Tehran University Medical Journal
Year:2007 | Volume:65 | Issue:4|Papers Count:24

Background: The object of this study was to investigate the antimicrobial resistance pattern among common nosocomial Gram-negative bacilli isolated from patients with nosocomial infections.Methods: From June 2004 to December 2005, 380 isolates of common Gram-negative bacilli (Klebsiella, Pseudomonas, Acinetobacter and E. coli) from 270 patients with nosocomial infections in Sina and Imam Hospitals, Tehran, Iran, were evaluated for susceptibility to Imipenem, Cefepime, Ciprofloxacine, Ceftriaxone and Ceftazidime by Disc diffusion and E-test methods.Results: The most frequent pathogens isolated were Klebsiella spp. (40%), followed by Pseudomonas (28%), Acinetobacter spp. (20%) and E. coli (12%). The most active antibiotic was imipenem (84%). 26% of all isolates were sensitive to Cefepime, 26% to Ciprofloxacin, 20% to Ceftazidime and 10% to Ceftrixone. The susceptibility rates of Klebsiella to Imipenem, cefepime, ciprofloxacin, Ceftazidime and Ceftriaxone were 91, 25, 21, 13 and 7 percent, respectively and 91, 19, 17, 21 and 21 percent, respectively, for E. coli. Among Acineto- bacter spp., the susceptibility rate was 77% for Imipenem and 21% for Ciprofloxacin. Among Pseudomonas spp., 75% of isolates were susceptible to Imipenem and 39% to Ciprofloxacin. The comparison of the resistance status of microorganisms by both Disc diffusion and E-test methods showed a clinically noticeable agreement between these two tests.Conclusions: Since antibiotic resistance among Gram-negative bacilli has increased, enforcement of policy regarding proper antibiotic use is urgently needed in order to delay the development of resistance. Although it is widely accepted that E-test is more accurate in determining the resistance of microorganisms, our study showed that the Disc diffusion test will give the same results in most occasions and is therefore still considered useful in clinical practice.

Background: Ultrasound (US) has been used in neuroprotection after cerebral ischemia; however, its use is controversial. Application of US in combination with fibrinolytic agents may improve fibrinolytic effects. In this study the effects of US, alone or in combination with tissue plasminogen activator (tPA), on brain ischemic injury were examined and we studied whether US is protective in the brain injured by ischemia under normothermic conditions.Methods: We performed two studies. In the first study, rectal and brain temperatures were compared. In the second study, we studied whether US alone or in combination with tPA is neuroprotective in thromboembolic stroke. To induce focal cerebral ischemia, a clot was formed in a catheter.Once the clot had formed, the catheter was advanced 17 mm in the internal carotid artery until its tip was 1-2 mm away from the origin of the middle cerebral artery (MCA). The preformed clot in the catheter was then injected, and the catheter was removed. The wound was then closed and the infarction volume, edema and neurological deficits were measured after MCA occlusion.Results: The temperature in the brain was approximately 0.50 °C lower than the rectal temperature. In the control, US+low tPA, low tPA, US+high tPA and, high tPA groups, the infarct volume (%) was 34.56±4.16, 17.09±6.72, 21.25±7.8, 13.5±10.72 and 20.61±6.17 (mean ±SD) at 48 h after MCA occlusion, respectively. The results indicate that US alone reduces the infarct volume by 30% compared to that of the control group (P<0.05). US improved neurological deficits and reduced brain edema significantly (p<0.05).Conclusions: This study indicates that US appears to have a protective effect, alone and in combination with tPA, in an embolic model of stroke.

Background: As less invasive surgical procedures, such as laparoscopy, become more common, patients can go home soon after the surgery.However, some pain is accompanied by such procedures due to peritoneal stretching, diaphragmatic irritation, or, to a lesser extent, abdominal puncture. It is important to reduce the level of pain to the point that narcotics are not necessary. The administration of opioids for pain after abdominal surgeries is common. The receptors involved seem to be susceptible to blockade with low-dose local anesthesia, although this is subject to some controversy. In this study, we assess and compare the effectiveness of intraperitoneal Bupivacaine and Lidocaine in pain reduction after diagnostic gynecologic laparoscopy in infertility patients.Methods: In this randomized clinical trial, 150 patients admitted to Dr. Shariati Hospital for diagnostic gynecologic laparoscopy were entered into three randomized groups. Group B received Bupivacaine after the diagnostic laparoscopic procedure, group L received Lidocaine and group C, the control group, received a placebo after the surgery, all administered intraperi- toneally. Postsurgerical pain was assessed using the numeric visual analogue scale at 6 and 24 hours after surgery.Results: In group B, the pain scores at 6 and 24 hours after surgery were significantly less than those of group L. Conclusions: Administration of Bupivacaine after diagnostic gynecologic laparoscopic procedures is more effective in pain control than Lidocaine.The effect of this drug is temporary, yet it significantly decreases early postoperative pain, reducing the need for additional postoperative analgesics. Furthermore, the time at which patients can be discharged from the hospital is significantly reduced.

Background: Sudden sensorinueural hearing loss (SSNHL) is a baffling condition for patients, and its etiology, audiologic characteristics, prognostic factors, and treatment are still controversial.Methods: In this prospective study, we performed pure tone audiometry (PTA), impedance acoustics (IA), auditory brainstem responses (ABR), otoacoustic emissions (OAE), and transiently evoked otoacoustic emissions (TEOAE) before beginning treatment for 53 patients with SSNHL. We then entered each patient, randomly and alternately, in one of two treatment groups: oral steroids + acyclovir vs. intravenous urographin.Results: In 22 (41.5%) of the 53 patients (22 female, 31 male), we found negative or no signal to noise ratio and overall correlation in TEOAE.Furthermore, 26 cases (49%) had positive overall correlations less than 50%, and five cases (4.4%) had overall correlations >50%. Although 15 cases (28.3%) responded well, 20 cases (37.7%) showed only a partial response, and 18 cases (33.9%) had poor or no response to our treatment. The mean value for overall correlation in the three subgroups of patients (no response, partial response, and complete response) was -3.5% (±1/16%), + 11% (±1.99%), and +36.6% (±3.07%) respectively (P = 0.01). From 52 cases, 20 had no reproducible wave in ABR (38.5%), three cases had abnormal ABR with normal OAE, all of which responded completely to treatments. Thirteen cases had abnormal ABR and OAE, none of which responded to treatment, and six cases had normal ABR with abnormal OAE, which often responded to treatment.Conclusions: ABR and OAE may be useful in the diagnosis of SSNHL and determining the site of such lesions as ischemia or neuropathy. The overall correlation (and S/N ratio) in TEOAE is a valuable prognostic factor in SSNHL.

Background: Tetralogy of Fallot is the most common cyanotic congenital heart disease. The systolic and diastolic function in both ventricles is altered even after successful corrective surgery for this defect with a transannular patch. Pulmonary regurgitation, a common complication after this treatment, is usually well tolerated in childhood. The aim of this study was to assess the combined diastolic and systolic function of both ventricles using the Doppler-derived myocardial performance index (Tei index) in patients who underwent surgical repair of tetralogy of Fallot using a transannular patch.In this article we discuss the impact of pulmonary regurgitation on right ventricular function and clinical outcome, the role of echocardiographic imaging, and current management strategies for patients with pulmonary regurgitation after this treatment.Methods: Sixty eight patients with tetralogy Fallot were studied in Shahid Rajaie referral Cardiovascular Center during 2003-2005. The studied population, 36 male and 32 female with a mean age of 7.5±4 years and a history of corrective surgery for tetralogy of Fallot using a transannular patch. These patients were randomly selected and assessed by Doppler echocardiography.Results: Fifty-seven patients (84%) had mild to moderate pulmonary regurgitation, whereas 11 patients (16%) had severe pulmonary regurgitation. Right ventricular Tei index was significantly increased in patients with severe pulmonary regurgitation compared those with mild to moderate pulmonary regurgitation (0.54±0.18 vs 0.24±0.11, P<0.01). Left ventricular Tei index was increased in patients with severe pulmonary regurgitation compared those with mild to moderate pulmonary regurgitation (0.46±0.22 vs 0.32±0.14, P<0.05).Conclusions: The findings of this study suggest that pulmonary regurgitation is a serious complication after repair of tetralogy of Fallot with a transannular patch. Delaying surgery in such patients risks irreversible ventricular function.

Background: The changes in motor control after the use of a supportive belt can contribute to the understanding of its effects on performance. The aim of this study is to quantify motion pattern values relative to the spinal column during the use of a lumbosacral belt.Methods: For fifty healthy female volunteers, the range of motion, maximum isometric torque and changes of phase angle of maximum torque and velocity in two positions, standing and sitting, in two directions, flexion and extension, following the use of a lumbosacral belt were measured using an isoinertial dynamometer (Isostation B200) and compared.Results: Range of motion in both directions in both positions was reduced significantly (P<0.05). Significant reduction of maximum isometric torque was observed in flexion while sitting and in extension while standing and sitting (P<0.05). Phase angle of maximum torque and velocity also changed significantly in both directions and both positions (P<0.05).Conclusion: The lumbosacral belt can act in different ways to prevent injury.It reduces the forces applied to lumbar vertebra and, by changing the maximum torque and velocity phase angles at the onset of range of motion, provides greater stability for joints. Furthermore, the belt can reduce stress imposed on the posterior joints of the spine and limits several momentary forces at the onset of joint movement. Under these conditions, joint injuries can be reduced and prevent some of the mechanical stress that causes lumbar joint disease.

Background: The aim of this study was to compare the outcome of treatment for ovarian cancer patients who have been treated by gynecologist oncologists and patients who have been treated by general gynecologists or general surgeons.Methods: We enrolled in this cohort retrospective study all patients diagnosed with primary ovarian cancer in Vali-e-Asr Hospital, Tehran, Iran, between April 1999 and January 2005. A total 157 consecutive patients with ovarian cancer were available for analysis. Of these, 60 patients were treated by gynecologist oncologists and 95 by general gynecologists, and two patients were treated by general surgeons.Results: The number of patients who underwent optimal cytoreductive surgery (residual tumor <1 cm) was higher in the gynecologist oncologist group, than in the general gynecologist group (P<0.001). Repeated surgeries were required for a majority of patients in the general gynecologist group, while only a few patients in the gynecologist oncologist group needed a second operation (P<0.0001). The interval between the initial surgery and the beginning of chemotherapy was significantly longer in the gynecologist oncologist group compared to that of the general oncologist group (P=0.001). Overall survival and disease-free survival was considerably greater in the gynecologist oncologist group. Optimal cytoreductive surgery and stage of disease are prognostic factors in patients with ovarian cancer.We can therefore conclude that patients with ovarian cancer who are treated by gynecologist oncologists have a better outcome.Conclusions: We suggest that patients requiring cytoreductive surgery for ovarian cancer be referred to a gynecologist oncologist rather than having a less specialized physician care for such cases.

Background: This study aimed to assess the quality of life in vitiligo sufferers and its relationship with a number of variables such as age, gender, educational level, place of residence, marital status, disease duration, disease extension, visibility of lesions and skin phototype (SPT).Methods: In this study we evaluate the quality of life in patients with vitiligo attending Razi Hospital in July and August 2005. Permission from Professor Finlay was obtained to use the DLQI (Dermatology Life Quality Index) questionnaire to evaluate the quality of life. One hundred patients with at least one vitiligo patch (age range= 14–57) answered the questionnaire.Other survey questions about mentioned variables were also answered. Scoring was done according to Finlay`s guidelines. The higher the score, the greater the impairment of quality of life.Results: The mean DLQI score in our study was 8.16 (sd=5.423) with a minimum of 0 and a maximum of 28. There were statistically significant relationships between DLQI scores and marital status, skin phototype and disease extension independently, but not between DLQI scores and other variables. The mean DLQI score was significantly higher in married compared to single patients. In fact this difference was significant in women. Married women had a statistically higher score than single women while single and married men had no significant difference. Patients with Skin Phototype IV showed a higher DLQI score than other SPTs, which was statistically notable (p=0.000). The patients with more disease extension had higher score that was statistically significant (p=0.000).Conclusions: This study shows that vitiligo has a major impact on the quality of life and indicates specific groups that are most affected by the disease. Hence, dermatologists should pay attention to the psychologic effects of this cosmetic disease and try to decrease its extension and disfiguring effects by various treatment modalities.

Background: Magnesium Sulfate (MgSO4) has been used as a pharmacologic agent in different situations for many years in the treatment of tachyarrhythmias, myocardial ischemia, preeclampsia, and tocolysis among others. The analgesic effect of MgSO4 for postoperative pain has been used since the 1990s. Postoperative pain is one of the most common complications in the perioperative period and can result in serious consequences in different organs if left untreated. Inguinal herniorrhaphy is among the most common surgeries and is almost always accompanied by severe pain. The object of this study is to determine the effect of a pre-induction infusion of MgSO4 on the reduction of postsurgical pain after herniorrhaphy.Methods: This double-blind, randomized clinical trial included 105 ASA class I and class II herniorrhaphy patients at Shariati Hospital in years 2004 and 2005. For statistical analysis, the c2 and T tests were used. The patients were divided into three groups based on block randomization. Patients in the following groups received: Group A, 200 ml of normal saline infusion (placebo); Group B, 25 mg/kg MgSO4 in 200 ml of normal saline; Group C, 50 mg/kg MgSO4 in 200 ml of normal saline. All groups were infused twenty minutes before induction of anesthesia using identical methods and dosage in all three groups. Heart rate and mean arterial pressure (MAP) at pre- and postintubation and so at skin incision time were charted. Visual analog scale (VAS) pain score, nausea, vomiting and the amount of morphine used before recovery room discharge and in six, twelve and twenty-four hours after recovery discharge was recorded.Results: The average age for the different groups was as follows: Group A: 33.6, Group B: 37.37, Group C: 32.74. Nausea and vomiting between the case and control groups were not statistically different (60% vs. 71.4%, p=0.0499), nor was the amount of Morphine used. On recovery room discharge, the VAS scores were 8.1, 7.2, and 5.5 for the first, second and third groups, respectively (P<0.001). However, no statistical significance was found for the VAS scores six hours after recovery room discharge.Conclusion: The results in this study show that pre-induction with MgSO4 has no remarkable effect on decreasing postoperative pain or morphine use for inguinal herniorrhaphy.

Background: The object of this study was to determine the epidemiological characteristics of deliberate self-poisoning in adolescents referred to the only poisoning center in Tehran.Methods: In a cross-sectional study, all cases of acute poisoning at the Loghman Hakim Hospital from May to December 2003 were reviewed. Data for adolescents (13-19 years of age) were analyzed by SPSS for Windows, version 13 and STATA, version 8.Results: From a total of 9203 cases of deliberate self-poisoning, 28.5% were adolescents (2626 cases). The male/female ratio was 1/2.2. Approximately 87% were unmarried and 56% were students, while a total of 4859 different drugs/agents were used for self-poisoning (an average of 1.85 for each case).The majority of patients was from urban areas and had no history of attempted suicide. There was no difference between males and females regarding history of psychiatric and somatic disorders, though there was a significant difference in the average of age between male and female adolescents.Conclusions: Among adolescents, self-poisoning is more common in girls while the mean of age is younger in boys. Although the prevalence of psychiatric disorders in adolescents appears to be less than the general population, this may be related to differences in their situations or due to underestimation of their frequencies. Psychiatric care should be a necessary component of the care administered to adolescents who attempt suicide and must be based on the needs and basic assessment of the patient’s status.Research regarding the familial history of abuse, neglect, self-harm/ poisoning should be undertaken so that such social issues can be prioritized and addressed.

Background: The aim of this survey was to evaluate the prevalence of some perinatal complications in birth weight discordance (BWD) among twin pregnancies.Methods: In a descriptive analytical cross-sectional study, 490 twin neonates (245 twin pregnancies) born at Mirzakoochakkhan Hospital from 1999 to 2003 were evaluated. Maternal and neonatal data of each delivery were collected for BWD, gestational age, maternal age, parity, infant gender, neonatal death, neonatal septicemia, mode of delivery, hyperbilirubinemia, blood transfusion and duration of hospitalization.Results: The average age of the mothers was 26±4.78 years, of which 51.8% were nullipara. The average gestational age was 35.02±2.73 weeks, with 15.9% before 32 weeks of gestation. The neonatal death rate was 7.8%, the majority of which involved male neonates and multiparas. The average duration of hospitalization was 6.07±4.45 days, 8.5 days for those twins with BWD³20%, and longer (9.14 days) for neonates with mothers younger than 20 years old. Septicemia was most frequent (31.3%) in twins with BWD of 30-34%, as was hyperbilirubinemia requiring blood transfusion (25%). Hyperbilirubinemia was more common in neonates with mothers aged less than 20 years and more than 35 years.Conclusions: BWD in twins is a predictive factor for septicemia and hyperbilirubinemia requiring transfusion. Therefore, healthcare workers and hospital wards dealing with twins with BWD should be especially ready and equipped to provide the additional care needed for these patients.

Background: Psychosocial stressors and the quality of the support system are important factors in attempted suicide. This research has studied these stressors and the condition of the support system in suicide attempt cases in Karaj, Iran.Methods: This is a part of the Iranian section of the widest multisided study on suicide prevention (SUPRE-MISS) proposed and directed by the WHO in eight countries, including Iran. Here we present data obtained from 632 suicide attempters presenting in emergency centers over a period of ten months.Results: According to the time lapse from the stressor to the suicide attempt, proximal stressors are considered to be precipitating while distal stressors are considered to be perpetuating factors. Although, family conflicts were found to increase the risk of suicide one year after the conflict, conflicts with family (25%) and spouse (35%) were the most frequent stressors one month before the attempt, acting as proximal factors. Conflict with spouse was more prominent for people who had been married less than seven years. Conflict with family was the most important stressors for 15-25 year-old attempters. Though it is not clear which areas of conflict are more crucial in a suicide attempt, especially considering gender differences, educational and financial problems were more prominent one year before the suicide attempt. The support system was more crucial for female attempters: Although they received more practical support than males, females complained more of deficiencies in support.Conclusions: The roles of different psychological stressors in attempted suicide vary according to the time lapse from the stressor until the suicide. Family and marital conflicts can be precipitating and perpetuating factors, while educational and financial problems appear to be perpetuating factors. Family is considered to be an important support system for a great number of attempted suicide cases, especially since it offers practical support. Support systems are crucial in preventive programs for suicide, especially among women.

Background: Following socioeconomic development, the amount of physical inactivity among a given population has typically increased.Physical inactivity is a risk factor for cardiovascular disease. The purpose of this study is to measure the prevalence of physical inactivity among the urban adult population of Yazd, Iran.Methods: This cross-sectional study was carried out on an urban population of 1500 employed persons over the age of 20 years via cluster sampling. We use the IPAQ (International Physical Activity Questionnaire) to evaluate physical activity levels. We evaluated the subjects according to their level of fitness, attitude toward physical activity and physical activity levels.Results: According to the fitness information provided by the participants, 2.1% were weak, 10% were moderately fit, 39.9% were fit, and 48% very fit.Regarding the attitudes of the participants toward physical activity, 1% was unfavorable, 32.4% were partly favorable, and 67.7% were favorable.Concerning the intensity of physical activity, 67.3% persons were inactive, 15% were sufficiently active, and 17.7% were highly active. After adjustment for age, 65.8% were inactive, 13.8% were sufficiently active, and 19.8% were highly active. According to gender, 81.6% of men were inactive, as were 54.4% of women. Inactivity according to age was as follows: 57.8% of the 20-24 year old, 66.9% of those aged 30-44 years, 70.4% of the 45-59 year olds, and 68.4% of those over the age of 60. Furthermore, physical inactivity was more prevalent in the higher socioeco-nomic group.Conclusion: The level of physical activity in urban population of Yazd is low. High risk is associated with employment, retirement, high socioeconomic class and higher levels of education.

Background: Neonatal cholestasis is an important disease of the liver and biliary ducts in infancy. In neglected cases, the disease has irreversible complications. Idiopathic neonatal hepatitis, biliary atresia, TORCH infections and choledochal cyst are important causes of neonatal cholestasis.The aim of this study was to determine the causes of cholestasis among neonates admitted to the Children’s Medical Center of Tehran University.Methods: This is a descriptive, retrospective study including 109 patients diagnosed with obstructive icterus, from 1994 to 2001. With data collected from hospital records, the inclusion criteria consisted of cholestasis with a conjugated bilirubin of up to 2 mg/dl from at least two laboratory samples (20% of total bilirubin). The definitive diagnosis of cholestasis included the laboratory investigations, which were in the patients’ hospital records and documented by their physicians.Results: Our patients (63 males and 46 females) had a mean age of 40±6 days. The most common clinical findings were icterus, acholic stool and hepatosplenomegaly. The most common cause of cholestasis was idiopathic neonatal hepatitis followed by biliary atresia, which together caused 75% of all the cases in this study.Conclusions: In our general population, the most common causes of neonatal cholestasis are hepatitis and biliary atresia. In other investigations, the etiology of neonatal cholestasis was different than that of this study.Because the number of different disorders presenting with cholestasis may be greater during the neonatal stage than at any other time of life, early diagnosis and treatment is very important for improved prognosis.

Background: People vary greatly in their response to painful stimuli, from those with a low pain threshold to those with indifference to pain. However, insensitivity to pain is a rare disorder, characterized by the lack of usual subjective and objective responses to noxious stimuli. Patients who have congenital indifference to pain sustain painless injuries beginning in infancy, but have sensory responses that are otherwise normal on examination. Perception of passive movement, joint position, and vibration is normal in these patients, as are tactile thresholds and light touch perception.Case report: A twelve-year-old boy was admitted to the hospital for a painless deformity, degeneration in both knees and a neglected femoral neck fracture that was inappropriately painless. Further examination revealed normal sensory responses, perception of passive movement, joint position, vibration tactile thresholds and light touch perception. Spinal cord and brain MRI were normal as was the electromyography and nerve conduction velocity (EMG/NCV) examination. There was no positive family history for this disorder.Conclusion: The deficits present in the different pain insensitivity syndromes provide insight into the complex anatomical and physiological nature of pain perception. Reports on pain asymbolia, in which pain is perceived but does not cause suffering, and related cortical conditions illustrate that there can be losses that independently involve either the sensory-discriminative component or the affective-motivational component of pain perception, thus highlighting their different anatomical localization.The paucity of experience with this entity and the resultant diagnostic problems, the severity of the associated disabling arthropathy and underscore the importance of this case report of indifference to pain.