ARCHIVES OF IRANIAN MEDICINE
Year:2012 | Volume:15 | Issue:5|Papers Count:16

Hepatitis B virus (HBV) used to be - and in many countries, still is - the most common cause of chronic viral hepatitis. Since the introduction of an effective vaccine against this virus, many countries have implemented neonatal HBV vaccination in their general health programs. We are beginning to observe the effects of this vaccination in most parts of the world, including Iran, where the prevalence of HBV infection is slowly declining. On the other hand, there is no effective vaccine against hepatitis C virus (HCV). The lack of an effective vaccine and increase in intravenous drug abuse, has led to a gradual increase in HCV infection in recent years.

in this issue of the journal, Shojaiefard et al. report the results of surgery upon 186 patients in which endoscopic removal of common bile duct (CBD) stones had failed. Endoscopic Retrograde Cholangiopancreatography (ERCP) is considered the standard primary treatment for CBD stones in patients with previous cholecystectomy. Even in patients with gall bladders, ERCP together with cholecystectomy is a well-accepted method. Laprascopic CBD exploration is time consuming, requires more expertize, and is associated with increased morbidity including biliray strictures. Thus, surgeons often pre fer to have the CBD stones removed endoscopically either before or after cholecystectomy.

Background: Detection of Hepatitis C virus (HCV) -infected people in each community assists with infection prevention and control. This study aims to evaluate the prevalence of HCV infection among high risk groups in Kohgiloyeh and Boyerahmad Province, Southwest Iran.Methods: This was a cross-sectional study conducted from 2009-2010 in Kohgiloyeh and Boyerahmad Province. High risk groups for HCV were the subjects of this study. Blood samples were taken from 2009 individuals at high risk for HCV that included inmates, injecting drug users (IDUs), health care workers, patients on maintenance hemodialysis, hemophilic patients, and those with histories of blood transfusions.Patients were residents of Yasuj, Gachsaran, and Dehdasht (3 main townships in the province). Samples were analyzed by ELISA for anti-HCV antibodies. Demographic features of participants were recorded by a questionnaire during sample collection. Data were analyzed by SPSS version 13 software.Results: Of 2009 subjects, HCV antibodies were detected in 172 (8.6%). Rate of infection was higher in males (11.4%) compared to females (3.2%). Rate of infection in inmates was 11.7% while this rate was 42.4% in IDUs, 4.2% in health care workers, and 6.1% in thalassemic patients. Significant correlation was found between HCV infection, history of imprisonment, and thalassemia.Conclusion: Results of this study have provided epidemiologic features of HCV and its risk factors in Kohgiloyeh and Boyerahmad Province, Southwest Iran. This information may assist in preventing the spread of HCV infection in this and other similar settings in the region.The findings of this study may help in improving surveillance and infection control in the community through management and monitoring of infected individuals.

Background: Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy.Methods: In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct (CBD) exploration according to our center’s protocol. Endoscopic retrograde cholangiopancreatography (ERCP) was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube insertion without routine intraoperative cholangiography (IOC).Results: We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 (87.2%) patients. A total of 186 (12.8%) underwent surgery. Of these, 82 (45.2%) had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 (44.1%) patients and choledochojejunostomy was performed in 20 (10.8%). Retained stones were found only in 4 cases which were treated by ERCP.Conclusion: ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions.

Background: The purpose of this study is to evaluate the validity and reliability of a Persian translation of the Modifiable Activity Questionnaire (MAQ) in a sample of adults from Tehran, Iran.Methods: There were 48 adults (53.1% males) enrolled to test the physical activity questionnaire. A sub-sample included 33 participants (45.5% males) who assessed the reliability of the physical activity questionnaire.The validity was tested in 25 individuals (48.0% males). The reliability of two MAQs was calculated by intraclass correlation coefficients. The validation study was evaluated with the Spearman correlation coefficients to compare data between the means of 2 MAQs and the means of 4 physical activity records.Results: Intraclass correlation coefficients between 2 MAQs for the previous year's leisure time was 0.94, for occupational, it was 0.98, and for total (leisure and occupational combined) physical activity, it was 0.97. The Spearman correlation coefficients between the means of the 2 MAQs and means of the 4 physical activity records was 0.39 (P=0.05) for leisure time, 0.36 (P=0.07) for occupational, and 0.47 (P=0.01) for total (leisure and occupational combined) physical activities.Conclusions: High reliability and relatively moderate validity were found for the Persian translated MAQ in adults from Tehran. However, further studies with larger sample sizes are suggested to more precisely assess the validity of the MAQ.

Background: Recently, harm reduction programs have been used to reduce mortality and morbidity among smokers. The main objective of this study was to evaluate the effect of harm reduction programs on the smoking patterns of subjects who presented to a smoking cessation clinic in Tehran, Iran.Methods: This observational study was conducted between September 2008 – September 2009 on 132 patients who were unable to quit smoking. Patients were enrolled by the first come first service method. During the study period, subjects were assigned to either group or individual visits every 15 days in conjunction with the use of nicotine gum. The main objective of this study was to evaluate at the third and sixth months of follow-up: the number of smoked cigarettes, level of expired carbon monoxide (CO), and numbers of nicotine gum used. Data were analyzed by the Wilcoxon rank, Fisher's exact, and Pearson's chi-square tests and SPSS version 17 software.Results: A total of 87.1% of the subjects were males. We noted decreases in the number of cigarettes smoked daily and the level of expired CO, whereas the amount of nicotine gum used significantly increased during the time interval between the first session and the third and sixth month follow-up visits (p<0.001 for all variables). During the follow up sessions, 64.4% of subjects reduced the number of cigarettes they smoked daily by at least 50% and 12.9% of subjects quit smoking.Conclusion: Behavioral and pharmacological therapy in harm reduction programs result in a decrease in the number of cigarettes smoked daily and a reduction in the amount of expired CO. Therefore, these methods can be beneficial in achieving complete smoking cessation.

Background: Quality of life is of significant importance in chronic hepatitis B (CHBV). We aimed to assess the psychometric properties of the Hepatitis B Quality of Life Questionnaire v1.0 (HBQOL) in a large sample of 320 Iranian patients with CHBV.Methods: After adapting the Iranian version through forward-backward translation and expert panel discussion, we administered HBQOL together with Short-Form 36 (SF-36), Medical Outcome Study Social Support Questionnaire (MOS-SS), Hospital Anxiety and Depression Scale (HADS), and the Iowa Fatigue Scale (IFS) to 320 non-cirrhotic Iranian patients. We used principal component analysis with Varimax rotation to determine the factor structure. To evaluate the psychometric properties of HBQOL, test-retest and internal consistency reliabilities, divergent and convergent validity with other instruments, and discriminatory power were calculated.Results: Thirty-one questions loaded on to six factors (Anticipation anxiety, Stigma, Psychological well-being, Vitality, Transmissibility and Vulnerability) which explained 63.6% of total variance. Test-retest reliability was 0.66. Cronbach’s a was 0.94 for the overall scale and between 0.7 and 0.9 for subscales, with the exception of the Vulnerability subscale. HBQOL and its subscales showed acceptable convergent and divergent validity with other instruments. Furthermore, Vulnerability subscale of HBQOL discriminated between patients with chronic active and chronic inactive hepatitis.Conclusion: The Iranian version of HBQOL is reliable, valid, and sensitive to the clinical conditions of the patients. This instrument has acceptable factor structure to measure several aspects of quality of life in patients with chronic HBV.

Background: The aim of this study was to assess the possibility of a primary end-to-end pharyngoesophageal anastomosis after standard tumor resection of the cervical esophagus by acute flexion of the neck.Methods: A total of 34 consecutive patients with primary cervical esophageal cancer, none having received prior radio- or chemotherapy, were treated by two methods based on intraoperative findings. In 18 patients, reconstruction after esophageal resection was carried out by the standard gastric pull-through technique (control group). In 16 patients, acute flexion of the neck after tumor resection allowed for reconstruction by primary end-to-end pharyngoesophagostomy (experimental group).Results: There was no operative mortality in either group. The mean operative time for the experimental group was about 50 minutes less compared to the control group. Self-limited postoperative anastomotic leakage in the neck was twice as common in the experimental group.Postoperative dysphagia was about three times as common in the experimental group [5 patients (31%)] compared to the control group [2 patients (11%)].Conclusion: In selected cases, segmental resection of primary cervical esophageal cancers reconstructed by end-to-end pharyngoesophagostomy is technically feasible by bending the neck acutely forward during anastomosis and maintaining it in the flexed position during a postoperative period of about 7 days. The advantages are reduced scope and duration of the operation. The downside is doubling of the frequency of postoperative cervical leakage.

Background: We aimed to examine cases of brucellosis that presented with severe thrombocytopenia and hemorrhagic diathesis.Methods: A total of 10 brucellosis cases with severe thrombocytopenia were included in this case-series study. Patients’ files were reviewed for their clinical and laboratory findings, as well as clinical outcomes and complications. Platelet counts of<20000/mm3 were diagnosed as severe thrombocytopenia.Results: The lowest thrombocyte count was 3000/mm3 while the highest was 19000/mm3 (mean: 12000/mm3). Patients had the following symptoms: epistaxis (7 cases), petechia with epistaxis (4 cases), bleeding gums (3 cases), ecchymosis with epistaxis (2 cases), melena and renal failure (2 cases), and hematuria (1 case). Patients were given rifampicin and doxycycline along with supportive hematological therapy. All were treated successfully with no evidence of recurrence at follow-up visits.Conclusion: Since brucellosis is endemic in developing countries, it must be considered in the differential diagnosis of cases that present with severe thrombocytopenia and hemorrhagic diathesis.

Background: Postpartum depression (PPD) affects approximately half of new mothers. Chronic exposure to progesterone during pregnancy and its withdrawal following delivery increases depression and anxiety. In addition, there are complex interactions between hormones, neurotransmitters, and trace elements. Zinc (Zn) and magnesium (Mg) influence the nervous system by impacting synaptic neurotransmission in the brain. Thiamine (Vit B1) deficiency results in a high percentage of depressive behaviors. Elevated levels of reactive oxygen species in pregnancy are implicated in the pathogenesis of major depression.Methods: We examined the effects of different combinations of Zn, Mg, and Vit B1 in an animal model of PPD. ZnCl, MgCl, and thiamine-HCl were administered to PPD-induced mice. Depression, anxiety-related behavior, and total antioxidant capacity (TAC) were assessed.Depression and anxiety-like behavior were evaluated by the forced swimming test (FST) and elevated plus-maze, respectively.Results: The acute combined administration of Zn, Mg, and Vit B1 significantly decreased immobility time in FST, increased the percentage of both time spent in- and entries to open arms in the elevated plus-maze, and augmented TAC.Conclusion: Our data suggest that acute administration of combined treatment with Zn, Mg, and Vit B1 on postpartum day 3 improves depressive symptoms and anxiety-like behaviors. Our evaluation of TAC is in accordance with behavioral results.

Background: Urinary tract infections (UTIs), including cystitis and pyelonephritis, are the most common infectious diseases in childhood.Escherichia coli (E. coli) accounts for as much as 90% of the community-acquired and 50% of nosocomial UTIs. Therefore, identification of E. coli strains is important for both clinical and epidemiological implications. Understanding antibiotic resistance patterns and molecular characterization of plasmids and other genetic elements is also epidemiologically useful.Methods: To characterize uropathogenic strains of E. coli, we studied 96 E. coli strains recovered from urine samples of children aged 1 month to 14 years with community-acquired UTIs in Jahrom, Iran. We assessed virulence factors (VFs), drug sensitivities, and plasmid profiles.Results: Drug sensitivities of the isolates were: 19.8% (ampicillin), 24% (trimethoprim-sulfamethoxazole), 29.2% (tetracycline), 75.5% (nalidixic acid), 80.4% (cefixime), 84.6% (gentamicin), 91.4% (ciprofloxacin), 96.8% (nitrofurantoin), 96.8% (amikacin) and 100% (imipenem).Totally, 76 isolates harbored plasmids with an average of 5.5 plasmids (range: 1 – 10) in each strain. Plasmid profiling distinguished 22 different E. coli genotypes in all isolates that ranged in similarity from 50% to 100%. PCR showed that the prevalence of virulence genes ranged from 15.62% for hly to 30.2% for pap.Conclusion: These data mandate local monitoring of drug resistance and its consideration in empirical therapy of E. coli infections. Plasmid analysis of representative E. coli isolates also demonstrates the presence of a wide range of plasmid sizes, with no consistent relationship between plasmid profiles and resistance phenotypes. Plasmid profiles distinguished more strains than did the antimicrobial susceptibility pattern.

Background: On January 9, 2011 Iran Air Flight 277 crashed during approach to Urmia, Iran. Out of 105 passengers, 27 survived. This brief report presents a perspective of the passengers’ sustained injuries.Methods: We reviewed the recorded injuries of all passengers as provided by the Legal Medicine Organization authorities. The Injury Severity Score (ISS), an anatomical scoring system, was used to provide an overall code for those who survived with multiple anatomical injuries.Results: There were a total of 96 ISS body region injuries among those who survived. Facial injuries (83%) were the most frequent injuries noted among fatalities, which was statistically significant (P=0.000). In those who survived, injuries to the head and neck (37%) and facial (33%) regions were relatively less frequent than other anatomical regions. The most serious injuries among survivors belonged to the extremity (85%) region, particularly lower limb fractures (62%). Differences in extremity injuries between the survivors and fatalities were not statistically significant.Conclusion: The findings of this study were similar to other studies where the most frequent serious injuries were fractures of the extremities, particularly the lower limbs.

It has been estimated that in 2008, non-communicable diseases (NCDs) accounted for 36 million death worldwide, contributing to 63 percent of all-cause global mortalities. Without any serious action, the NCD epidemic is projected to kill 52 million people annually by 2030.High blood pressure has been reported as the leading underlying cause of as many as 7.6 million premature global deaths and 92 million disability adjusted life years (DALYs) in 2001...

Meckel’s diverticulum is located on the antimesentric border of the ileum, approximately 45 to 60 cm proximal to the ileocecal valve, and results from incomplete closure of the omphalomesentric or viteline duct. Common complications presenting in adults include bleeding, obstruction, diverticulitis, and perforation. Tumors within Meckel's diverticulum are a rare, but recognized complication.A 62year-old woman presented with peri-umbilical pain that had localized to the right iliac fossa. On examination, she was tender in the right iliac fossa, with localized peritonism. At surgery, a perforated Meckel’s diverticulum was found that was associated with free intra-abdominal fluid and hemorrhage. A 25 mm nodule was found at the apex of Meckel's diverticulum. We resected 100 mm of the small bowel and a primary anastamosis was performed. Histopathological examination of the resected lesion revealed a mesenchymal tumor categorized as a gastrointestinal stromal tumor (GISTs).GISTs arising from Meckel's diverticulum are an extremely rare, but recognized complication. Surgery is considered the standard treatment for non-metastatic GISTs with enbloc resection and clear margins.

Hydatid disease is an endemic illness in some countries. The main sites of involvement are the liver and lungs, but rarely, it can be seen in other organs as well. Herein, we report a case of primary adrenal hydatid cyst accompanied by arterial hypertension.

Synovial sarcomas are most frequently observed in the extremities. Although synovial sarcomas are the third most common histological type of soft-tissue sarcomas of the extremities, primary mediastinal synovial sarcoma is extremely rare. Monophasic synovial sarcoma is the most commonly observed subtype. Whereas the biphasic subtype is less common. We present our case which was diagnosed as biphasic synovial sarcoma located in the anterior mediastinum, which is considered to be a rare entity. The patient underwent surgical resection together with multimodal adjuvant radiotherapy and chemotherapy.