ARCHIVES OF IRANIAN MEDICINE
Year:2009 | Volume:12 | Issue:4|Papers Count:23

In an editorial entitled ‘Time to Connect’, the editors of the magazine Nature1 extended an invitation to Iranian scientists to connect with their western counterparts in various scientific fields in a spirit of cooperation. The subject alluded to in that article concerned Iran’s nuclear energy program, which is so charged by political issues on both sides that I am sure they had little response from Iranian scientists in that respect. We Iranians fully realize that we are considered a pariah state and are thus ostracized by the international community as they rightly mentioned in their editorial. It is unfortunate that in this light, all our historical achievements in science, poetry, or statesmanship are ignored and mocked with historically incorrect depictions….

Background: We estimated the chronic rejection of kidney transplant using an eternal Weibull regression.Methods: In this historical cohort study, we enrolled all patients with chronic renal failure who were admitted to Shahid Labbafinejad medical center (Tehran, Iran) from 1984 to 2003. Using Matlab 7.0, we considered the eternal proportion q, as a logistic-type function of the covariates and modified the survival function. We estimated the survival function in unmodified and modified forms using Weibull distribution.Results: The chance of chronic rejection was 1.95 times higher among those who received a kidney transplant before 1996. Considering all cases who received renal transplantation after 1984, males had a chance of rejection 20% less than females.Next to the eternity, Weibull model was fitted to patients who received renal transplantation after 1996. Treatment protocol was changed after 1996 expecting fewer chronic rejections; thereafter, the eternal proportion was estimated to be 0.81. This seems quite considerable as a percentage of non-failure cases.Conclusion: Providing a non-zero eternal proportion, the modified model would be superior over the unmodified model.

Background: Critical analysis of shortcomings of emergency medical management of earthquake casualties will provide an invaluable insight to improve outcomes for future events. Using a critical analysis methodology to evaluate the quality of emergency medical management after Bam earthquake, we suggest a practical strategic approach to decrease morbidity and mortality after such events.Methods: We designed a questioner to register the basic demographic data and the keybiologic parameters of all rescued victims arriving in hospitals. Based on that questioner a data bank was created and used for different analyses. In addition, published official reports and on the scene observations of our nephrologist colleagues were other sources of our data.Results: Bam earthquake was publicly announced more than six hours after its occurrence. The earliest time when local and international rescue teams arrived at the scene was 12 hours after the disaster. Fifty-four percent of hospital inpatients had been admitted on the second or third day after the earthquake. The mean time of being under the rubble was 4.8±4.9 hours. The mean time between extrication and initiation of intravenous fluid infusion was 18.9 hours (min: 10 minutes, max: 96 hours).Conclusion: Problems encountered in the aftermath of the Bam earthquake were related to the lack of prepared action plan and data management system. Here, we present a specifically designed earthquake chart. By following the chart, rescue paramedic personnel and emergency medical teams will be able to recognize high-risk victims, in order to provide timely medical management.

Background: The traditional autopsy is unpleasant for the family members of the dead person. The aim of this study was to assess abdominal traumas by a laparoscope and to determine the accuracy of laparoscopic examination in comparison with the traditional autopsy. Methods: From December 2004 through August 2005, 50 fresh cadavers (<24 hours old) of blunt trauma victims were selected. They were first assessed by a laparoscope for intraperitoneal and retroperitoneal organs and then the traditional autopsy was performed as gold standard. The organs were assessed regarding the nature and intensity of damages and the results were compared with laparoscopic findings. The diagnostic accuracy of laparoscope was determined for each case with 95% confidence intervals (CIs) using Fisher's exact test.Results: The accuracy for investigation of intraperitoneal and retroperitoneal organs and the overall accuracy values were significant. The accuracy of laparoscope for detecting intraperitoneal organ damage was 90% (95%CI of 81.7% to 94.8%) while for the retroperitoneal organs was 92% (95%CI of 84.7% to 96%). The overall accuracy of laparoscope was 84% (with 95%CI of 74.3% to 90.5%).Conclusion: The sensitivity and specificity of laparoscopic examination for intraperitoneal organs are acceptable but its accuracy for retroperitoneal organs is lower. Therefore, it seems that laparoscopic examination is an eligible substitute for the traditional autopsy.

Background: To determine the prevalence of cigarette smoking in Tehran and some of its determinants.Methods: In a cross-sectional population-based study, a sample from citizens of Tehran was obtained using stratified random cluster sampling. Through a face to face interview, data such as the history of smoking in the past (abstinence from smoking) and at the present time (active smoking), and number of cigarettes per day and per year were collected. In general, people who smoked more than 100 cigarette-days were considered smokers. Pack per year was used to evaluate the severity of smoking.Results: Out of the sampled people, 4565 participated in the study. Of these, 74.4%, who were over 15 years of age, were studied for smoking. The prevalence of smoking in Tehran was 11.9% (95%CI, 10.6 – 13.3). Some 20.6% of the male participants (95%CI, 18.2 – 23.1) and 2.9% of the female participants (95%CI, 2.2 – 3.7) were smokers (P<0.001). The prevalence of smoking significantly increased with age until 54 years of age (OR=1.07; 95%CI, 1.06 – 1.08). People with higher education smoked more. Also, married people smoked significantly more than singles (OR=2.7; 95%CI, 1.85 – 3.95). Smokers used 209 cigarette pack-years on average, which was significantly higher in men and in people with lower education (P<0.001). Conclusion: The results of this study showed lower prevalence of cigarette smoking has relatively decreased compared with previous studies. However, healthcare officials should consider educational and healthcare programs to decrease the prevalence of smoking.

Background: Communication is an important aspect of everyday life especially for elderly people. Hearing loss can impair the exchange of information and therefore reduces the quality of life. The purpose of this study was to investigate the quality of life in elderly people who are hard of hearing after wearing a hearing aid.Methods: Hearing-impaired old people who referred to the rehabilitation centers of Tehran Welfare Organization for having a hearing aid completed the Hearing Handicap Inventory for the Elderly questionnaire before and three months after using a hearing aid. Scores of the effects of hearing loss on quality of life were compared for each subject and between males and females. Results: The results showed a significant improvement of the quality of life after three months of using a hearing aid in all participants and betterment of their most important problems i.e., the communication and exchange of information.Conclusion: In conclusion, with respect to the beneficial effects of hearing aids in presbycusis and due to the significant improvement in the quality of life, hearing aids are recommended for this group of population.

Background: Dry type localized cutaneous leishmaniasis, one of the most prevalent cutaneous parasitic infections in Kerman Province, is presented as a polarized disease in which cytokine profiles secreted by immune cells play a major role in its presentation. In order to clarify the idea, immunohistochemical study of skin biopsies were performed to elucidate the cytokine release capabilities of immune cells.Methods: Skin biopsies of acute, chronic nonlupoid, and chronic lupoid recidivans lesions of dry type localized cutaneous leishmaniasis were studied by immunohistochemical staining methods for immunophenotypic patterns (CD4, CD8, CD14, CD19, CD56, CD11a, CD18, CD1a, HLADR, CD54) and cytokines (INF-gamma, IL-12, IL-4, TNF-alpha) released by immune inflammatory cells.Results: The descriptive analysis of data showed that the mean percentage of positive immunostained cells of CD4, CD8, and CD14; antigen-presenting cells (CD1a, HLA-DR); and markers of the extravasated positive memory T cells (CD11a, CD18, CD54) are more frequent in lupoid recidivans than in acute active and chronic nonlupoid lesions, in order of frequency. Conclusion: Based on the results, it seems that Th1-like response is predominant in acute active form and lupoid recidivans while Th2-like response is predominant in chronic nonlupoid lesions. It seems that lupoid recidivans is a type IV hypersensitivity reaction to the reactivation of hidden antigens.

Background: Many studies have attempted to identify histologic features that help to distinguish atypical hyperplasia from hyperplasia without atypia and well-differentiated endometrioid carcinoma of the endometrium; however, few have evaluated the reproducibility of these diagnoses.Methods: Five pathologists independently reviewed 100 endometrial curettage specimens chosen to represent the spectrum of proliferative lesions of the endometrium. This included simple hyperplasia, complex hyperplasia, atypical hyperplasia, and well-differentiated endometrioid carcinoma. Slides were reviewed once for interobserver agreement among the five pathologists and twice for intraobserver agreement by one of them.Results: The results were assessed using the weighted kappa statistic. The mean intraobserver kappa value was 0.86. The mean interobserver kappa values by diagnostic category were as follows: simple hyperplasia without atypia: 0.74; complex hyperplasia without atypia: 0.33; atypical hyperplasia: 0.34, and well-differentiated endometrioid carcinoma: 0.64; with a kappa value of 0.53 for all cases combined.Conclusion: A major interobserver discrepancy exists in the diagnosis of complex and atypical hyperplasia which are the most similar mimics of endometrioid carcinoma.

Background: To evaluate the prevalence of abdominal aortic aneurysm in Iranian candidates for coronary artery bypass graft surgery and its associated factors. Methods: Totally, 2843 consecutive candidates for coronary artery bypass graft surgery underwent ultrasonography of abdominal aorta. The relation between abdominal aortic aneurysm with gender, age, smoking, dyslipidemia, hypertension, diabetes, and carotid and coronary stenosis was evaluated.Results: The prevalence of abdominal aortic aneurysm was 2.7% and 0.7% in men and women subgroups, respectively. The prevalence was 3.8% in men older than 65 years. The largest diameter of abdominal aortic aneurysm was 61.7 mm. Only two men had aneurysm larger than 55 mm, which led to changing their surgery schedule to stenting. Gender, age, smoking, smoking more than 40 years, diabetes , hypertension, and significant carotid stenosis were associated factors of abdominal aortic aneurysm.Conclusion: Compared with the results sited in Western studies, the prevalence of abdominal aortic aneurysm is lower in Iran (P<0.0001). Its associated factors in our study were similar to previously published studies. Significant carotid stenosis, a factor not reported previously, was an associated factor in our study. Because of the low prevalence of abdominal aortic aneurysm in our population, screening the candidates for coronary artery bypass graft surgery is not recommended.

Background: For many years, subcutaneous therapeutic port system was known as a major route to access central veins. However, significant complications have been reported through recent years. One of the most important complications of subcutaneous port implantation is skin necrosis. In order to decrease this complication, we would like to introduce subpectoral fascia port implantation through this study.Methods: Five hundred and twenty four patients with a variety of neoplastic diseases underwent port implantation, from March 2003 to March 2008 (60 months). All suitable size catheters were put in the superior vena cava through the internal jugular vein under general anesthesia. The ports were placed in the subcutaneous pocket (SCP group) in 342 patients and in the subpectoral fascia pocket (SPFP group) in 182 patients. Data were analyzed using Chi-square test and survival analysis for time (Kaplan-Meier).Results: A total of 538 devices were placed for 524 patients in two groups (14 patients received a second device after removal of the first one, due to failure of the first implantation). Mean followup period was 508 days (8 – 2025 days).Common complications observed in the SPFP group were as follows: wound infection (7 cases, 3.8%), catheter obstruction (7 cases, 3.8%), catheter displacement (6 cases, 3.2%), port related infection (5 cases, 2.7%), and pocket hematoma (2 cases, 1.1%).Common complications observed in the SCP group were as follows: catheter displacement (12 cases, 3.5%), skin necrosis (11 cases, 3.21%), port exposure (9 cases, 2.6%), port related infection (8 cases, 2.3%), catheter obstruction (8 cases, 2.3%), and port rotation (3 cases, 0.9%). Conclusion: The results showed that port implantation in the subpectoral fascia pocket had a lower rate of skin complications than the subcutaneous pocket implantation. According to this study, this procedure was not complicated by skin necrosis over the port, port exposure or port rotation.

Cancer-testis antigens are tumor antigens that their expression is almost limited to male germ cells in the testis. Some of cancer-testis antigens are also expressed in the ovary and in trophoblasts. Recently their expression has been seen in different types of tumors.Many pathophysiologic studies suggest that a blood-testis barrier exists in the testis. Because spermatogenesis begins at puberty, new cell-surface antigens are expressed when the immune system has refined the ability to distinguish self from nonself. So, sperms in the testis do not stimulate immune responses. In addition, although antigen-presenting cells are commonly seen in the interstitial spaces of the testis, these cells are scarcely seen within the seminiferous tubules. So, testis is considered as an immune-privileged site, and testis-specific genes, if expressed in cancers can be immunogenic. For this reason cancer-testis antigens are promising candidates for cancer immunotherapy and have become a major focus for the development of vaccine-based clinical trials in recent years. In addition, these antigens can also be used as biomarkers for early detection of cancers.

Marjolin's ulcer is defined as a malignant, ulcerating neoplasm occurring in cicatricial tissues. The cancer is usually a well-differentiated squamous cell carcinoma. Wide resection is complicated with a recurrence rate of 20% to 50% and a metastasis rate of 54%. Therefore, we chose amputation as the modality of treatment for heel Marjolin’s ulcers in Urmia and presented their results in this study.During the last 10 years in Urmia, nineteen cases of heel Marjolin's ulcers has been detected. About 47% were due to childhood burn. Malignancy was mainly squamous cell carcinoma. The mean latent period of malignant transformation was 11 years. All cases were treated with amputation, without any recurrence or metastasis in an average four-year follow-up period. The squamous cell carcinoma of Marjolin's ulcer has the worst prognosis in comparison with other squamous cell carcinomas and it requires an aggressive treatment.

Septic arthritis is a fearful condition because of its mortality and the potentially late sequels on immature skeleton including limb shortening, osteomyelitis, destruction of joint surface, severe limitation of motion, and dislocation.This study was performed to reveal the final outcome of our patients and find out the possible risk factors of poor result.The case records of 243 children who were admitted with the diagnosis of septic arthritis in Imam Khomeini and Bu Ali Sina Hospitals, Mazandaran Province, were studied between 1996 and 2005. The diagnosis was based on clinical and ultrasound findings in all patients and positive smear in 67% of them.Among these patients, we had access to 162 cases who had definitely septic arthritis and went through surgical interventions because of the involvement of the hip joint or uncertain response to medical treatments. As four out of six poor outcome cases were related to hip sepsis, hip was the main site of involvement and complications.Six cases of severe complications out of 162 showed the favorite result due to early diagnosis and intervention and highlighted the grave prognostic factors which were delayed diagnosis, infantile age and hip sepsis.

A 51-year-old woman with neurofibromatosis type 1 presented to our department for investigation of a left breast lump (50×50×30 mm); a mass in the right breast (40×40×20 mm) was also detected on physical examination. The lumps were suspected to be malignant based on physical examination and ultrasonography. Biopsy and frozen sections subsequently confirmed a diagnosis of bilateral invasive ductal carcinoma. A standard bilateral radical mastectomy was performed, followed by postoperative chemoendocrine therapy. Tumor recurrence has not been observed within the first 23 months following the surgery.

This report presents a palmaris profundus tendon anomaly in the carpal tunnel. The case was a 19-year-old female who underwent carpal tunnel surgery. After dividing the transverse carpal ligament, the palmaris profundus tendon was discovered. The abnormal tendon was within the carpal tunnel, laying over the investing tissue of the median nerve, and inserted deeply into the palmar aponeurosis. A segment of the abnormal tendon was excised and the patient’s symptoms resolved completely.  

Calcifying odontogenic cyst is an uncommon developmental odontogenic cyst first described by Gorlin in 1962. It is considered as an extremely rare cyst and accounts for only 1% of jaw cysts reported. Because of its diverse histopathology, there has always been confusion about its nature as a cyst, neoplasm, or hamartoma. In this report, we present a rare case of calcifying odontogenic cyst with ameloblastic proliferation—an extremely rare histologic variant in a 22-year-old male in the right mandibular molar region. The lesion was surgically removed. After enucleation no recurrence has been recorded in the ensuing 14 months.

Maffucci’s syndrome is a rare congenital mesodermal dysplasia combined with dyschondroplasia and hemangiomatosis. About 150 cases have been reported till now. Maffucci's syndrome is often combined with other neoplasms. Herein, we report a patient with Maffucci’s syndrome and hemangiomas on the dorsum of the tongue, which is rare in this syndrome.

A 51-year-old woman presented with progressive dysphagia to solids and liquids and heartburn of two months' duration. She also reported recent weight loss of six kilograms. On endoscopic examination, there was a submucosal mass lesion with intact mucosa, narrowing the esophageal lumen from the submucosa in the posterior aspect of the esophageal wall in the distal part of the esophagus extending to the lower esophageal sphincter.Endosonography showed a 27×28 mm anechoic mass lesion originating from the wall adjacent to the aorta, with a fluid level containing faint echogenic material inside.

During the first half of the 20th century, all subspecialties of internal medicine were managed by general internists and there was no gastroenterologist in Iran. The first group of Iranian gastroenterologists who had completed their training program in France started working in Tehran in 1951. Later on, other specialists trained in USA and the United Kingdom joined them. Some of these specialists and some internists with special interest in gastroenterology and hepatology were in charge of gastroenterology education in divisions of internal medicine in the Medical Schools of Tehran, Shiraz, Isfahan, and other universities, while most of them were also practicing gastroenterology in their private offices on a part-time basis. The establishment of subspecialty training program in gastroenterology and hepatology was firstly started in 1976 in Tehran University and later on and since 1984 in Shaheed Beheshti, and Shiraz Universities. This was a major step in the progress of this subspecialty, which is now one of the most active medical disciplines in Iran. In this paper, we aimed to describe the development and evolution of gastroenterology and hepatology in Iran during the last 60 years with emphasis on physicians and scientists, who played a major role in providing the first gastroenterology services in the country or had a major role in training, education, and research in this field. We also describe the attempts that led to the establishment of the Iranian Association of Gastroenterology and Hepatology, as the most important nongovernmental organization in this field.

Because the cyst wall originated from the submucosal layer in the Endoscopic Ultrasound (EUS) study, the diagnosis of duplication cyst was considered preoperatively. Duplication cysts are rare congenital anomalies that arise during early embryonic development. They are most frequently found in the proximal small intestine, although they can also be found in the esophagus, stomach, and colon.

A well-written paper on history of medicine was recently published by Sajadi and co-workers in the "Annals of Internal Medicine".1 The paper focused on one of the major scientific contributions of the reputable medieval Iranian scholar, Ibn Sina (in Latin Avicenna), to medicine and pharmacology. The authors looked mainly at Ibn Sina's impact on applying logic to drug testing as the basis for further development of modern pharmacologic and clinical trials. Later, in the 18th century, Dr. James Lind (1716 – 1794), the Scottish physician, started formal experimentation with drugs and as Mellinkoff says:" he had conducted the first scientific, controlled experiment in the history of clinical medicine."2 In addition, the paper of Sajadi and colleagues also briefly introduces Razi (Rhazes), the Iranian medical scholar of the10th century AD, as the first known physician who used a control group in a human trial.

Dear Editor I read with much enthusiasm the article by Dr. Merat et al. in the latest issue of your prestigious journal.  The authors have performed a difficult study and provided valuable information regarding hepatitis B in Iran. But there are some points which I would like to raise regarding this study: 1) Although the study has covered large number of people in three different provinces, these selected areas cannot be considered representative of the whole country regarding demographic characteristics.  

With great interest we read the comments by Dr. Nasseri Moghaddam on our paper reporting the prevalence of hepatitis B virus (HBV) infection in three provinces of Iran. He describes important points which need further discussion and clarification…