Tehran University Medical Journal
Year:2008 | Volume:66 | Issue:6|Papers Count:16

Background: Relaxation of the corpus cavernosum plays an important role in penile erection. Previous studies have suggested that nitric oxide (NO) appears to be the most important relaxant involved in the erection process. The aim of the present study was to evaluate the effect of cholestasis in nNOS and eNOS activity of corpus cavernosum.Methods: forty-two adult male Sprague-Dawley rats were divided equally into seven groups: control, sham operated, 2-, 7-, and 14-day bile duct-ligated animals, 7-day bile ductligated chronically treated with L-NAME (3 mg/kg/day, i.p.) and 7-day bile duct-ligated animals chronically treated with Naltrexone (20 mg/kg/day, i.p.). The animals in each group were killed and the cavernosal tissues analyzed histologically by light and transmission electron microscopy, with NOS activity detected on NANC nerves and endothelium using an NADPH-diaphorase staining technique.Results: our results showed that NADPH diaphorase staining in corporal NANC nerves and endothelium of sham-operated and control group had equal intensity. The staining was more intense in 2-day cholestatic rats than in control group, the staining intensity increased in 7-, and 14-day groups too. There were no significant differences between control group and 7-day cholestatic rats that had been treated chronically with L-NAME or Naltrexone.Conclusions: These results state that in corpus cavernosum of cholestatic rats there is a time-dependent increase in NOS activity of the corporal NANC nerves and endothelium.Inhibition of nitric oxide and endogenous opioids by L-NAME or Naltrexone during cholestasis may play a key role in preventing the adverse effects of cholestasis.

Background: Antimicrobial resistance is a growing threat among hospitalized patients.The mortality and morbidity due to antimicrobial-resistant bacteria are severe.Extended-spectrum betalactamase (ESBL) Enterobacteriaceae are especially alarming because they are capable of hydrolyzing third-generation cephalosporins and monobactams. Thus, antimicrobial treatment for infections due to these resistant pathogens will remain under critical scrutiny.Methods: Gram-negative bacterial pathogens were collected from selected centers and were identified by biochemical methods. Of these, 392 E. coli isolates were tested for antimicrobial susceptibility to 17 antibiotics by the disk agar diffusion (DAD) method.The phenotypes of ESBLs were determined using the disk diffusion synergy test (DDST) as recommended by the interpretative guidelines of the NCCLS.Results: Most of the bacterial resistance in this study was against carbenicillin (78.06%), trimethoprim- sulfamethoxazole (63.21%), and piperacillin (61.98%), with very low resistance to imipenem (0.76%). More than 50% of the isolates were simultaneously resistant to the three antibiotics, carbenicillin, trimethoprimsulfamethoxazole and piperacillin. In total, 99 E. coli isolates (25.25%) were ESBL positive.Conclusions: Organisms expressing ESBLs in this study were widely distributed, often possessing the multidrug resistance phenotype. Limiting the use of broad-spectrum cephalosporins is recommended to control this high rate of ESBL expression.

Background: The components of the classical complement pathway play an important role in the pathogenesis of systemic lupus erythematosus (SLE) and are reportedly useful biomarkers of disease activity. In this study, we evaluate disease activity, complement function (total hemolytic complement, CH50) and complement protein levels (C3, C4, C3d, C4d, SC5b-9), comparing the results of patients with active disease versus those with inactive disease.Methods: This cross-sectional study included 78 hospitalized women with SLE, 24 of whom were in the active group, with SLE disease activity indexes (SLEDAI.2K) of >6, and 54 in the inactive group, with SLEDAI.2K of £6. Serum CH50 was measured using a red blood cell hemolytic assay. C3 and C4 levels were determined by nephlometry and plasma levels of C3d, C4d, SC5b-9 by ELISA. The data were statistically analyzed using SPSS.Results: The mean (±standard error) C4d levels of the inactive group were significantly higher than those of the active group (23.39±1.1mg/ml and 16.9±1.6mg/ml, respectively; p=0.003). There was also a significant correlation between C3 and C4 levels (p=0.807). The mean values of the other proteins (C3, C4, CH50, SC5b-9, and C3d circulating immune complex concentrations) were not significantly different between the inactive groups vs. the active group: 89.35±6.8 vs. 85.54±7.6mg/dl, 18.33±2.3 vs.20.45±2.4mg/dl, 149.03±4.3 vs. 157±4.3U, 1414.4±114.94 vs. 1471.1±216.9ng/ml, 9.43±0.96 vs. 13.31±3.16mgEq/ml, respectively (p>0.05).Conclusions: According to our results, C4d levels may be used as a biomarker of disease activity. The significant correlation between C3 and C4 may confirm the activity of the classical pathway in SLE patients.

Background: The typical features of eccentric exercise-induced muscle damage are delayed-onset muscle soreness (DOMS) and prolonged loss of muscle strength. It has been shown that passive warmth is effective in reducing muscle injury. Due to the interaction of different systems in vivo, we used isolated perfuse medial gastrocnemius skeletal muscle to study the direct effect of temperature on the eccentric contraction-induced force loss.Methods: After femoral artery cannulation of a rat, the left medial gastrocnemius muscle was separated and then the entire lower limb was transferred into a prewarmed (35oC) chamber. With the chamber temperature at 31, 35 and 39oC before and during eccentric contraction. Isometric force loss was measured after 15 eccentric contractions (N=7-9).Results: Maximum contraction force reduction has been used as an index for eccentric contraction-induced force loss. In this study eccentric contraction caused a significant reduction in maximum isometric tension (p<0.01), but no significant difference was seen in isometric force loss at 31oC and 39oC compared with that at 35oC.Conclusions: Our results suggest that temperature changes before or during eccentric contractions have no effect on eccentric contraction-induced force loss.

Background: The insertion of endotracheal tube is essential for most surgical operations, mechanically ventilated patient in ICU wards, During cardiopulmonary resuscitation and so for transport of patients. The aim of this study was determination of airway related distances in Iranian patients.Methods: In a cross- sectional study during year 2007 in Imam Khomeini university Hospital a total of 75 ASA class I and II patients who were admitted to pulmonary ward evaluated for determination of incisor-vocal cord and incisor- carina distances. The nasal nare- vocal cord distance was determined too.Results: A total of 71 patients, 45(63%) male and 26(36.6%) female were evaluated. The Incisor-vocal cord distance in males and females was 16.83±0.75mm against 15.04±1.12mm (P=0.03). The difference of nare-vocal cords and Incisor- vocal cord distances was 2-3Cm.Conclusions: There was direct association between height and tracheal length in the study patients. The tracheal length (suitable insertion depth) in our patients was different from the recommendations (23 & 21 Cm for men and women) for non- Iranian, 25.9 versus 22.6 for Iranian men and women respectively. The difference of nasal nare-vocal cord and upper incisor-vocal cord distances in our patients was 2-3 cm, the lower range of accepted or reported one. We offer to do another experience with larger study group to apply the data to Iranian population.

Background: Post-tonsillectomy pain is often severe and usually prevents patients from routine eating and drinking. A new option for reducing postoperative pain is "preemptive analgesia", the pre-, intra- or post-operative administration of analgesic agents. Ketamine, an N-methyl D-aspartate receptor antagonist, has recently received attention for this aim. Herein, we study the effect of submucosal injection of ketamine in the tonsillar bed for the reduction of post-tonsillectomy pain.Methods: In this double-blind clinical trial, three groups of patients underwent infiltration of 0.5mg/kg ketamine, 1mg/kg ketamine or normal saline in their tonsillar bed. Age, sex and weight of patients, duration of surgery, systolic and diastolic blood pressure (before and after surgery), volume of blood loss, reoccurrence of bleeding, time to initiation of oral intake, nausea, vomiting, pain score and dysphasia were recorded in information sheet. Data analysis was performed by one-way ANOVA and chi squared tests, with significance at a P value of <0.5.Results: There is no significant difference between the three groups with regard to age, sex, weight, duration of surgery, blood pressure (before surgery), volume of blood loss, nausea and vomiting. However, for the ketamine groups, pain score, dysphasia, need for opioid administration and time to initiation of oral intake is significantly lower (P<0.00). Reoccurrence of bleeding was observed in one patient in the lowerdose ketamine group, which is not statistically significant. The effectiveness of the two doses of ketamine is similar, with no statistical difference between the two groups (P=0.84).Conclusions: This study demonstrated that a submucosal injection of ketamine into the tonsillar bed preoperatively is a safe option for reducing post-tonsillectomy pain, dysphasia, need for opioid and time to initiation of oral intake, without increasing the risk of excessive bleeding, reoccurrence of bleeding, nausea and vomiting.

Background: Various imaging tests as well as different scoring systems based on symptoms, signs and laboratory findings are commonly used to improve diagnostic accuracy in acute appendicitis. The aim of this study was to compare the diagnostic accuracy of MANTRELS scoring system (designed by Alfredo Alvarado), which is based on symptoms, signs and laboratory results, with sonographic findings.Methods: In this prospective observational study, 106 patients with acute abdomen suspicious of acute appendicitis at Sina Hospital, Isfahan, Iran, were studied from March 2004 to February 2006.Results: The disease was most common in patients aged 20-29 years, with male predominance. All patients had appendectomies. One hundred patients had acute appendicitis and six had negative appendectomy. Among the patients with acute appendicitis, 88% had an Alvarado score of ³6 and 12% had a score of £5. Among the six patients with negative appendectomy, 66.7% had Alvarado scores of £5 and 33.3% had scores of ³6, which was significantly different (p=0.005). The sonographic results were abnormal in 71.9% of patients with acute appendicitis and in 25% of patients with negative appendectomy, which was not significantly different (p=0.08). In our study, the diagnostic accuracy of an Alvarado score ³6 was 88% and that of the sonographic results was 71.9% for acute appendicitis. If the Alvarado score ³6 and abnormal sonographic findings are considered together, the diagnostic accuracy improves to 97.2%.Conclusions: This study showed that clinical findings and laboratory results are more important than sonographic findings alone.

Background: Identification of the best screening measure for the risk of chronic disease is essential. This study aims to comparatively assess the ability of waist circumference (WC), body mass index (BMI), waist-to-hip ratio (WHpR) and waist-toheight ratio (WHtR) to predict hypertension among women in Tehran.Methods: In this population-based cross-sectional study, a representative sample of 926 adult women aged 40-60 years were selected using a multi-stage cluster random sampling method. Demographic data were collected and anthropometric measures including weight, height, WC and hip circumference were assessed according to a standard protocol. BMI was calculated as weight in kilograms divided by the square of the height in meters. Cut-off points of 80 cm for waist circumference, 25kg/m2 for BMI, 0.87 for WHpR and 0.5 for WHtR were used. Blood pressure was measured and hypertension defined according to the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 6).Results: In this study, the mean age of women is 48.7±5.6 years. Mean WC, BMI, WHpR and WHtR are 85.1±9.9cm, 29.4±4.6kg/m2, 0.82±0.06 and 0.55±0.06, respectively.Although all anthropometric indicators have a significant association to hypertension, WC has the highest sensitivity, specificity and accuracy in predicting hypertension in both age groups of 40-50 and 50-60 years. This measure also has the greatest area under the ROC curve compared to other anthropometric measures: 0.70(0.69-0.71) for WC, 0.65(0.62-0.67) for BMI, 0.62(0.60-0.64) for WHpR and 0.65(0.63-0.67) for WHtR.Conclusions: Among this group of women in Tehran, waist circumference is the best screening measure for hypertension. However, no data are available regarding similar patients who have emigrated; thus similar studies on Iranian women who have emigrated are recommended.

Background: Hypopharyngeal cancer usually presents with cervical mass, hoarseness, radiated otalgia, and dysphagea in the advanced stages. Radical surgery followed by radiotherapy plays an important role in the treatment of patients with hypopharyngeal cancer. However, there is no general consensus as to which is the best method of reconstruction after surgical resection. The aim of this study was to evaluate the complications of pectoralis major myocutaneous flap (PMMF) and gastric pull-up (GPU) techniques to reconstruct a circumferential defect after laryngopharyngoesophagectomy.Methods: We retrospectively reviewed the records of 64 patients who underwent radical surgery and reconstruction with either PMMF or GPU technique. Demographic characteristics, tumor location, proximal margin involvement, history of radiotherapy, presence of lymphadenopathy, cervical dissection, and postoperative complications such as fistula, anastomotic site stenosis, swallowing dysfunction, and stoma stenosis were compared between the two groups. Postoperative complications of the reconstruction methods were compared.Results: A total of 64 patients, 43(67%) in GPU group and 21(33%) in PMMF group, were studied. The groups did not differ in demographic characteristics. The locations of the tumoral lesions were in larynx (n=7), proximal esophagus (n=5), posterior cricoid (n=5), pyriformis sinus (n=7), posterior wall (n=7), and miscellaneous (n=41).Six patients (6.3%) had proximal margin involvement, 19 patients (29.9%) had history of radiotherapy, 26 cases (40.6%) had lymphadenopathy, and 49 cases (76.5%) had cervical dissection. There was no significant difference between the two groups regarding stenosis or swallowing dysfunction rates, but fistula was seen lower following GPU compared with PMMF (p<0.001).Conclusions: The GPU technique results in similar functional stenosis or swallowing dysfunction rates, but lower fistula compared with PMMF reconstruction.

Background: Giardia lamblia is one of the most prevalent protozoa infections of the human small intestine. Although anyone can be infected by Giardia, women and children are more susceptible. Giardia infection can cause malnutrition, diarrhea and indigestion of fat. In this study, the effect of breast-feeding on the prevalence of Giardia among children is investigated.Methods: A total of 482 children, aged 6 to 24 months, from the urban areas of Semnan, Damghan and Garmsar in Iran, were enrolled in this survey. Each mother underwent an interview and filled out a questionnaire that included mother’s age, family size, birth order of the child, age and sex of the child and type of milk consumed, among other variables. Then, each mother was given a sample container with 30cc of phenol alcohol formaldehyde (PAF) and an applicator for sampling her child’s stool. Each mother was trained to consecutively sample her child’s stool for three days, to put the stool into the provided container using the applicator and to shake it until the sample and liquid appeared homogenous. The sample was examined using the direct method, using formalin-ether and thionine. Data was analyzed using the c2 tests and logistic regression using SPSS version 11.5.Results: The mean age of the children was 13.6(±5.6) months. Of these children, 45.6% were girls. The prevalence of G. lamblia infection was 8.5%. There was a significant relationship between Giardia and the age of the child, education level of the mother and type of milk the child consumed (p<0.05), such that children who had not consumed their mothers' milk were more likely to be infected compared to those who had been breast fed (OR=2.38, 95% CI: 1.13-5.03, P=0.023).Conclusions: Results show that breast-feeding is a safer method of feeding with regard to Giardia infection. Therefore, mothers should be educated to breast-feed their children and not use other types of milk or milk substitutes. This important issue must be considered by policy makers for education and subsidy programs.

Background: Macrosomia is a term applied to newborns with a birth weight of >4000g. This condition leads to several maternal and fetal complications including maternal traumas as well as newborn injury. This study was designed to evaluate the risk factors of macrosomia among Iranian women.Methods: This cross-sectional study performed between July 2001 and July 2002, included 2000 term deliveries involving newborns with birth weights of >2500g. The records of 77 mothers of live born infants weighing >4000g were compared to those of the control group (231 women). Stillborn and neonates who were <2500g were excluded from the study.Results: Among the 2000 deliveries performed in Imam Hospital, 77(3.8%) of the newborns weighed >4000g and 12(0.6%) weighed >4500g. The mean age of the mothers, maternal BMI, history of diabetes mellitus, multiparity, fetal sex and underling maternal disease were found to be associated with increase risk of fetal macrosomia. There was no significant relationship between prolonged gestation, weight gain more than 16kg during pregnancy and past history of macrosomic delivery and macrosomia.Conclusions: It is possible to prevent macrosomia by weight and diabetes control before the decision to become pregnant. To prevent pregnancy among multipara mothers aged >35 years old, highly protective contraceptive methods should be used.Furthermore, if a mother is diagnosed with a macrosomic fetus by sonography or other imaging methods, more care should be taken during the delivery to decrease the risk of fetal injury, such as asphyxia and brachial plexus palsy.

Background: Stromal tumors of the gastrointestinal tract (GISTs) are uncommon and the cell of origin is actually mesenchymal. Stemming from smooth muscle, 90% of GISTs, or leiomyomas, are found in the lower two thirds of the esophagus. Typically solitary, multiple tumors (leiomyomatosis) are occasionally reported. Remaining intramural during their growth, most of their bulk protrudes toward the esophageal outer wall, with a freely-movable, normal-looking overlying mucosa. In this study, we report a rare case of esophageal leiomyomatosis treated by esophagectomy.Case Report: A 70-year-old man presented with discomfort upon swallowing, dysphagia, nausea, belching and weight loss. After barium swallow, only dilatation of the esophagus from the retained food and saliva was seen. CT scan revealed a 10-cm dilatation of the thoracic esophagus. An endoscopy and upper GI series was performed, but no pathology was found. Esophageal manometry and pH monitoring for gastroesophageal reflux were normal. Upon endoscopic ultrasonography, a thickening of the esophageal wall was identified 20-30 cm from the dental arch. The patient was diagnosed with a GIST, referred to surgeon and a transhiatal esophagectomy was performed. The patient was discharged from the hospital in good condition and has had no problem during the one-year period of follow up.

Background: The prevalence of Rh alloimmunization has decreased following the use of anti-D immunoglobulin. With serial amniocentesis, Doppler sonography of the middle cerebral artery and treatment of anemia with intrauterine blood transfusion, perinatal mortality has declined. However, Rh alloimmunization in twin pregnancies poses a diagnostic and therapeutic challenge.Case report: We are reporting, for the first time in Iran, the successful treatment of severe Rh alloimmunization in a dichorionic- diamnionic twin pregnancy leading to the live births of both neonates. Before treatment, the fetal hemoglobin levels were 3.1g/dl and 3.9g/dl, with ascites in both fetuses. The fetuses were treated with several IUTs.Results: After treatment, the neonates were delivered, weighing 2200 and 2300g, with good Apgar scores, at a gestational age of 34 weeks.Conclusion: 10% of population in Iran is Rh-negative, although Prophylaxis for Rh alloimmunization is universal, as other part of the world it cannot irrigated. For the best management of these cases, we need a well-equipped referral center.