 2.2 to 3.2]) or attempted suicide (relative risk = 1.5 [95% CI: 1.4 to 1.7]). Suicide and attempted suicide rates were highest among 20 – 29 years old and decreased with increasing the age. Self-immolation was the most common method of suicide, while drug overdose was the predominant method of suicide attempt. Suicidal behavior was associated with a higher level of education. A higher completed and attempted suicide rate was found among the married people than those who never married. Conclusion: The findings of this study highlight the need for further studies to identify population at high risk for suicide as the first step towards planning a well-organized approach to reduce the suicide rate.

Background: Pain as a common symptom of shoulder disease, has diverse etiologies. NSAIDs, physiotherapy, neural blocks, intraarticular injections, and surgery are the most commonly used methods of treatment. The goals of this study were to reduce pain and improve the range of motion of the affected shoulder. Methods: Among 70 patients referred to a private pain clinic with chronic shoulder pain as their major complaint (duration of pain 21 mo), 63 patients were chosen for regional blocks as follows: suprascapular (25%), sub-acromial bursa and suprascapular (40%), sub-acromial bursa and field block (FB) (14%), brachial plexus (11%), cervical epidural (6%), and FB (4%). Pain relief evaluation was done according to Visual Analog Scale (VAS) (using a 100-segmented ruler). Pain relief > 50% was considered successful and special health-care and medical exercise therapy recommended. Results: Average age of patients was 49.2 ± 13.7 years (females = 64% and males = 34%). Sixty-seven percent of patients had significant pain relief after a week, 73% after 4 weeks, and 81% after 12 weeks (P < 0.0001). Conclusion: Regarding the results of pain relief after 1, 4, and 12 weeks postinjection, it appears that the pain relief state is likely to be permanent after the first week.

Between 1980 and 1998, we performed 27 valgus osteotomies for nonunion of femoral neck fractures. Patients were aged 17 to 79, with an average of 45 years. Twenty-four patients had undergone previous surgery. Prior to osteotomy, the average neck-shaft angle was 105° (80 – 130°), with an average shortening of 2.5 cm (1.5 – 4.5 cm). After valgus osteotomy, 24 of the 27 fractures healed after 3 – 10 months (average, 5 months). One patient died 2 months after surgery (79 years old) and two had implant failures. Five patients had mild avascular necrosis at the time of study, which was not symptomatic. Pain and limitation of motion improved remarkably, so that the majority of the patients did not have to use crutches. Shortening was reduced to an average of 1 cm. We recommend valgus osteotomy of the proximal femur in the nonunion of femoral neck fractures.

Malaria is an important tropical disease in terms of morbidity and mortality. It is difficult to identify hidden contaminated cases through the use of ordinary techniques, such as microscopic methods, in endemic regions. In the present study, two techniques were used to assess the rate of contingent malaria contamination in healthy inhabitants: microscopic study (thin and thick blood smears) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). One hundred blood samples were collected from healthy individuals who lived in Chabahar, southeastern Iran, in June 2002, during peak mosquito season. Three positive samples (3%) were detected by PCR method, all of which had been reported negative by microscopic examination. It seems that the most appropriate method for populationbased screening of blood donors for malaria parasites could be through the detection of parasite nucleic acids using PCR. Such a strategy would also reduce transfusion-transmitted malaria in endemic areas.

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is characterized by headache, papilledema, and normal cerebrospinal fluid (CSF) findings, all occurring in the absence of enlarged ventricles or an intracranial mass on computerized tomographic (CT) scan or magnetic resonance imaging (MRI). Papilledema is a cardinal feature of IIH, however, in rare cases, IIH may occur without papilledema or even with pseudopapilledema. We describe an overweight woman with long-standing headache and mild right abducent nerve paresis with a normal neurological examination including fundoscopy, Snellen visual acuity, and perimetery. After normal findings on brain MRI and laboratory tests, a lumbar puncture was performed, which was normal except for a CSF opening pressure of 400 mmH2O. However, after repeated lumbar punctures and the diagnosis of IIH, the patient’s headache gradually subsided and her diplopia improved. In obese patients with chronic headaches and cranial nerve paresis, the diagnosis of IIH should be considered, even in the absence of papilledema. A lumbar puncture is helpful both diagnostically and therapeutically.

Capgras syndrome is one of the delusional misidentification syndromes, in which the patient believes that familiar persons are replaced by a double. In this case report, a middle-aged woman with a long time history of grandmal epilepsy has been reported. She believed that her sons replaced her possessions and furniture continuously. Replacement of inanimate objects was considered as a rare variant of Capgras syndrome in recent years. The patient’s history is discussed from different points of view.

Neurilemmoma is a benign neoplasm of Schwann cell origin, most frequently occurring in the extremities and the trunk and head regions. The breast is a very unusual site for this tumor. We report a case of breast neurilemmoma in a 27-year-old woman. The palpable mass was localized in the lower outer quadrant of the right breast. This intramammary tumor appeared ultrasonographically as a well-circumscribed, inhomogeneous solid mass. Microscopically, it had a pattern similar to that of neurilemmoma at other sites.

Ureteral metastasis from gastric cancer is rare. It is usually diagnosed in the setting of an advanced gastric cancer or on postmortem examination. Isolated ureteral metastasis without involvement of other sites is extremely rare. We describe a 67-year-old man with gastric cancer and right ureteral metastasis. The patient was from Ardabil Province, a high incidence area for gastric cancer in Iran. He presented with right flank pain which was found to be due to ureteral obstruction. Surgical relief of the obstruction was sought and the surgical biopsy specimens showed metastatic undifferentiated carcinoma in the ureteral wall. A search for the primary lesion revealed gastric cancer. He denied any symptoms referable to his upper GI tract. The patient is doing well on chemotherapy 6 months after the initial diagnosis.