Iranian Red Crescent Medical Journal
Year:2013 | Volume:15 | Issue:9|Papers Count:23

Objectives: The objective of this study was to provide a model for reducing outpatient waiting time by using simulation.Materials and Methods: A simulation model was constructed by using the data of arrival time, service time and flow of 357 patients referred to orthopedic clinic of a general teaching hospital in Tehran. The simulation model was validated before constructing different scenarios.Results: In this study 10 scenarios were presented for reducing outpatient waiting time. Patients waiting time was divided into three levels regarding their physicians. These waiting times for all scenarios were computed by simulation model. According to the final scores the 9th scenario was selected as the best way for reducing outpatient's waiting time.Conclusions: Using the simulation as a decision making tool helps us to decide how we can reduce outpatient's waiting time. Comparison of outputs of this scenario and the based- case scenario in simulation model shows that combining physician's work time changing with patient's admission time changing (scenario 9) would reduce patient waiting time about 73.09%.Due to dynamic and complex nature of healthcare systems, the application of simulation for the planning, modeling and analysis of these systems has lagged behind traditional manufacturing practices. Rapid growth in health care system expenditures, technology and competition has increased the complexity of health care systems. Simulation is a useful tool for decision making in complex and probable systems.  

Background: Seyyed Esmaeil Jorjani is one of the most prominent pioneers and scientists of Islamic and Iranian traditional medicine in the 11th and 12th centuries (4th and 5th centuries A.H.). The number of his books is not certainly clear, but it is signified that he has written a couple of great books concerning medicine for Persians and too many treatises in such fields as philosophy, theology, medical ethics, human anatomy, chemistry, pharmacy and other sciences. His most famous and important book is "Zakhireh Khwarazmshahi" or "The Treasure of King Khwarazm", which is really a complete and valuable medical encyclopedia in Persian language.Objectives: In the present study, authors have attempted to state the life and time of Jorjani and his views by studying the history, old medical sources, and other provided recent medical literature in these fields.Materials and Methods: Old and new references about this scientist have been used.Results: The biography of Hakim Jorjani has been well reviewed and described precisely.Conclusions: Based on our findings, it is clear that Jorjani described and explained the symptoms, signs and treatments of several diseases, introduced the activities of various medicinal plants, and compound formulations. He achieved all of this during his continuous visits to prestigious medical centers and famous people of his time.

Objectives: The aim of this study was to determine the frequency of sabA gene in Helicobacter pylori (H. pylori) strains isolated from different clinical outcomes in Tehran, Iran.Patients and Methods: The study included 120 patients with dyspeptic symptoms admitted to the endoscopy suite of gastroenterology section of Firouzgar University Hospital, Tehran, Iran from March to August 2011. Gastric biopsy specimens were evaluated for the presence of H. pylori using standard microbiological method and polymerase chain reaction (PCR) assay. The sabA genopositive was determined by PCR in H. pylori strains.Results: H. pylori isolates were recovered from 82 patients with duodenal ulcer (DU;n=17), gastric ulcer (GU;n=15), gastric cancer (GC;n=13), and gastritis (G;n=37). The frequency of sabA gene in H. pylori strains was 100% in gastric cancer, 86.7% in gastric ulcer, and 83.3% in both gastritis and duodenal ulcer.Conclusions: This is a report on the prevalence of sabA gene in H. pylori isolated from different gastric patients in Iran. The results showed a high prevalence of sabA in our clinical H. pylori isolates.

Background: Many industrial devices have an excessive vibration which can affect human body systems. The effect of vibration on cochlear histology has been as a debatable problem in occupational health and medicine.Objectives: Due to limitation present in human studies, the research was conducted to survey the influence of vibration on cochlear histology in an animal model.Materials and Methods: Twelve albino rabbits were experimented as: Vibration group (n=6; exposed to 1.0 m.s-2 r.m.s vertical whole-body vibration at 4-8 Hz for 8 hours per day during 5 consecutive days) versus Control group (n=6; the same rabbits without vibration exposure). After finishing the exposure scenario, all rabbits were killed by CO2 inhalation; their cochleae were extracted and fixed in 10% formaldehyde for 48 hours, decalcified by 10% nitric acid for 24 hours. Specimens were dehydrated, embedded, sectioned 5 μm thick and stained with Hematoxylin and Eosin for light microscopy observations.Results: Severely hydro pic degenerated and vacuolated inner hair cells (IHCs) were observed in vibration group compared to the control group. Inter and intracellular edema was appeared in supporting cells (SC). Nuclei of outer hair cells (OHCs) seemed to be pyknotic. Slightly thickened basilar membrane (BM) was probably implied to inter cellular edematous. Tectorial Membrane (TM) was not affected pathologically.Conclusions: Whole-body vibration could cause cochlear damages in male rabbits, though vibration-induced auditory functional effects might be resulted as subsequent outcome of prolonged high level vibration exposures.

Objectives: This study aimed to determine the frequency of latent and active TB infection among IDUs.Materials and Methods: In a cross-sectional study between 2008 and 2009, IDUs referred to the methadone maintenance treatment (MMT) centers in Hamedan-Iran, undergone tuberculin skin test (PPD; purified protein derivative) were recruited. The participants with positive results for PPD test (>5 mm and>10 mm in HIV positive and negative cases), undergone other complementary procedures such as chest-X-ray and sputum smear test.Results: Overall, 268 IDUs between 18 and 70 (mean: 34.5 [8.2]) years were included in the study. PPD test had positive findings in 49 cases (18.3%). There was no significant difference of PPD positivity between HIV positive and negative participants (17.7% vs.18.5%). An active TB was found among IDUs.Conclusions: The high prevalence of latent and active TB among IDUs indicates the need for TB screening tests among this population.

Background: Sperm dysfunction caused by reactive oxygen species (ROSs) is one of the major causes of infertility in men, which leads to, lipid peroxidation (LPO) and the formation of stable peroxidation products like Malondialdehyde (MDA) in seminal plasma. MDA is effective factor in reducing fertility.Objectives: The aim of this study is to determine two biochemical markers of oxidative stress; TAC and MDA, and them correlation to quality-quantity factors in Asthenoteratospermic and Oligoashenoteratospermic men.Patients and Methods: A total of 42 semen samples including: 15 samples normospermic as control group, 12 Asthenoteratospermic and 15 oligoasthenoteratospermic were collected from Babol IVF center; Iran. Semen analysis was performed according to WHO (1999) guidelines. Seminal plasma TAC and MDA levels in all patients were measured by TBARs and FRAP methods, respectively.Results: Seminal plasma TAC level in normospermic men was significantly higher than asthenoteratospermic men (P<0.001) and oligasthenoteratospermic men (P<0.001) and had posetive correlation with sperm count, motility and morphology. In contrast MDA levels in normospermic men were significantly lower than in asthenoteratospermic men (P=0.049) and oligoasthenoteratospermic men (P=0.001) and had negative correlation with sperm count, motility and morphology.Conclusions: These results suggest that lipid peroxidation and decreasing total antioxidant capacity lead to low motility; morphology and sperm count in spermatozoa of astheno-and oligoastheno-teratospermic men. Therefore, evaluation of oxidative status and antioxidant defenses system may be as a useful tool for diagnosis and treatment of male infertility especially in idiopathic male infertility.

Background: Appendicitis is one of the most common causes of mortality, despite medical advances it continues to be a major problem.Objectives: The main goal of this study was healing initial of appendectomy infection wounds with aggressive washing method.Patients and Methods: This study is a semiexperimental investigation which was performed on 300 patients with perforated appendicitis and infected ulcers who were selected randomly during 2001-2005. Patients were investigated with aggressive washing and primary repair, and necessary data was collected and analyzed.Results: From all patients, 284 were improved, and 16 cases were complicated, from them 10 patients in the first week, 4 patients in the second week, and 2 patients in the third week had ulcer infection.Conclusions: The results showed that aggressive washing method is an effective technique in patients with perforated appendicitis and wound infection.

Background: Zoonotic Cutaneous Leishmaniasis (ZCL) is an endemic health problem in many rural areas of Iran, with doubled number of incidences over the last decade. Different species of rodents serve as natural reservoir host for ZCL. The disease is considered as a major health problem in rural areas of Mirjaveh, Chabahar, and Konarak Counties of Sistan va Baluchistan Province.Objectives: This study describes the identity of Leishmania species, isolated from Meriones hurrianae from Chabahar County using RAPD-PCR methodology.Materials and Methods: Rodents were entrapped by live traps baited with roasted walnut, tomato, and cucumber during spring and summer. All rodents were identified based on external features including fur color, ears characteristics, tail length, hind feet, body measurements, and internal features of teeth and cranium. Giemsa-stained impressions from rodents’ ears were examined for amastigotes microscopically. The samples from infected rodents were cultured in NNN+LIT medium and then the harvested parasites at the stationary phase were subjected to DNA extraction followed by amplification with RAPD-PCR.Results: All the 28 entrapped animals were identified as M. hurrianae. Five animals showed to harbor Leishmania parasite by microscopy. Leishmania DNA isolated from five M. hurrianae produced distinctive bands of L. major with four primers. However, the products that were amplified with primers AB1-07, 327, and 329 were stable and reproducible. This is the first report on the isolation and identification of L. major from M. hurrianae from Iran.Conclusions: Regarding infection rate of 17.8%, M. hurrianae seems to play the major role in the maintenance and transmission of disease to humans in this area.

Background: Upper gastrointestinal (UGI) endoscopy is a tool used frequently in the evaluation of patients presented with hematemesis.Objectives: The purpose of this study was to evaluate clinical presentations and features of UGI bleeding (UGIB) in children.Methods/Patients and Materials: A descriptive retrospective analysis was carried out on the medical records of the patients. Children and adolescents aging 0–18 years who were presented with UGIB were recruited in the survey over a period of 10 years (2000 to 2010) in Children's Hospital, Tabriz, Iran.Results: There were 447 patients included in this study and they were all evaluated by upper endoscopy. Clinical manifestations included hematemesis (120 cases, 26.85%), melena (60 cases, 13.42%), and hematochezia (11 cases, 2.46%). Age-related analysis showed that erosive esophagities was a more common cause of hematemesis in the younger age group (under 1 year of age) with a prevalence of 37% when compared with elder children and adolescents (40%). Peptic ulcer disease was seen in only 7.4% of infants under the age of one. Overall, Esophagitis and erosive esophagitis was the most common endoscopic finding (179, 40%).Conclusions: There were 80 (17.90%) patients receiving endoscopic hemostatic therapy. In children with UGIB, upper endoscopy is a diagnostic procedure for the categorization of underlying causes of upper gastrointestinal bleeding in children and various endoscopic lesions may be found in a patient with the impression of UGIB.

Background: Evidence based medicine (EBM) is very important in the process of decision making, diagnosis and treatment of patients. For years, medical schools have developed instructions for EBM to determine the attitude and knowledge of physicians towards EBM and their related educational needs.Materials and Methods: This study was a questionnaire study among physicians. One hundred twenty physicians were selected using stratified random sampling in Ilam. A main outcome measure was attitudes and knowledge of physicians toward EBM, ability to access and interpret evidence, and best method of moving from opinion based to EBM.Results: Of the 120 questionnaires we have sent, 94 (78.3%) were answered.56.6% were using the internet to answer their patient’s questions and 23.8% used the internet to obtain clinical evidence. Mean and standard deviation (SD) of knowledge and attitude scores were 24%±23% and 72%±10%, respectively. Pearson correlation shows a significant relation between knowledge of physicians and years of graduation (r=-0.37, P=0.00). There was a significant difference between mean of knowledge score of general practitioners, specialist and subspecialist (P=0.026).Conclusions: Knowledge and attitude of young physicians were more based on EBM compare to old physicians. A significant difference in knowledge mean score of physician shows that the EBM is still new in Iran, the future physician’s critical need to learn EBM and necessity of entering EMB at all medical levels.

Background: Due to the importance and uniqueness of the characteristics of the health sector, one of the most important priorities of the Ministry of Health is measuring the efficiency and quality of services which are provided for the people who refer to the health sectors. In all health systems, responding to the needs and wishes of patients is a crucial priority.Objectives: The main purpose of this study is to prioritize the features of the services from the perspective of patients, by applying the Logit model.Materials and Methods: This study is a descriptive cross-sectional study and in terms of results it can be classified to an applied study. Data were collected by a questionnaire filled by 330 patients in Imam Khomeini hospital, and for estimating the utility function the software STATA version 10 was applied. In this study the preferences of patients who admitted to hospitals were identified by calculating the marginal utility of the characteristics, where we also used Marginal Rate substitutions (MRS).Results: Determination of the marginal utility characteristics shows that the first priority in receiving hospital services is the type of examination, and the last priority in the cleaning service of the sections and restrooms. Waiting time between hospital arrivals and admission has a negative sign which indicates a negative impact on patient preference.Conclusions: The results of this study are consistent with studies by Kara Hanson and Barbara Mc Clean, where in their study they also showed that by the patient’s perspective, hospital examination is the most important quality characteristic (coefficient=2.78). In other words, the ultimate purpose of the hospital visit is the quality of service and examination, where many patients are willing to wait longer or pay higher costs to get the best services.

Background: During laparoscopy, insufflation of an inert gas in the peritoneal cavity creates a working space to facilitate surgery. The space should be large enough to facilitate surgery without increasing intra-abdominal pressure (IAP) over a threshold limit (usually 15 mm Hg).Objectives: This experimental study was performed to evaluate the effects of increasing in intra-abdominal pressure on internal organs.Materials and Methods: Twenty female mixed breed dogs (20±3 kg, 18±1.2 months) were selected. They were randomly divided to two groups (n=10). The intra-abdominal pressure was maintained 12 mm Hg and 20 mm Hg during the operation in control group and in test group respectively.Results: Histopathologic evaluations revealed more pathological changes at the kidney of all the dogs in test group in comparison to control group.Conclusions: Our findings revealed that organs that their blood supplies are related to one single or two arteries and their blood drainage are related to one or two veins are more sensitive to increased intra-abdominal pressure.

Background: Gastric ulcer is a serious digestive system problem and affects 5% to 10% of people during their life. Chemical antigastric ulcer drugs have side effect, cannot prevent recurrence of ulcer and also show drug interaction with many other medicaments. Tragopogon graminifolius DC. (TG) is a herb which is widely used in the west of Iran and traditionally consumed for the treatment of gastrointestinal disorders. TG was introduced as one of the most beneficial plants for digestive ulcer in Iranian traditional medicine.Objectives: The aim of the present study was to determine the acute toxicity and protective effect of hydroalcoholic extract of TG (HeTG) against ethanol induced gastric ulcer.Materials and Methods: Male Wistar rats were divided into five groups (n=7). HeTG at the doses of 50, 100, and 150 mg/kg were administered orally for 15 days and gastric ulcer was induced by pure ethanol (1 ml/200gr body weight). Ulcer index and protective rate were calculated and histological changes were determined.Results: HeTG was nontoxic up to 2000 mg/Kg. Ulcer index decreased in extract groups significantly. Protective rates of HeTG were 48.94%, 46.39%, and 43.99% in 50, 100, and 150 mg/kg extract, respectively.50 mg/kg HeTG group had higher protective effect. There was relatively normal cellular arrangement in HeTG groups.Conclusions: TG showed protective effect against ethanol induced gastric ulcer. This study confirmed traditional medicine claims of TG.

Background: Postpartum hemorrhage is a significant cause of maternal mortality and morbidity, worldwide.Objectives: The aim of this study was to compare the efficacy between carbetocin and syntometrine in prevention of postpartum hemorrhage.Materials and Methods: This study was a double blind randomized clinical trial that carried out on 200 pregnant women referred to Shabiehkhani maternity center of Kashan, during 2011. The first group received intramuscular syntometrine and the second group received intramuscular carbetocin after placental delivery. All of the participants were followed for 24 hours and blood pressure, pulse rate, uterine tone, hemoglobin concentration at first and 24 hours after delivery, and the need for additional uterotonic drugs and drug side effects were evaluated. Finally all data were analyzed using t-test, chi square tests and logistic regression.Results: The mean fall in hemoglobin level in the carbetocin group was significantly lower than the syntometrine group (P<0.001). Also there were significant differences between the two groups, regarding additional uterotonic drug requirements (P=0.002). Moreover systolic blood pressure and uterine tone immediately and 30 minutes after drug administration were significantly different (P<0.001). Incidence rate of tachycardia in the carbetocin group was 13%, in contrast to 5% in the syntometrine group (P=0.04).Conclusions: This study revealed that carbetocin is more effective than syntometrine in prevention of postpartum hemorrhages. Thus it can be used as a good alternative of syntometrine for low-risk women.

Background: Advanced ambulance service (Emergency Medical Services/EMS) is considered to be an integral part of emergency medical care as the first assets responding to emergencies and disasters in the prehospital setting in most developed countries.Objectives: The aim of this study was to evaluate the current situation of Shiraz’s EMS by comparing data obtained during two different time periods.Materials and Methods: This is a retrospective analytic and comparative study in which data obtained from Shiraz EMS during two one-year periods (21st of March 2011 to 20th of March 2012 and 22nd of September 1999 to 21st of September 2000) were compared. Furthermore, these data were also compared with available data from Gothenburg’s EMS (2010).Results: Of 84084 missions performed by Shiraz EMS during one year trauma cases were the most common [39282 (46.7%)]. The most common cause of trauma was road traffic accidents (RTA) (27257; 76.5%). Near 56% of all patients were transported to hospitals; some 47% by ambulances and 8.8% by private cars. Around 36.2% of patients received definitive medical treatment at the scene. While there was an increase in response and evacuation times, the number of deaths at scene before ambulance arrival decreased.Conclusions: Although Shiraz’s EMS has expanded during last decade and the mortality rate at scene has decreased, the number of RTA-related trauma cases, along with the response and evacuation time, has increased. More than one third of the patients received definitive treatment and could be dismissed directly from the scene. Standardized triage and treatment protocols are needed to improve the EMS activity.

Background: In the past 10 years, 13 fatal earthquakes have occurred in Iran and led to death of 30, 000 people whom most of them were killed in the earlier hours of the disaster. Disaster Medical Assistance Teams are groups of trained medical and non-medical personnel with various combinations that on the optimal conditions are deployed just within 8 hours of notification and are able to work self-sufficiently for at least 72 hours without any outside help and can treat up to 250 patients per day. Currently there are no such rapid-response teams in case of unexpected events in Iran, which causes the responses to such disasters, not to be organized or practiced. For instance, there were many rescue forces in 2003 Bam earthquake but not enough skilled ones to cope with; consequently they themselves became a problem in crisis management instead of solving the problem.Objectives: In this study, we have investigated which of the following is more efficient: changing the size and combination of the team depending on the type of disaster and environmental conditions or, determine a fixed combination team.Materials and Methods: Totally, several reasons for dynamic combination and size of the teams are presented. later, earthquake disaster is divided into 3 phases in terms of time including the acute phase (1st to 4th day after disaster), the sub-acute phase (5th to 14thday) and the recovery phase (after the 14th day), and finally the appropriate team combinations in every phases are offered.Results: Regarding to introduction and considering the existing statistics in different legal Iranian resources and by division of the earthquake disaster to three phases including acute phase (1st to the 4th day after disaster), sub-acute phase (5th to 14th day) and recovery phase (after the 14th day) Conclusions: The countries pioneer in disaster medical assistance teams, now are inclined to deploy different teams consistent with each kind of disasters or with other effective components on the combination of system. Every disaster has its own condition and would require different combination of relief and medical forces. For example, people’s health needs in flood is different from the earthquake.

Background: In recent years, with socioeconomic changes in the society, the presence of women in the workplace is inevitable. The differences in working condition, especially for pregnant women, has adverse consequences like low birth weight.Objectives: This study was conducted with the aim to model the relationship between working conditions, socioeconomic factors, and birth weight.Patients and Methods: This study was conducted in case-control design. The control group consisted of 500 women with normal weight babies, and the case group, 250 women with low weight babies from selected hospitals in Tehran. Data were collected using a researcher-made questionnaire to determine mothers’ lifestyle during pregnancy with low birth weight with health-affecting social determinants approach. This questionnaire investigated women’s occupational lifestyle in terms of working conditions, activities, and job satisfaction. Data were analyzed with SPSS-16 and Lisrel-8.8 software using statistical path analysis.Results: The final path model fitted well (CFI=1, RMSEA=0.00) and showed that among direct paths, working condition (b=-0.032), among indirect paths, household income (b=-0.42), and in the overall effect, unemployed spouse (b=-0.1828) had the most effects on the low birth weight. Negative coefficients indicate decreasing effect on birth weight.Conclusions: Based on the path analysis model, working condition and socioeconomic status directly and indirectly influence birth weight. Thus, as well as attention to treatment and health care (biological aspect), special attention must also be paid to mothers’ socioeconomic factors.  

Background: Many diagnostic and treatment procedures are done in hospitals and clinics. Offering services in these areas have a prominent role in promoting patients’ satisfaction levels and their prospective about health services. Objectives: This study is going to assess the satisfaction levels of patients referring to the six military hospital clinics in Iran. Materials and Methods: In this cross-sectional study, 330 outpatients and 696 inpatients admitted to the six military hospital clinics in Iran were randomly questionnaires from June to August 2008. Basic socio-demographic data along with a clinic satisfaction level assessment questionnaire were filled for outpatients. A hospital satisfaction level assessment questionnaire also was applied to record inpatients’ data. All collected data were recorded and then analyzed tests X2 and ANOVAs was used and with significantly lower levels of 5% (P < 0. 005). Results: We found that 96% of the study population was satisfied with clinic services and more than 98% of the respondents were satisfied with inpatient ward services. In clinic services, the satisfaction level in numbering and waiting time, access to the clinic, physical environment, welfare and helping facilities, and personnel and physicians’ behavior were 78. 2%, 80. 6%, 89. 1%, 91. 2% and 93. 6% respectively (P < 0. 001). With regard to inpatient services, the satisfaction level of patients with physician services, nursing routine services, behavior of nurses, nutritional condition, welfare facilities, reception unit services, discharge unit services and accounting unit services were 94. 7%, 91. 9%, 91. 9%, 91. 5%, 91. 5%, 91. 2%, 90. 8% and 88. 2%, respectively (P = 0. 013). Conclusions: On the basis of the findings, most respondents reported having a favorable satisfaction with clinic and hospital health services. However, planning to reduce patient’ s waiting time in clinics and training physicians to offer more instructions to the patients seems necessary. Since discharge and accounting unit services had the lowest satisfaction levels of inpatients services, responsible managers must have special attention to these official processes.

Objectives: To determine the effect of acupressure on third liver point on primary dysmenorrhea. Patients and Methods: Female students living in dormitories of Kashan University of Medical Sciences in Iran who had PD were studied for three menstrual cycles between March till June 2012. Individuals with depression score higher than 19 according to the Beck-21 Depression scale were excluded. In the first cycle, pain intensity was assessed without intervention, and 67 samples with a pain score greater than 4 according to the visual analogue scale (VAS) were selected. Then they were randomized into third liver point (liv3) and control (placebo) groups using randomized block design with 1: 1 allocation ratio based on pain intensity. In the second and third cycles, pressure was applied by the research unit intermittently for 16 minutes (2 minutes pressure, 2 minutes resting) with the starting of blood flow. Primary outcome of this study was the pain intensity which was compared between first and third cycles. Someone who divided groups, samples and data analyzer was blinded. Results: In the treatment group 27 samples and in the control group 32 samples were analyzed. Friedman test showed significant differences in pain intensity before and after the intervention within both groups (P < 0. 05). There were no significant differences between the groups according to the ordinal regression test in 3 cycles (P > 0. 05). Conclusions: The pressure on the LIV3 applied in this investigation was effective in reducing primary dysmenorrheal pain. So using this method is recommended to reduce PD.

Background: Nausea and vomiting of pregnancy (NVP) is the most common medical condition of pregnancy, affecting up to 85% of expecting mothers. NVP can have serious adverse effects on the quality of a woman's life, social, and domestic functioning, and her general well-being. Therefore, it is very important to treat this condition. Objectives: The effectiveness of ginger and acupressure in the treatment of NVP was compared in the present study. Patients and Methods: 159 eligible pregnant women with symptoms of mild to moderate nausea and/or vomiting before 16 weeks gestational age participated in a 7-day clinical trial. They were divided randomly into three groups: the acupressure, ginger, and control. Participants did not receive any intervention for three days and interventions were performed for the women in acupressure and ginger groups for four days. No intervention was performed for the control group. Data was collected by self-recorded symptoms according to the Rhodes index. Data was analyzed by ANOVA, Kruskal-Wallis, Chi-square, and Fisher exact tests for quantitative and qualitative variables. Results: There were no statistical differences in the baseline demographics between the three groups. ANOVA test showed that there were significantly differences in mean difference Rhodes index scores (vomiting, nausea, retching and total score) in the three groups (P < 0. 001). Conclusions: Ginger is more effective than acupressure to relieve mild to moderate nausea and vomiting in symptomatic pregnant women in less than 16 weeks of gestational age.

Dermatitis artifacta is a factitious dermatological disorder with many forms of presentation of self-inflicted skin lesions in any part of the body. Dermatitis artefacta is a rare and difficult condition for diagnosis and treatment mostly because of the patient's denial. The liaison among primary care physicians, psychiatrists and dermatologists can be important in the management of these patients. In this report we describe a 17-year-old girl with dermatitis artefacta which was presented as bullous lesions on her face induced with a native herb combining with fake headaches.

Conversion of knee arthrodesis to total knee arthroplasty is a difficult procedure accompanied by many complications due to soft tissue and extensor mechanism contracture and bone defects. We report two cases of distal femur osteosarcoma that had been undergone wide resection arthrodesis initially. Arthrodesis was converted to total knee arthroplasty with hinged prosthesis after many years. We describe patients' history and outline their surgical therapy and prognosis. To the best of the authors' knowledge, few cases have been previously reported in the literature.

Proximal femoral fracture (PFF) is one of the most important etiologies of mortality and morbidity in elderly. Reported mortality rate is in a range of 1.3-16% pre-operatively up to 22-42% postoperatively (1, 2).Mortality rate in elderly patients with this problem is estimated about 30%.In Iran, and there are a relatively lower number of incidences for hip fracture than in western countries. Effective factors on mortality rate are aging, gender, intertrochanteric fractures and immobility before fracture (3). PFF usually requires a great amount of health care which causes patients to be hospitalized for a long time. Increased life expectancy leads to increased age and senescence. On the other hand, disorders such as cardiovascular diseases and diabetes result in additional concerns about complications caused by these fractures (4). Also increased rate of obesity in general population have worsened complications which have made treatments less effective (5). One of the most important therapeutic goals is to achieve movement ability after fracture in these patients. Walking with and without using crutch, and ability for mobility is expected in the cases (6). Established risk factors for decreased mobility in patients are osteoporosis, decreased bone density, prolonged consumption of corticosteroids, aging and central obesity. Several studies have shown direct relation between BMI and mortality rate in patients with the noted fractures (7, 8).