Caspian Journal of Internal Medicine
Year:2012 | Volume:3 | Issue:3 (11)|Papers Count:14

Rheumatoid arthritis is an inflammatory arthritis which changes the biomechanical properties of bones and leads to the alterations in bone components through the increased production of pro-inflammatory cytokines or by hormone mediated mechanisms (1-3).In addition to traditional risk factors of osteoporosis, physical disability, inadequate treatment, and disease activity are also responsible factors of bone loss and osteoporosis in RA (4-6). Furtheremore, disease duration, seropositivity for anti-cyclic citrullinated peptide antibody (anti-CCP) and rheumatoid factor (RF) have been shown to be associated with bone loss in RA (7, 8).

Background: Osteoporosis (OP) is a common complication of inflammatory arthritis such as rheumatoid arthritis (RA). In this study we evaluated Osteoporosis and its related factors in RA patients.Methods: This cross-sectional study was carried out from 2010 to 2011 on 121 women with RA aged 45-75 years. These patients were selected and divided in two groups according to their bone mineral densitometry (BMD) status, osteoporotic and non-osteoporotic. The data about OP and potential related factors were recorded. T-test for quantitative and X2 for qualitative variables were used for group comparison.Results: The mean age of the patients was 55.7±10.1 and the duration of the disease was 10.1±9.2 years. Thirty nine (32.3%) of patients had T score£-2.5 [28 (23.1%) in the lumbar spine and 20 (16.5%) in the femoral neck of regions]. The age and body mass index (BMI) were the most significant factors related to OP (p=0.00, p=0.01). Surgery induced menopause was conversely related to OP in neck of femur (p=0.04). OP in femur was related to overall fracture in patients (p=0.02) and also with seropositivity for RF (p=0.04) and body mass index (p=0.01).Conclusion: The prevalence of OP in our patients was higher than expected. Old age, menopause, low BMI and seropositivity were the main risk factors of osteoporosis.

Background: Vitamin D deficiency seems to be associated with pulmonary function deterioration. The present study was designed to investigate the relationship between serum vitamin D and forced expiratory volume in patients with chronic obstructive pulmonary disease (COPD).Methods: From September 2011 to April 2012 eighty consecutive patients with COPD presented to an outpatient clinic of Babol University- Teaching Hospital entered to the study. Diagnosis of COPD was confirmed according to clinical findings and pulmonary function test. Serum 25-hydroxyvitamin D (25-OHD) was assessed by chemiluminuscence method and postbronchodilator forced expiratory volume in 1s (FEV1) was measured in all patients. The objective of this study was to determine the relationship between serum 25-OHD concentrations and FEV1 value. The patients were classified according to serum 25-OHD concentrations as less 10 ng/ml, 10-19.9; 20-29.9; 30-39.9; and 40 ng/ml or higher. The mean values of FEV1 for each class of serum 25-OHD were determined and compared.Results: The mean age of patients was 67.4±11.5 years. The mean FEV1 volume in serum 25-OHD deficient COPD was lower than sufficient COPD (1.550±0.55 vs 1.650±-0.58, p=0.45). Mean FEV1 values increased from 1.55±0.55 L in patients with mean serum 25-OHD<20 ng/ml to 1.94±0.74 L in COPD patients with mean serum 25-OHD±>40 ng/ml. There was a dose-response pattern of relationship between FEV1 and serum 25-OHD. However, the relationship did not reach to a statistically significant level.Conclusion: These findings indicated a relationship between serum 25-OHD concentration and FEV1 volume in patients with COPD and suggest optimization of serum vitamin D levels in COPD.

Background: Foot ulcers (FU) are a significant complication of diabetes mellitus (DM) and a preceding factor leading to lower extremity amputation. The aim of this study was to evaluate the management of diabetic foot ulcer (DFU) in Babol, north of Iran.Methods: Five hundred twenty cases of diabetic foot ulcer that were hospitalized in two main teaching hospitals of Babol University of Medical Sciences from March 2005 to September 2011 were evaluated. Glycemic control, wound and foot care, ulcer treatment and site of amputation were determined and the collected data were analyzed.Results: Four hundred forty seven (84%) had inappropriate glycaemic control. Three hundred-sixty-four (70%) received oral anti-diabetic drugs. Ulcer care was proper and improper in 46% and 54% of cases, respectively. Quality of foot care was inappropriate in 66% of patients. Most patients were treated surgically (85%) including debridement (28%) and amputation (57%). Major amputations were the most common (63%) and below knee amputation was more predominant (61%).Conclusion: The results show that diabetic foot ulcer management is not appropriate in this region, and the rate of amputation is relatively high. Improvement and organization of existing facilities are recommended.

Background: Titanium (Ti) implants are commonly coated with hydroxyapatite (HA). However, HA has some disadvantages such as brittleness, low tensile strength and fracture toughness. It is desirable to combine the excellent mechanical properties of ZrO2 and the chemical inertness of Al2O3 with respect to the purpose of this project which was coating Ti implants with HA-ZrO2-Al2O3 to modify the surface of these implants by adding ZrO2 and Al2O3 to HA. The purpose of this study was to evaluate the efficacy of hydroxyapatite coating nonocomposite.Methods: From September 2009 to January2011, functionally graded HA-Al2O3-ZrO2 and HA coatings were applied on Ti samples. HA-Al2O3-ZrO2 and HA sols were orderly dip coated on the substrates and calcined. Scanning electron microscopy and EDS were used to estimate the particle size of the surfaces and for morphological analysis. The morphology of non-coated HA-coated HA-Al2O3-ZrO2 (composite-coated) and doublelayer composite coated samples were compared with one other. Mechanical test (heat & quench) was also done for comparing single-phase (HA), composite and double-layer composite samples.Results: The morphology of HA-Al2O3-ZrO2 coating is more homogenous than HA-coated and uncoated samples. Furthermore, single-layer coating is more homogenous than double-layer coating. EDS analysis was done on HA-coated sample and showed that the Ca/P ratio in the film was similar to the theoretical value 1.67 in HA.Conclusion: Surface modification of Ti implants can be done by coating them with singlelayer of HA-Al2O3-ZrO2. Single-layer hydroxyapatite-alumina-zirconia coated sample has the most homogenous morphology on the surface.

Background: Thalassemia is the most common hereditary anemia and beta thalassemia major is its most severe form. Endocrine abnormalities in thalassemia major are common disturbing complications that need prompt management. The purpose of this study was to determine the endocrine disorders and bone mineral density in patients with major b-thalassemia in Qazvin, Iran.Methods: In this cross-sectional study, 77 patients with b-thalassemia major (15-36 years old) were enrolled. Physical examination, laboratory tests, bone radiography and bone density measurements were performed. Then, the data were analyzed.Results: Forty patients were males. The mean age was 21.26±4.53 years old. The mean BMI was 20.15±2.79 kg/m2. Impaired puberty, short stature, hypothyroidism, diabetes mellitus, IGT, hypoparathyroidism, vitamin D deficiency and vitamin D insufficiency were observed in 46.8%, 33.8%, 18.2%, 16.9%, 13%, 7.8%, 45.5% and 24.7% of patients, respectively. Nearly 80% of patients had low bone mineral density. Bone mineral density was significantly associated with hypogonadism (p=0.001), short stature (p=0.026), hypoparathyroidism (p=0.031), hypothyroidism (p=0.048), diabetes mellitus (p=0.002) and vitamin D deficiency (p<0.001).Conclusion: Impaired puberty and short stature were the most common endocrine complications in our population. Low bone density (osteopenia, osteoporosis) is significantly different in b-thalassemic patients with and without endocrine complications.

Background: Pseudocholinesterase (PChE) polymorphism has been a subject of several pharmacogenetic studies worldwide. The patients with atypical homozygous genotype do not only have reduced serum cholinesterase activities but also their elimination rate for some pharmacologically potent drugs decrease drastically. This study was designed to evaluate the PChE polymorphism in Mazandaran province (northern Iran) for the first time.Methods: About 5 ml plasma samples were collected from 200 healthy volunteers who visited "Iran Blood Transfusion Organization" centers all across Mazandaran province for blood donation. The PChE activity in presence or absence of dibucain was measured and based on obtained dibucain number (DN) volunteers were categorized to normal homozygous (Eu,u), atypical heterozygous (Eu,a), and atypical homozygous (Ea,a).Results: The average (±SD) of the PChE activity among the blood donors was 9.14±1.93 IU (ranging from 4.1 to 16.6 IU). Only 2 persons (1%) had DN between 60 to 70 (Eu,a) and no one was categorized in 20<DN<30 (Ea,a) group. Nine volunteers (4.5%) in normal group (Eu,u) had DN values less than 72. The within- run and between run-precisions (CV) for DN measurements in our laboratory were found to be 2% and 4%, respectively.Conclusion: According to the findings, only 1% of the sample population had atypical heterozygous phenotype taking into account the experiment precision, the frequency of Ea,u is less than 4%. These findings suggest that the atypical allele frequency in northern Iran's population is probably less than the other regions of Iran and some other countries.

Background: Bone-specific alkaline phosphatase (BAP) is synthesized by the osteoblasts and is presumed to be involved in the calcification of bone matrix, though its precise role in the formation process is unknown. The aim of the present study was to measure the BAP activity in Paget's and normal specimens by two different techniques.Methods: Total ALP (TAP) as well as BAP activity-measuring tests were repeatedly undertaken at different times during the day and different days on the serum samples (inter and intra assay). Precision and repeatability of the phenylalanine inhibition (PHI) and heat inactivation (HI) techniques were approved during ten times repetition of all the tests on two normal samples besides one sample from Paget's disease of bone. The measurement of TAP and BAP activities was also carried out on 50 serum samples from normal adults using the standard IFCC-AACC and the established methods, respectively.Results: Coefficients of Variation (CV) for intra-assay of BAP were 2.33% and 3.16% by HI and PHI methods, respectively. Also, the inter-assay CV of BAP was 2.87% and 3.49% for mentioned methods in Paget's sample, respectively. In addition, the correlation of HI and PHI methods was found to be r=+0.873 for bone-specific isoenzyme.Conclusion: Regarding the appropriate precision, repeatability and correlation of HI and PHI techniques, as well as their cost effectiveness can be of use in the quantification of bone alkaline phosphatase isoenzyme activity, especially when bone is involved.

Background: Tramadol is a synthetic analgesic. Seizures have been reported in patients receiving this drug. In this study we evaluated the correlation between tramadol consumption and seizure occurrence.Methods: Twenty-eight subjects with a history of tramadol consumption and seizure were studied. Electroencephalograms (EEG) were performed in the first 24 hours and again one week later. Subjects were followed up for a mean of 18 months after the initial attack.Results: In the 28 subjects, 26 (92.8%) were males and 2 (7.2%) were females. The mean age of the subjects was 28.4 years. Thirteen patients had abused more than 400 mg/day of tramadol. Sixteen subjects concomitantly used other drugs. The seizures occurred within the first 24 hours of tramadol intake in 25 of the subjects. The first EEG was abnormal in 12 cases, but the second EEG was abnormal in only one case. Neuroimaging of only one subject displayed patchy white matter lesions.Conclusion: In conclusion, the neurotoxicity of tramadol commonly manifests as generalized tonic clonic seizures most frequently within 24 hours after tramadol intake and was more common in subjects concomitantly consuming alcohol, illicit drugs, antipsychotics, or anti-depressants.

Background: Confounding can be thought of as mixing the effect of exposure on the risk of disease with a third factor which distorts the measure of association such as risk ratio or odds ratio. This bias arises because of complex functional relationship of confounder with both exposure and disease (outcome). In this article, we provided a conceptual framework review of confounding issues in epidemiologic studies, in particular in observational studies and nonrandomized experimental studies. We have shown in 2 by 2 tables with analytical examples how the index of association will be distorted when confounding is present. The criteria, source of confounding and several points in confounding issues have been addressed. The advantages and disadvantages of several strategies for control of confounding have been discussed.

Background: Sub-acute bacterial endocarditis (SBE) rarely presents with features of a small vessel vasculitis. Patients with SBE can also develop multiple serological abnormalities including ANCA. In this report, we present a case of infective endocarditis mimicked ANCA associated glomerulonephritis.Case presentation: A 57-year old male with a clinical picture of rapidly progressive renal failure (RPGN) and positive seology for PR3-ANCA (C-ANCA) was referred to our hospital. The renal histology findings were compatible with focal and segmental glomerular necrosis. After receiving corticosteroid therapy, the patient became febrile and his general condition worsened. Cardiac ultrasound echocardiographic study disclosed multiple large vegetation on the aortic valve. After appropriate antibiotic therapy and valvular surgery, the patient’s condition improved and his serum creatinine reached 1.7 mg/d.Conclusion: Misdiagnosis of SBE as ANCA-associated vasculitis and an inappropriate immunosuppressive therapy can have catastrophic consequences.

Background: Many of the multiple traumatized patients who refer to the hospital need transfusion. Transfusion-related acute lung injury (TRALI) is a serious clinical syndrome associated with the transfusion of plasma-containing blood components. In the article, we present a case of TRALI following transfusion of packed red blood cells.Case Presentation: A 24 year old male referred to Shahid Beheshti Hospital due to multiple trauma with left femoral and humerus fractures. Due to severe anemia he received 3 units of packed red blood cells. The symptoms of TRALI began 2 hours after transfusion. He was transferred to intensive care unit (ICU) due to metabolic acidosis and severe hypoxia. The TRALI was confirmed after ruling out the other probable pulmonary diseases. He recovered and was discharged.Conclusion: Transfusion related acute lung injury should be considered in any case receiving transfusion of plasma containing blood components.

This refers to Dr. Ziaee et al.’s manuscript published in your valuable journal about serum homocysteine level entitled “Effects of folic acid plus levothyroxine on serum homocysteine level in hypothyroidism”. In this clinical trial study the efficacy of concomitant administration of folic acid and levothyroxine versus single levothyroxine prescription on serum homocysteine level was compared with hypothyroid patients. The authors concluded that “levothyroxine can decrease serum homocysteine level partly; still its combination with folic acid empowers the effect. Combination therapy declines serum homocysteine level more successfully (1).”

Shivering is the most common complication after anaesthesia and postoperative pain is another important impediment to recovery from surgery. Postoperative pain and shivering are two postoperative challenging components (1). Prevention of postoperative pain and post anaesthetic shivering should be considered and managed as two important components which demonstrably improve the patient’s outcome.