ARCHIVES OF IRANIAN MEDICINE
Year:2006 | Volume:9 | Issue:1|Papers Count:17

The primary goal of therapy in patients with chronic hepatitis B is suppression and long-lasting maintenance of hepatitis B virus DNA to its lowest possible level. The threshold of hepatitis B virus DNA level for therapy is ≥.105 copies/mL for HBeAg-positive patients and ≥.104 for those with HBeAg-negative chronic hepatitis B. Interferon alpha-2b, lamivudine, and adefovir-dipivoxil are approved by FDA and could all be used as an initial first-line therapy in chronic hepatitis B. Adding lamivudine to either conventional interferon or peg-interferon did not increase the efficacy. Adding lamivudine to adefovir had also no additional effect in compensated patients. Response rate is about 30% . 40% with first-line drugs. Peg-interferon, which recently received the FDA approval, is associated with an increased response rate. Further long-term studies are required to use peg-interferon as a widespread first-line treatment. Treatment strategy is changing towards using prolonged combination therapy with evolving nucleoside analogues with or without an immunomodulatory agent, aiming at eradicating covalently closed circular DNA.

Background: The study concerns the prevalence of avian schistosomes in intermediate and definite hosts in Mazandaran Province, northern Iran.Methods: A total of 14190 fresh-water snails belonging to various genera were sampled and tested for cercarial emission by lighting and then crushing. During the same period, the nasal blood vessels and mesenteric veins of aquatic birds, mainly belonging to the Anatidae family, were examined under dissecting microscope for detecting adult worms.Results: Forty-seven (0.33%) of examined snails mainly Lymnaea gedrosiana, L.palustris, L.stagnalis, and Planorbis planorbis were found to be infected with larval stages of Trichobilharzia spp. Adult schistosomes were observed in 25 (18.1%) wild waterfowls. The most infected birds were Anas platyrhynchos, A.clypeata, and Aythya ferina, respectively.Conclusion: Annually migration of various species of aquatic birds toward the northern parts of Iran and the simultaneous presence of intermediate snails in the water resources of this area, combined with long hours of sunshine in the summer months, suggest that cercarial dermatitis could be a prominent health problem, especially among paddy field workers in this area.

Background: Chronic venous stasis ulcers of the leg are still a challenge in vascular surgery. Innovation of new surgical techniques using endoscopic instruments have ushered in a new era with less complications and better results. This study was designed to evaluate the safety and long-term outcomes of this technique for the first time in Iran.Methods: Subfascial endoscopic perforator vein surgery was performed on 10 legs in 8 patients who had signs of chronic venous insufficiency (between September 2001 and September 2003). Patients were followed up for a mean of period 12.5 months.Results: The operations were performed successfully in all patients. No serious complications occurred intraoperatively. There was no mortality or significant morbidity. Complete healing of skin ulcers was observed in 5 active and 2 healed ulcers in less than 12 weeks. There were 2 recurrences after 4 and 27 months, respectively.Conclusion: Subfascial endoscopic perforator surgery is a safe procedure for the treatment of venous stasis ulcers. Rapid ulcer healing can be expected in selected patients.

Background: Neural tube defects have a complex and imperfectly understood etiology involving both genetic and environmental factors. In this case-control study, we tried to determine the association of known risk factors for neural tube defects in patients referred to universityaffiliated hospitals with neurosurgical services in the city of Tehran.Methods: Risk factors were assessed in-person through interviews with infants’ mothers. We found 192 neural tube defect cases. One hundred and ninety-three apparently normal babies were randomly selected from the same hospitals to serve as control cases.Results: Maternal age of less than 18 years (P = 0.02), female sex of the child (P = 0.01), birth in spring and summer seasons (P = 0.001), history of not using folic acid (P = 0.001), less than 5 prenatal visits (P = 0.001), and poverty (P = 0.02) were the most important risk factors for neural tube defects. Logistic regression analysis of these risk factors confirmed these correlations. A negative history of consuming folic acid had the most significant statistical correlation with these malformations.Conclusion: Poor quality diets were an important environmental risk factor in this study.

Background: Fistula thrombosis in patients on maintenance hemodialysis is an important morbidity factor. Arterial or venous thrombotic events have been described as complications in patients on regular hemodialysis. This study was designed to evaluate the risk factors for arteriovenous fistula thrombosis. Methods: One hundred and seventy-one patients with arteriovenous fistula on maintenance hemodialysis were studied prospectively during a period of 14 months for any episode of arteriovenous fistula thrombosis, after anticardiolipin antibodies were assayed by ELISA. Other risk factors for thrombosis such as the presence of diabetes or hypertension, the use of erythropoietin (rhEPO), fistula site, gender, age, ultrafiltration, hypotension during dialysis, and the number of dialysis visits in a week were assessed. Results: Fifty-six percent of patients had IgG-anticardiolipin antibodies ≥ 10GPL, which was significantly correlated with dialysis duration (23.18 ± 24.56 months in patients with anticardiolipin antibodies ≤ 10GPL vs. 37.73 ± 36.35 months in patients with 20 ≤ IgG-anticardiolipin antibodies < 40GPL). Within the 14 months of follow-up, 36 episodes of arteriovenous fistula thrombosis occurred in 31 patients (18.1%). Considering anticardiolipin antibodies and other risk factors in a Cox proportional hazard model, only fistula site (P = 0.021, RR = 2.48, CI = 1.14 – 5.37) and erythropoietin (Eprex) use (P = 0.021, RR = 10.92, CI = 1.43 – 83.02) seemed to have an influence on fistula patency. According to fistula site, the survival of brachiocephalic fistulas were significantly (P = 0.007) better than radiocephalic ones (1- and 3-year survival were 95% and 87% for upper, and 88% and 72% for lower ones, respectively). Conclusion: Although the incidence of the anticardiolipin antibody was high in our patients, in the presence of other risk factors for thrombosis, we found no correlation between IgGanticardiolipin antibodies and arteriovenous fistula thrombosis. Instead, erythropoietin (Eprex) use and fistula site seem to have an important role in the correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis.

Background: Several agents have been used for neonatal umbilical cord care, but we did not find any study evaluating the effect of human milk on umbilical cord separation time.The purpose of this study was to compare the effect of topical application of human milk, ethyl alcohol 96%, and silver sulfadiazine on umbilical cord separation time in newborn infants.This study was undertaken place at a primary-level newborn nursery at a university teaching hospital and a private hospital. Of 373 singleton near- to full-term newborns enrolled in the study, 312 completed the study.Methods: Newborns from birth were randomized to either: 1) mothers milk group, 2) alcohol group, 3) silver sulfadiazine group, and 4) control (no treatment) group. Mothers milk for group 1, ethyl alcohol for group 2, and silver sulfadiazine ointment for group 3 were applied to the umbilical stump three hours after birth and continued every eight hours until two days after umbilical cord separation. The time to umbilical cord separation and any discomfort such as infection, hemorrhage, and granuloma formation were reported by mothers. Nothing was applied to the umbilical stump of the control group and they received dry cord care only.Results: It was observed a significant difference in the mean cord separation time among the four group. No significant complications were observed in any group.Conclusion: Breast milk could be substituted for other topical agents for umbilical cord care, but a multicenter study is required in order to advise it for routine umbilical cord care.

Background: Abortion is a public health concern because of its impact on maternal morbidity and mortality. Each year, about 79 million unintended pregnancies, excluding miscarriage, occur worldwide. More than half of these unintended pregnancies end in abortion. The purpose of this study was to determine the ever-event incidence of abortion (spontaneous and induced) and some related factors in a population-based sample of reproductive age women. Methods: From July 2003 through January 2004, 2470 women were included in the study through multistage random sampling and were interviewed. Data were collected using a checklist with questions about demographics and specific items regarding abortion history. Information about age, literacy, gravidity, marriage age, abortion, type of abortion, family history of abortion, history of family marriage, smoking, drug use, alcohol use, coffee intake, and incidence of abortion during the previous year were recorded. Statistical analysis included Student’s t-test, Chi-square, ANOVA, and logistic regression using SPSS software. Results: Out of the 2,470 women in the study, 775 (45.7%), had at least one abortion in their lives. Of the women who had an abortion, 20.6% reported induced abortion and 74.2% reported spontaneous abortion. Forty-one point four percent of women aged 45 years and older had at least one abortion in their lifetime. Fifty-one (2.1%) women had a history of abortion during the previous year; the largest proportion was 5.4% for the age group 15 – 24 years. The most common method of induced abortion in the previous year was dilatation and curettage (42 to 67%). In multivariate analysis, household number, coffee consumption, gravidity, smoking, and history of abortion in the family were the most important factors related to abortion in the different age groups of women. Conclusion: This study shows that the occurrence of at least one abortion in the life of women in our setting is high and varies by age group. There is a need for expanded comprehensive sexual and reproductive health services, and more education and accessibility of contraception methods.

Background: This study determines the expression of P53 protein and the intensity of immunoreactivity in basal cell carcinoma in comparison with the adjacent nontumoral epidermis in sun-exposed areas of the head and neck regions. The mean age of immunoreactivity in tumoral and adjacent nontumoral epidermis is also determined. Methods: This descriptive-analytical study was performed retrospectively over a 5-year period on 150 basal cell carcinoma cases in the Pathology Department of Alzahra Hospital in Isfahan. Proper quality paraffin blocks were chosen for immunohistochemical staining for P53 through the immunoperoxidase method. The intensity of immunoreactivity was graded. The age of the patients was also recorded. Results: Positive P53 immunoreactivity was observed in 123 basal cell carcinoma tissues (82%) and in 117 adjacent nontumoral epidermis (78%) (P = 0.38). The frequency of severe immunoreactivity in tumoral tissue and in adjacent nontumoral epidermis was 46% and 32%, respectively (P = 0.046). The mean age of P53 expression was 66.2 years for tumoral tissue and 66.1 years for nontumoral epidermis. The mean age of those who did not express P53 was 52.6 and 55.9 years for the tumoral and nontumoral epidermis, respectively (P < 0.001). Conclusion: No significant difference was detected between P53 immunoreactivity in tumoral tissue and adjacent nontumoral epidermis. Intensity of P53 immunoreactivity was greater in tumoral specimens. Comparison of mean ages showed a significant difference between P53- expressing and non-P53-expressing groups.

Background: Recently, there has been an increase in the incidence of major vascular complications such as infected pseudoaneurysm due to intravenous drug use.Objective: For better understanding of the existing controversies regarding the optimal surgical management of infected pseudoaneurysm, the present study was conducted. Methods: Medical charts of 36 consecutive patients who underwent surgery in Taleghani Hospital, Tehran, Iran from 1996 through 2003, were retrospectively analyzed.Results: We studied the hospital records of 33 cases; two patients had bilaterally infected pseudoaneurysms and one underwent an emergency reoperation. The total number of operations was 36. Eleven cases (30.5%) underwent ileofemoral reconstruction and 25 (69.5%) arteries were ligated. All patients presented with infected femoral or brachial pseudoaneurysms due to intravenous drug abuse. Postoperatively, there was no hemorrhage, vascular thrombosis, amputation, or mortality. Three cases (8%) had incisional infections (2 [18%] after reconstruction and 1 [4%] after ligation operation) and 7 patients (19%) had claudication (all after ligation).Conclusion: Ligation is the optimal management for infected pseudoaneurysm, because it is easy, cost-effective, and safe. Reconstruction is not recommended, because of an extended infection at the location of pseudoaneurysm and at the artificial graft site.

Background: Mycobacterium tuberculosis-specific CD8+ and CD4+ T lymphocyte responses restrict the spread of extracellular pathogens by limiting M.tuberculosis replication. Alterations in cytolytic function, inappropriate maturation/differentiation, and limited proliferation could reduce their ability to control M.tuberculosis replication. Methods: In an attempt to further characterize the immune responses during M.tuberculosis infection, we enumerated γδ and αβ receptor-bearing T cells expressing CD8 or CD4 phenotype and analyzed the differentiation phenotypes of CD8+ and CD4+ T lymphocyte  subpopulations in 47 cases (23 new cases and 24 multidrug resistant patients) and 20 control subjects, using flowcytometry. Results: We found that the CD4/CD8 ratio was significantly lower in newly-diagnosed M.tuberculosis patients compared to multidrug resistant and control subjects (P < 0.003). Also, we found that a large proportion of CD8+ T lymphocytes in newly-diagnosed patients was defined by increased surface expression of CD57 as compared to the two other settings (P < 0.002). This increase was more profound in patients with an inverted CD4/CD8 ratio. Analysis of the late activation antigen revealed that this was predominantly HLA-DR+ (P < 0.003). No significant changes were observed in the percentages of CD8+CD57+ T cells between the different settings. Moreover, the co-stimulatory molecule CD28+ tended to be underexpressed by CD8+ T cells in multidrug resistant patients when compared to newly-diagnosed subjects (P < 0.002), but not to the control subjects. In contrast, the frequency of CD28+ marker on CD4+ T cells was higher in the setting of multidrug resistant compared with those of new cases (P < 0.0001). No significant changes were observed in percentages of γδ receptor-bearing T cells between different groups. Conclusion: We suggest that the increase in the proportion of CD57+ within CD8+ T cells in newly-diagnosed patients results from M.tuberculosis antigenic stimulation, which is a hallmark of many infections and that the protracted accumulation of CD57+ T lymphocytes might reflect an end-stage differentiation phenotype.

Background: Growth is an increase in the physical dimensions and its result is a quantitative change in the body. Development is a progressive increase in the skills and functional capacity of a child and its result is a qualitative change in a child’s function. Methods: This investigation was a descriptive, decompositive, and observative study, which was performed on a random group of 5,378, 6- to 12-year-old children in 45 schools in the urban population of Mashhad, Khorasan Province, Iran. Results: The height and weight averages of the studied children were more than the averages of Nelson’s Textbook of Pediatrics. However, as age increased, the height and weight averages of the studied children became less than the averages of Nelson. Conclusion: To accelerate children’s physical growth, we should closely follow up on factors which could fortify children and affect their growth.

Background: Platelet transfusion is accompanied by febrile nonhemolytic transfusion reactions. The generation of cytokines (like IL-1 beta, IL-6, IL-8, and TNF-alpha) in platelet concentrates by white cells is suggested to be responsible for febrile nonhemolytic transfusion reactions. The number of white cells in the platelet concentrates is crucial to cytokine generation.Methods: This study was performed to determine whether WBC reduction in platelet concentrates by prestorage leukodepletion filters or inactivation by gamma radiation reduced the levels of these cytokines during storage for 3 days. Each of the platelet concentrates (n = 54) was prepared from a single random donor by platelet-rich plasma. This was then divided into four groups: 1) unfiltered, nonirradiated random-donner platelet concentrates (n = 13); 2) unfiltered, gamma-irradiated random-donner platelet concentrates (n = 16); 3) filtered, nonirradiated randomdonner platelet concentrates (n = 14); and 4) filtered, gamma-irradiated random-donner platelet concentrates (n = 11).Cytokine levels in platelet concentrates supernatants were measured by ELISA kits according to the manufacturer’s recommendations.Results: Our results showed that IL-8 was detected in unfiltered, nonirradiated, and gammairradiated random-donner platelet concentrates but not in the filtered random-donner platelet concentrates. TNF-alpha was only detected in unfiltered, nonirradiated units. Compared with unfiltered platelet concentrates, prestorage filtration prevented a rise in the IL-8 and TNF-alpha on day 3 of storage. The concentration of IL-1 beta was lower than the minimum concentration value of the kit used for this purpose. IL-6 was detected only in 7 units of all filtered platelet concentrates on day 3.Conclusion: These data indicate that gamma irradiation can not prevent generation of IL-8 in platelet concentrates during storage, but prestorage leukoreduction of platelet concentrates can prevent accumulation of IL-6, IL-8, and TNF-alpha during storage.

Restless legs syndrome is one of the most common sleep and movement disorders. For lack of sufficient information on this syndrome in Iran, this study was conducted at Alzahra Hospital, Isfahan, Central Iran, to determine the epidemiology of idiopathic, familial and sporadic forms of the syndrome. From September 1999 to April 2003, 61 patients in two groups were selected. A questionnaire with emphasis on sleep history and neurological history was completed and a thorough physical examination was performed for each patient. Familial and sporadic groups had mean ± SD ages of 22 ± 2.1 and 41 ± 3.2 years, respectively (P < 0.05). Female to male ratio was 2:1. The mean ± SD ages for women and men were 31 ± 5.3 and 42 ± 6.1 years (P < 0.05), respectively. Our findings support the current opinion that restless legs syndrome should be divided into the early-onset disease with a clear genetic component and the late-onset disease with an unclear etiology.

Specific cutaneous associations in patients with Becker’s nevus have been reported. We present a patient with typical clinical and histopathological features clearly consistent with Becker’s nevus associated with ipsilateral breast hypoplasia. The changes were distinct and could be separated from smooth muscle hamartoma. We include clinical and histological illustrations of our case.

Although the incidence of occupational and adult lead poisoning has declined, the problem still exists. We encountered three patients with lead poisoning in Iran, all of whom associated with presented with diffuse abdominal pain, which was at times colicky in nature, anemia, constipation, nausea, vomiting, and slightly abnormal liver biochemistries. A history of opium ingestion was present in each of these patients. None of the patients reported known occupational exposure to toxins. Diagnoses of lead poisoning were confirmed through the detection of elevated blood lead levels. The cause of lead poisoning was attributed to the ingestion of contaminated opium. Opium adulterated with lead had not been previously recognized as a source of lead poisoning in Iran. It is, therefore, pointed out that lead poisoning should be considered as a differential diagnosis for acute abdominal colic of unclear cause in patients with opium addiction.

Delusion of parasitosis is a rare condition in which the patient has a strong conviction that he or she is infested by small organisms. The condition may exist as an isolated phenomenon, or may occur in association with other psychiatric syndromes. We report a single case of a rare form of this phenomenon. A middle-aged woman who met forth edition of diagnostic and statistical manual of mental disorders criteria for major depressive disorder with psychotic features is described. She had delusions of oral parasitosis. She felt lizards and small organisms in her mouth. To the best of our knowledge, there has been only one previous report of delusions of oral parasitosis to date. We discuss the interesting aspects of this case.

Hereditary hemochromatosis is a common cause of chronic liver disease in western countries. No report of this disease has appeared from Iran and the few studies which have focused on chronic liver disease have failed to identify a single case of hemochromatosis. In this report, we present the first case of hereditary hemochromatosis during our 25 years of gastroenterology practice in Iran.