ARCHIVES OF IRANIAN MEDICINE
Year:2009 | Volume:12 | Issue:5|Papers Count:19

Background: We conducted this study to report the demographics and clinical profile of patients with nonarteritic anterior ischemic optic neuropathy referred to a referral neuroophthalmology center in Iran.Methods: During a five-year period, 107 patients with nonarteritic anterior ischemic optic neuropathy were studied. A detailed history of previous or current systemic diseases was obtained and a complete ophthalmic evaluation including best corrected visual acuity, color vision testing, and computerized perimetry was performed.Results: Sixty-six men and 41 women with a mean±SD age of 52.7±10.3 (range: 30 – 80) years were studied. Most (62.2%) of the patients aged more than 50 years. Twenty-two (20.5%) patients had had an episode of nonarteritic anterior ischemic optic neuropathy in the fellow eye. Overall, 51 (47.7%) patients had no evidence of a previous or current systemic disease. Diabetes mellitus and hypertension were reported in 40.1% and 26.1% of the patients, respectively.The best corrected visual acuity was 20/200 or worse in 43 (40.1%) eyes and 20/40 or better in 43 (40.1%) eyes. The best corrected visual acuity was significantly better in nondiabetic patients (0.62±0.69 LogMAR) than diabetics (0.96±0.84, P=0.03). The visual field analysis of reliable fields (76 eyes) revealed that the mean deviation ranged from -32.6 to -1.3 dB with a mean±SD of -19.7±8.08 dB. Diffuse defect was the most prevalent defect detected on 36.8% of visual fields of the study eyes followed by inferior altitudinal defect (26.3%). In the fellow eyes, without any evidence of prior optic nerve problem, inferior and superior arcuate scotoma were found in 30% and 20% of the eyes, respectively.Conclusion: Characteristics of nonarteritic anterior ischemic optic neuropathy patients in a population of Iranian patients were similar to nonarteritic anterior ischemic optic neuropathy as described in previous studies, with the exception of higher proportion of younger patients and a higher propensity for diabetes. Visual field defects were common in clinically normal fellow eyes.

Background: The scholastic achievement of children with cochlear implants is one of the most important determinants of recipients’ quality of life after cochlear implantation. The present study aimed to study the scholastic achievement of 27 children with cochlear implants attending mainstream schools and to compare their scholastic performance to their normal- hearing peers. Methods: From 30 children living in Tehran with an average age of 40 months at the time of cochlear implantation at our center, 27 participated in this study. The results of children’s examinations and their performance in Persian literature, mathematics, and dictation in comparison to their normal peers and their overall scholastic performance during final examinations were the two measures utilized to assess the children’s school performance. Parents reported their children's medical and educational history, characteristics of the family, and their participation in their children's therapy by completing questionnaires.Results: Mean score was 18.84 (SD=2.86) for mathematics, 19.18 (SD=1.59) for Persian literature, 19.35 (SD=1.36) for dictation, and 19.19 (SD=1.54) for overall academic performance. Compared to their normal-hearing classmates, most children with cochlear implants had an aboveaverage performance in mathematics, Persian literature, and dictation (59.3%, 66.7%, and 74.1%, respectively). The overall examination results showed that nearly half of them (48.1%) performed above average. Conclusion: The results of this study well indicate that children with cochlear implants can achieve a satisfactory scholastic performance in mainstream schools with their implant duration as the most important factor determining postimplant outcomes.

Background: The development of reconstructive venous surgery has been hampered by the lack of suitable grafts. Patency rates with grafts in the venous system are commonly less satisfactory than in arterial system, mainly due to nonpulsatile flow velocity and the low pressure in veins. Grafting of the inferior vena cava may be necessary in cases of trauma and major tumor surgery involving the vein. Several types of grafts have been evaluated. Reconstruction of the vena cava with autologous vein is so time-consuming and requires extra incisions. Prosthetic material is associated with a higher risk of infection and thrombosis. We, therefore, created an animal model of inferior vena cava reconstruction using a flap of parietal peritoneum.Methods: A tube, 5 cm in length and 1cm in diameter, was constructed from the parietal peritoneum of the anterior abdominal wall of ten dogs. It was anastomosed end-to-end as an interposition graft to the inferior vena cava. The observation period was two months. Results: Eight of ten grafts were macroscopically and venographically patent, while the other two were occluded. Eight out of ten specimens (for pathologic examination) which revealed patent lumens were completely endothelialized. No infection or other problems were noted.Conclusion: The peritoneum is an accessible and safe substitute for reconstruction of the inferior vena cava.

Background: Despite claims of rarity, some studies indicate that the prevalence of inflammatory bowel disease has increased in Iran during the past decades. Establishment of a registry and the clinical characteristics are presented in this study.Methods: Two hundred ninety-three patients with ulcerative colitis and 207 with Crohn’s disease, referred to tertiary referral gastrointestinal centers in Tehran from 2004 through 2007, were assessed. Demographic and clinical features, intestinal and extra intestinal manifestations, inflammatory bowel disease in relatives, measles infection and vaccination, nutrition during infancy, and drugs and surgical interventions were assessed.Results: The mean±SD age at the diagnosis was 33.8±12.9 years in Crohn’s disease and 37.1±13.7 years in ulcerative colitis. Male: female ratio was 0.9:1.0 for Crohn’s disease and 0.7:1.0 for ulcerative colitis. A total of 177 (85.5%) patients with Crohn’s disease, and 254 (86.7%) patients with ulcerative colitis had never smoked. Measles vaccination was mentioned in 150 (72.5%) of Crohn’s disease and 214 (73%) of ulcerative colitis patients. Breastfeeding during infancy was reported in 178 (86%) and 257 (87.7%) of Crohn’s disease and ulcerative colitis patients, respectively. Appendectomy was reported in 37 (17.9%) of Crohn’s disease and 16 (5.5%) of ulcerative colitis patients, whereas tonsillectomy was reported in 11.6% of each group. Conclusion: Demographic and clinical characteristics of inflammatory bowel disease patients are similar to that of other developing countries, in this study, more inflammatory bowel disease cases have been assessed in comparison with previous studies, which may be due to different time scales of socioeconomic evolution and environmental factors in Iran.

Background: Postpartum depression is defined as a major depressive episode that occurs within four weeks after delivery. However, investigators describe a dramatic increase in the incidence of mood disorders after childbirth with the largest risk during 90 days after delivery. We aimed to study the risk factors of postpartum depression in women living in rural areas of Isfahan Province in Iran.Methods: We assessed 6627 women, two to 12 months after delivery, for depression and putative risk factors.Results: Unemployment, low education, mothers' young age, undesired gender of the child, unplanned pregnancy, and history of depression were the main risk factors of postpartum depression. History of depression, low education, primiparity, unplanned pregnancy, and undesired gender of the child had the highest risk score for postpartum depression in this group of Iranian women.Conclusion: Risk factors of postpartum depression in Isfahan Province were very similar to other studies, but the negative impact of low level of education, unplanned pregnancy, and undesired gender of the child on postnatal depression seems to be characteristic of this population.

Background: Having considered the physiologic challenges during pregnancy, scientists have searched for different delivery methods with minimal medical intervention. The use of water immersion by women for relaxing during labor is being used worldwide. We aimed to evaluate the controversies surrounding water birth and to find out the interest of Iranian women in this delivery method.Methods: In a randomized clinical trial, 106 pregnant women were assigned to control and experimental groups. The experimental group underwent the labor and delivery in standardized warm water pools. The control group gave birth by conventional delivery method at the hospital. A questionnaire was completed during the labor for women in both control and experimental groups including the method of delivery; labor length; use of different drugs such as analgesics, opiates, antispasmodic, and oxytocin; use of episiotomy, and newborn’s Apgar score and weight. Results: Totally, 53 cases and 53 controls with the mean age of 26.4±5.9 and 27.1±5.9 years, respectively, completed the study. Women in the control group required oxytocin, antispasmodics, opiates, and analgesics more frequently than those in the experimental group (P<0.001).Meanwhile, the active phase and the third stage of labor were shorter experimental group by 72 and 1.3 minutes, respectively (P<0.004, and P<0.04). All the participants in the experimental group gave birth naturally, whereas only 79.2% of the controls had normal vaginal delivery. Conclusion: Our results revealed the advantage of water birth delivery. Those who gave water birth experienced less pain and completed the delivery sooner. Meanwhile, normal vaginal delivery was accomplished more frequently with this group. These all lead to a decreased necessity for medical interventions as well as an increased socioeconomic advantage for the society.

Many families are directly involved in caring of their children with the lifelong autistic spectrum disorders. Sometimes, they are the victims of their children’s behaviors.The family, including siblings, may have to explain the children’s behaviors to others. Their mothers have poorer mental health with difficulties in family adaptability and cohesion. Its burden is not just limited to psychologic aspects but on the quality of life, economic aspects, and parent-child relationship.This is a narrative review of some of the aspects that families of children with autistic spectrum disorders are facing.

Homeless people are usually prone to be infected with multiple infectious diseases such as human immunodeficiency virus, hepatitis B virus, and hepatitis C virus, as well as syphilis. In this cross-sectional study, using a questionnaire and enzyme-linked immunosorbant assay, we evaluated the seroprevalance of hepatitis B and C viruses, human immunodeficiency virus, and syphilis, as well as their risk factors in 202 homeless men. A total of 70 (34.7%), 87 (42.8%), and 13 (6.4%) subjects were infected with hepatitis B, hepatitis C and human immunodeficiency viruses, respectively. Ten (0.5%) had a simultaneous infection with hepatitis B and C viruses and human immunodeficiency virus.Only one participant was seropositive for rapid plasma reagin. History of smoking and opium addiction was present in 144 (71.6%) and 109 (54.2%) subjects, respectively. Although all human immunodeficiency virus-positive subjects were hepatitis C virus positive, 10 (76.9%) had a history of intravenous drug abuse. Risk factors including intravenous drug abuse (P<0.005) and imprisonment (P<0.05) were significantly associated with all the three infections. We found no significant association between high-risk sexual behavior and these infections.Although syphilis seems not to be an important risk factor among homeless adults, all hepatitis B, hepatitis C, and human immunodeficiency virus infections have quite noticeable frequencies among Iranian subjects. History of intravenous drug abuse should be taken into account in screening of homeless people.

The aim of this study was to investigate the efficacy and safety of oral iron chelators, deferiprone in combination with desferrioxamine in comparison with desferrioxamine alone. A total of 70 transfusion-dependent thalassemia major patients were randomly selected to receive one of the following two treatments: deferiprone in combination with desferrioxamine (n=35, desferrioxamine+deferiprone group) or desferrioxamine alone (n=35, desferrioxamine-only group). Changes in serum ferritin, liver enzymes (alanine aminotransferase and aspartate aminotransferase), blood urea nitrogen, and creatinin were evaluated before the treatment and then six and 12 months after the treatment, and any side effect caused by iron chelators was reported during the study. Student’s t-test and repeated measures were used to compare different mean values for quantitative data and Chi-square to compare qualitative data.Serum ferritin decreased more significantly in patients on desferrioxamine+deferiprone therapy compared to patients who only received desferrioxamine (P<0.017). Side effects of deferiprone, including neutropenia, severe gastrointestinal upset, and arthropathy occurred in eight, four, and two patients, respectively but none led to discontinuation of the treatment. Beta-thalassemia major patients with iron overload due to transfusion could be successfully treated with a combination of desferrioxamine and deferiprone. This regimen is more effective than desferrioxamine-only therapy in decreasing serum ferritin; therefore, it also could be more effective in reducing iron overload and related complications in beta-thalessemia major patients.

Diabetes is a relatively common ill-health condition in Iran with a prevalence of 7.7% in the age range of 25 – 64 years and with a rather high burden. It is not only a chronic devastating disease which causes high rates of death directly, but also a strong risk factor for some other common chronic conditions, e.g., cardiovascular diseases. The worst complications of diabetes develop when quality healthcare services are not provided to patients or are not used by them. This study was conducted to depict the first national picture of quality of care provided for known diabetic patients in Iran.The study was conducted alongside the “Iran's National Noncommunicable Diseases Risk Factor Surveillance survey” of 2005; a cross-sectional study with a multistage cluster sampling approach which targeted Iranians older than 15 years of age.Only 6.4% of the respondents had a HbA1c test during the year before questioning and 25.7% reported to have undertaken a lipid profile examination in the same period of time. Positive responses for eye and foot examinations in the year leading to survey were 39.8% and 20.5%, respectively. About 97.4% of the patients had poor control according to their most recent HbA1c levels. About 25% needed an improvement in diabetes control according to their blood levels of low-density lipoproteins, and 45% of them were hypertensive.All measures of quality of care of diabetes type II were poor in Iranian diabetic patients except for eye examination. Healthcare system of the country needs to focus on patients' easier and better access to laboratory facilities together with a strong training program for care providers and patients to help with better implementation of clinical guidelines and standards of care. A follow-up mechanism is needed to check the trend of quality of care of diabetes in Iran.

Nonmissile low-velocity penetrating brain injuries are unusual among civilian population. Work related penetrating head wounds are rarer among this group.Here, we report two rare cases of penetrating head wounds caused by industrial grinder tool. The patients (both men) were struck to the head by detached blades of the grinder tool. Depressed fractures, penetrated bone fragments, and dural lacerations were all treated by the routine fashion. Paranasal sinus damage and further cerebrospinal fluid leakage were also treated conservatively. The reported cases are unexpected variants of injuries that neurosurgeons may come across and their management is still beyond the scope of textbooks. Skill and experience of the general neurosurgeons can handle the cases properly but prevention of such incidents using safer and guarded instruments should be stressed to manufacturers. 

Malignant mesenchymal tumors of the larynx constitute 0.3% to 1% of all laryngeal cancers. Of them, osteosarcoma is the rarest. Osteosarcoma of the larynx may be a difficult clinical diagnosis. Pathologic confirmation of osteoid is required for the diagnosis. Treatment is primarily surgical. It is believed that aggressive surgical intervention directed at complete tumor extirpation is the treatment of choice. Outcomes of such patients are generally poor. Most patients die because of pulmonary metastasis. A case is reported here and a review of all available published cases of osteosarcoma of the larynx is presented.

Although prostate cancer is among the most frequent malignancies in the elderly, this tumor may be under-reported, and it seems that its socioeconomic burden is not well-estimated. Chronic urinary obstruction caused by the cancer may cause renal failure, with hemorrhagic tendency, neurologic disturbances, cutaneous disorders, and diverse fingernail changes. Black or brown nail pigmentation has been associated with benign and malignant conditions, including antineoplastic drugs' side effects, subungual metastases, and melanoma. Metastasis of fingernail melanoma can affect lymph nodes from the wrist to elbow and axillary regions. Coexistent melanonychia and wrist lump, mimicking melanoma with sentinel lymph node is reported. It is recommended to consider the differential diagnosis of nail changes due to chronic renal failure.

Fetus in fetu is an extremely rare condition in which a fetus or fetus-like structure with a vertebral axis is seen in the body of its twin. This paper presents a case of fetus in fetu in a twoday- old female newborn who was referred for an abdominal mass, biliary vomiting, and feeding intolerance. After plain abdominal X-ray and ultrasonography, the patient underwent abdominal surgery with the primary diagnosis of teratoma or fetus in fetu. We found a retroperitoneal mass that consisted of double fetus in fetu and a separate undetermined mass. The pathologic examination confirmed double fetus in fetu and revealed a separate immature teratoma. She was discharged from the hospital after seven days in a healthy and normal condition.The level of serum alpha-fetoprotein was normal after three months of follow-up.

This article presents a 28-year-old man who had stage III diffuse large B-cell lymphoma (Figure 1). He had undergone surgical resection and chemoradiotherapy three years ago as the primary treatment. Recently, he has developed a gradual headache and insomnia; computerized tomography showed mass lesions in the brain (Figure 2). Work-up for the primary lesion was negative at that time….

A 25-year-old man who had suffered from Hodgkin’s disease mixed cellularity type, stage III B, since eight years ago, was referred to our center for cutaneous eruptions evolving for one year. According to his oncologist, the chemotherapy with eight cycles of adriamycin (doxorubicin), bleomycin, vinblastine, and dacarbazine (ABVD), revealed an apparently good remission. On examination, he exhibited confluent erythematous papules and plaques with some areas of atrophy, scar, and pigmentation Which involved symmetrically the lower limbs (Figures 1 and 2). Clinical examination also disclosed mildly enlarged laterocervical lymph nodes….

Following the establishment of Gastroenterology and Hepatology Fellowship Programs in 1987, significant developments in research and health care delivery have been achieved. The number of published articles has increased significantly and now more than 10 approved research centers are involved in several longitudinal and population based studies in GI epidemiology, viral hepatitis and GI oncology around the country. Before 1987 less than 50 gastroenterologists were working in the country, but now more than 300 gastroenterologists are involved in public and private health care delivery systems. Advanced diagnostic and therapeutic endoscopic procedures and complex surgical procedures such as liver transplantation are a routine now. These achievements are indicative of hard work and determination of dedicated physicians after the Islamic Revolution, and the support of governmental and non-governmental sectors. The future prospect of development in the discipline of gastroenterology and hepatology in Iran seems to be very encouraging.

The report by Naghavi et al. entitled ‘Adverse Health Outcomes of Road Traffic Injuries in Iran after Rapid Motorization’ in your May 2009 issue of Archives of Iranian Medicine (AIM) discusses the increasing rate of deaths and injuries following road traffic accidents (RTAs) in Iran.1 The authors have tried to implicate the poor quality and lowsafety standards of the cars and motorcycles manufactured in Iran as well as the low price of petrol and the decreasing ratio of travel by public transportation as compared with privately owned cars as the main causes for this increasing rate of death and disability from RTAs in Iran.

We were asked by the Editor of AIM to provide comments on the letter written by Dr. Touraj Nayernouri in response to our paper ‘Adverse Health Outcomes of Road Traffic Injuries in Iran after Rapid Motorization’ in the May 2009 issue of the journal. Dr. Touraj Nayernouri criticized our paper because we underlined the importance of the massive production of unsafe vehicles along with some other factors as potential causes of recent increase in the number of road traffic injuries and deaths in Iran. He believes that compared with “disrespect for the law and a total disregard for the highway code by the majority of the drivers in Iran” the mass production of unsafe vehicles is of minor importance to serve as a cause for road injuries and deaths.