Tehran University Medical Journal
Year:2005 | Volume:62 | Issue:11|Papers Count:16

Background: Rupture of liver is a rare and life threatening pregnancy complication. This important accident is more common during preeclampcia and HELLP syndrome. Also it is reported in old multiparous. Hemorrhagic shock is usually the commonest symptom and sign. Maternal and fetal mortality rate is more than 50%. Case: A 39, year old gravid 9 para 8 woman presented to the emergency room with abdominal pain and hypotension, anemia, fetal distress. Urgent laparatomy was planned, the uterus was intact and gross hemorrhage was in the pelvic and abdominal cavity. The fetus was delivered by cesarean section and the exploration proved 8-cm rupture in the right lobe of liver. Both mother and fetus saved in this dangerous complication. Conclusion: Liver rupture should be considered when there occur pain in the upper part of the abdomen and signs of hemorrhagic shock, even in the case of an uncomplicated pregnancy.

Background: Hemolytic uremic syndrome is defined as microangiopathic hemolytic anemia, thrombocytopenia and variable levels of renal failure. This syndrome is the most common cause of acute renal failure in early childhood. Several studies analyzing prognostic indicators have shown variable results with respect to age, prodrome, anuria, hypertension, proteinuria and central nervous system involvement. The purpose of this study was to assess. the prognostic significance of certain indicators in the outcome of the hemolytic uremic syndrome. Materials and Methods: In this study 80 patients with hemolytic uremic syndrome (HUS) from 1982 to 2002 which were admitted to the Children"s Hospital Medical Center were investigated through a Descriptive Retrospective case series (DRCS) study. The patients were divided into five prognostic categories as follows: group A, CrCI >75 ml/min group B, CrCI >75 ml/min/ 1.73m2 with proteinuria, hypertension or both, group C, 10 ml/min < CrCI <75 ml/min , group D, CrCl < 10 ml/min, group E, Death during acute phase of illness. Results: There were 41 boys and 39 girls. The mean age of the patients at presentation was 38.6 months (range 2 to 144 months). Out of28 children (20 girls, 8 boys) died during the acute phase of the illness (18 as a result of their central nervous system complications, 5 cardiovascular (CV) disturbances, 1 septicemia and 4 unknown). Diarrhea (+) HUS was present in 61 (76.3%) patients (11 with acute watery diarrhea and 50 with a history of bloody diarrhea) and 19 (23.1%) with a recent history of upper respiratory tract infection. In the first 3 months after onset (acute phase) 86% of all children needed dialysis therapy, 5% had creatinine clearance (CrCl) > 75 ml/min/ 1.73 m2, 64.6% had CrCl between 10 ml/min/ 1.73 m2 and 75 m1/min/ l.73 m2, and 30.4% had CrCl < 10 ml/min/ 1.73m2. The mortality rate in our group of children was 35%. It was significantly higher in female than- male (71% versus 28.6% p<0.05). The rate of CrCl below 10 ml/min was significantly lower in patients under 4 years old (p=0.05). There was a positive correlation between CrCl bellow 75 ml/min/ 1.73m2 and major neurological symptoms or death than children with (CrCl) > 75 ml/min/ 1.73m2 (p<0.05). In those children with CrCl < 10 ml/min/ 1.73 m2, there was also a higher incidence of hypertension than children with CrCl; over 10 ml/min/ 1.73 m2 (p<0.05). Conclusion: HUS has higher mortality. The immediate outcome was significantly poor in patients with either occurrence of major neurological signs or cardiovascular (CV) disturbances on admission, age over 4 years old, hypertension and female gender were also predictors of a worse prognosis.

Background: Myocardial infarction is one of the most important causes of death in the world. Early identification and confirmation of acute myocardial infarction (AMI) is essential for correct patient care and disposition decisions. Measurement of blood myoglobin (Mb) is known to be a sensitive method in this regard. During myocardial infarction, blood Mb increases in blood earlier than CK and also returns to the normal concentration more rapidly. It seems that the release of the Mb from myocardium is due to irreversibly damaged or necrotic tissues. Here we report a study on the isolation of Mb from sheep and rat cardiac muscles. Materials and Methods: Mb was isolated from sheep heart by homogenizing the cardiac muscle in 70% - saturated ammonium sulfate, followed by chromatography on a column containing carboxymethyl (CM) - sephadex. Two major isoforms of Mb were separated and distinguished by their different patterns seen by electrophoresis on polyacrylamide gel (SDS- PAGE). Both isoforms were identical in size when examined by gel filtration chromatography but differed slightly when analyzed by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate. The MW of isoforms were 14500 Da and 17000 Da respectively. We also isolated Mb from rat heart (the same method) but only one isoform (band) with MW of 14500 Da was distinguished. Results & Conclusion: We found that the isolation procedure originally designed for sperm whale Mb can be equally useful for isolating Mb from sheep heart. Results by both gel filtration chromatography and electrophoresis indicated the absence of major contaminants in our final Mb preparations so it can be used as a standard. The identification of two major isoforms of Mb suggests various research possibilities. The different immunoreactivities of two isoforms may provide the potential to prepare monospecific polyclonal or specific monoclonal antibodies for the development of a sensitive and specific immunoassay. In many respects, the isoforms of Mb are similar to various isoenzymes. Various tissues may contain different isoforms or different proportions of the two isoforms, and this may be potentially useful in differentiating between different tissue injuries; e.g., cardiac injuries from skeletal muscles damages. Determination of Mb isoforms may also provide a better diagnosis for various muscle diseases.

Background: Along with the development of medical sciences, new methods of treatment are introduced. One of these new methods in ENTa field is FESSb. It is more effective than any other surgical procedures and has less postoperative complications. It also shortens the duration of hospital stay. Because of the importance of endoscopic surgery in diagnosis and treatment of nasal and sinus diseases, we assessed both the results of such surgeries and the degree of the patients" satisfaction of the procedure. This retrospective study was performed on the patients who underwent FESS in Imam Khomeini Hospital of TUMSc (2002 Sep.). Material and methods: In this study several variables were investigated. These variables were: identifying data, symptoms and signs on admission, duration of disease before endoscopic surgery, predisposing factors, surgical procedures, postoperative complications and the patient"s satisfaction of clinical improvements after surgery. In order to assess the degree of patients" satisfaction of , their improvements, a one-year follow-up of the patients was performed. In this follow-up all the patients were examined; complete improvement and the consequent satisfaction of the patient as well as incomplete improvement and the patient"s complaint of remaining symptoms were all considered. Results: Only 70 of the 93 records were statistically accepted and assessed. The results are as follows: - Complete recovery: 66% of the patients - Relative recovery: 27.50% of the patients - No change in the symptoms on admission: 6.50% of the patients. It should also be added that in none of the patients the symptoms on admission was worsened. Conclusion: Endoscopic sinus surgery is more effective than any other surgical procedures, has less postoperative complications, and shortens the duration of hospital stay. So it is recommended that the equipments be provided for the clinical and university centers so that this useful treatment procedure can be improved and applied vastly more than before.

Background: Numerous studies in Europe have documented a high prevalence of Celiac disease in children with type I diabetes mellitus (IDDM). This study was undertaken to estimate the prevalence of celiac disease in children with IDDM in the children"s Hospital Medical Center (2000-2002). Materials and Methods: 35 patients with IDDM were screened, using immune globulin IgA antiendomysium antibody. When EMA produced positive finding patients, referred to were done a duodenal biopsy. Results: 3 patients (8.57%) positive for IgA-EMA. These patients underwent intestinal biopsy. Changes consistent with celiac disease were documented in 2 patients. Histologic findings ranged from focal to total villous atrophy (March I-III). Conclusion: there was a high prevalence of positivity to EMA in children with IDDM. EMA was a sensitive screening test. The prevalence of celiac disease in children with IDDM in the both North America and Europe screening with EMA for all children with IDDM in recommended, even if there are no gastrointestinal symptoms.

The Gluteus Maximus Myocutaneous Island flap is a useful, safe and versatile flap for the repair of sacral defects. This flap providing adequate muscle and subcutaneous tissue padding over the sacral defect. In ambulatory patients this flap has shown long-term stability, as well as improved cosmetic appearance, and preservation of muscle function that is very important in these patients. It is now our recommended procedure of choice for the surgical treatment of this type of defects.

Background: Ovarian ,cancers are some of the most common and fatal gynecological malignancies in all around the world. Identifying the various characteristics of the patients suffering from these masses can help the physicians in determining the high risk groups and assessment of the sonographic findings can help them in anticipating the malignancy risk of these masses. Materials and Methods: Demographic features of 159 patients with ovarian masses in addition to sonographic features of them are analysed in this study and according to them a scoring system is suggested to differentiate between benign and malignant masses. This scoring system has been determined according to abdominal sonography and age and gravidity of the patients. Results: Totally 14.5% (23 patients) of the masses were benign and 85.5% (136 patients) were malignant. Among the malignant types epithelial masses consisted 70.6% (96 ones) of the cases. The age mean in epithelial types was the most (51.68 years standard deviation [SD] ±13.51-18.79 years old) and in the germ cell ones was the least (21.61 years - SD±16.41-12 to 67) the epithelial masses were more in fifth sixth and seventh decades of life while the germ cell ones were more in second and third. The benign types had more frequency in the third to sixth decades of life. In total 5.81 % (5 cases) of all the patients and 10% (5 cases) of the ones with epithelial masses had positive familial history of ovarian and breast cancers and only one patient (0.7%) had positive past medical history of breast cancer. In sonographic aspect the epithelial tumors were mostly mixed (53.2%-50 cases) or cystic (43.6%-41 cases) and with septum (71.9%-69 cases). The germ cell types were predominantly solid (78.6%-19 patients) and the benign ones were mostly mixed (52.2%- 12 patients) and cystic (47.8%-11 patients) and without septum (82.6%- 19 patients), the benign masses had the highest mean of diameter (98.77 mm, SD±35.39-42 to 180 mm) and the epithelial ones had the lowest (74.8 mm, SD±32.78- 11 to 200 mm). Eventually, using these information a scoring system is described with 93.55% (95% confidence interval (Cl) 88.6% to 98.5%) sensitivity and 77.77% specifity (95% Cl 73.65% to 81.89%). Conclusion: Regarding to this system we can assume the masses which take 9 points or more as malignant ones, using age, gravidity, size of the tumor, echogenisity and presence or absence of septum.

Background: Routine paraclinic evaluation of preoperative patients tends to cause unnecessary costs, extra ri5k to the patients, inefficient operating room schedules and extra medicolegal risk. Furthermore, it seldom affects clinicians preoperative evaluation and decision making process for healthy patients. Numerous studies have shown that about 60% of these will not be performed if they are ordered according to recognizable indications based on history and physical examinations unfortunately the "indication based" method can not replace to "routine" method due to difficulty and complexity to performing. Materials and Methods: We reviewed records of 1700 patients on a retrospective descriptive study in Sina Hospital from September 2000 to the end of September 2001. These patients had undergone general surgical procedures. and were categorized as American society of anesthesiologists classification I or II. Results of complete blood count, fasting blood sugar, blood urea nitrogen, serum creatinin, sodium, potassium, chest X-ray, electrocardiogram and urinalysis were compared between patients under 40 years of age (n=894) and patients aged 40 and over (n=806). Results: Among 4935 tests performed in patients under 40 years of age, only 1004 (20.3%) were indicated, and treatment plan was not altered due to the results of routine tests in any case. In the other group, patients aged 40 and over, 6300 tests were performed, from which 3361 (53.3%) were indicated and treatment plans of 5 patients were influenced by the results of routine tests. Conclusion: Routine preoperative paraclinical tests is not cost effective method, otherwise the "indication based" also is difficult and complex method. We offer routine preoperative paraclinical tests only in patients over 40 years to combine ease of "routine" with a great reduction in medical costs and no adverse affect to patient care.

Background: The term preconditioning refers to the paradoxical phenomenon in which pretreatment with a potential noxious stress-stimulus can increase cellular tolerance to subsequent noxious stress-stimuli. Ischemic injury to the kidney is associated with high mortality. Improving the ability of this organ to tolerate ischemic injury is important and may be achieved by repetitive short periods of ischemia and reperfusion. In previous study, we showed that prior induction of brief periods of ischemia-reperfusion (IR) by clamping the right renal artery prevents reduction in vitamin E levels during subsequent renal IR. In the present study, we investigated whether this model of ischemic preconditioning (IPC) could improve renal function and structure in subsequent IR. Renal tissues were evaluated histologically and serum BUN & creatinine as renal functional indices were measured. Materials and Methods: 28 adult male Sprague-Dawley rats weighing 200-250 g were randomly divided in to 4 groups (Control, IR, IPC and IPC-IR). In the IR group, right renal artery clamped for 30 min followed by 10 min reperfusion. IPC group has experienced 3 periods of intermittent "5 min ischemia" followed by "5 min reperfusion". IPC-IR group was experienced both conditions, first IPC and then IR. Duration of the procedure was the same in all groups. At the end of the procedure, blood samples were drawn from right renal vein for serum BUN &. creatinine measurements and kidney was formalin fixed for histological evaluations. Results: The results showed that 30 min ischemia in IR group significantly (P<0.05) reduced renal function demonstrating by increase in serum creatinine levels as compared with the control group. These results in IPC group also showed a significant difference with IR: group but no significant difference in serum BUN and creatinine between IR and IPC-IR group Were detected. Histological evaluation showed no structural damage in IPC group and minor trend to improvement in IPC-IR group. Conclusion: Our findings suggest that, this model of preconditioning couldn"t highly improve renal function in the early phase of reperfusion but the structural damage in the IPC-IR group Was lower than that of the IR group. The protective functional effects of preconditioning in the late phase needs more study.

Background: Childhood obesity is increasing worldwide and is an important risk factor for many chronic diseases. Obesity generally causes increase in body weight and must. be evaluated according to the standard values for the individual age and sex. Materials and Methods: This survey had 2 stages. At the first stage, 835 8-11 old girls were studied. Height, weight were measured and BMI was calculated. Iranian BMI reference, CDC 2000 and IOTF 2000 references were used to define obesity. When using Iranian or CDC references, the prevalence of obesity was defined as the percentage of children above the 95th percentiles of the BMI. When IOTF reference was used, the students who had a BMI more than the BMI equivalent to 30 at age 18 considered as obese. At the second stage of the study, all the obese students (according to Iranian - reference) considered as Case group (n = 134) and 134 Control girls with the normal weight (5th percentile £ BMI <=5th Percentile) were chosen randomly and obese children were matched with non - obese children by sex, age, school and Classroom. Parental BMI were calculated using self - reported height and weight. Mothers and fathers having a BMI> 30 Kg/m2 were identified as obese. Results and Conclusion: The prevalence of obesity among all the study samples (n=835) were 16%, 9.6%, 6.6% according to Iranian, CDC 2000 and IOTF 2000 references respectively and obese girls had significantly higher possibility of having obese parents than controls (P<0.02).The results of this study indicates that childhood obesity is increasing in Tehran.

Background: Postal (mail) questionnaires are a common way of gathering data in most surveys. One major limitation to mail survey is non-response bias. No response to questionnaire can causes low validity. Ideally response rate should be 100% in order to ensure a representative sample of the population. Since 1950 a large number of procedures to improve responses rates of mailed questionnaires survey are described in the survey literature such as: questionnaire"s layout, length, color, cover letter, incentives, introductory telephone call, prepaid return envelop arid.... Looking to the research findings of such studies shows some discrepancy and uncertainty about inducements strategies. Materials and Methods: The present study attempts to determine .the most effective the inducements strategies for minimizing non-responses mail questionnaires by looking at 75 original research and Meta analysis. Results: The results of study among the major area that examined indicates that: incentives (mean=16.50 &SD= 7.58), follow up letter postage and envelop (mean=9.75 &SD=4.63), questionnaire characteristics (mean= 7.15 &SD.=7.56), had most influences on response rates (p= 0.001 for all area). Other factors (color of questionnaire, quality of paper, introductory letter) however effects on increasing response rate, but no statistical significance were found.Conclusion: The result of this study has implication for researcher to minimize non response bias.

Background: Vascular access (VA) is a prerequisite for initiation of hemodialysis (HD) in patients with end- stage renal disease (ESRD). Frequency and potency of V A types are varibus in different societies. We have done this study to achieve this goal. Materials and Methods: This descriptive retrospective study was performed over two months (august and September 2003) iq four HD centers in Isfahan, Iran. All of the patients who were treated with HD for more than 1 month were studied for the number, type of V A and some demographic factors. The questionnaires were completed at the patient"s bedside. Results: There were 320 patients. (199 male and 121 female). Mean age was 50.64± years. Among 412 permanent VAs which were created in the duration of HD, only 4 and 7 of them were graft and dual _ lumen cuffed catheters, respectively. All of the others were arterio venous fistula (AVF).The mean number of created permanent VAs in females was more than males. It was increased by some factors such as increasing the duration of HD, increasing the interval between creating permanent VA and initiation of HD. Although the latest was not statistically significant. 1 Year, 2-year, 3-year and 5- year survival of AVF was 80%, 78%, 73% and 69%, respectively. Primary failure of AVF was. 13%. Conclusion: Regarding the statistics of other centers, survival of AVF was low in Isfahan. The prevalence of grafts & dual - lumen cuffed catheters is lower than other countries. The majority of our patients use AVF as a VA. The earlier the patient is encouraged to create a permanent VA before initiation of HD, the AVF survival is higher.

Background: Lipids and lipoproteins abnormalities are characteristics of Nephrotic Syndrome. The typical abnormalities include elevated concentration of serum TC, TG, LDL-C, ApoB and decrease in HDL-C levels. Methods and Materials: In this study serum Triglyceride(TG), Total Cholesterol (TC), Low Density-Lipoprotein- Cholesterol (LDL-C) ,Apolipoprotein B (ApoB) and High-Density Lipoprotein-Cholesterol (HDL-C) levels determined in 24 male control grope(GI) and 27 male patient (GII) with Nephrotic Syndrome .TG, TC were determined enzymaticly (Bohringer-Mannhein). HDL was isolated by ultracentrifugation. The concentration of LDL-C was Calculated (Fridewald), ApoB concentration was determined by Nephlometry . Results: There were significant racial different in serum TG, TC, ApoB, LDL-C and HDL-C between patients (GII)and controls(GI) (p<0.001,<0.001,<0.05 ,<0.001 and<0.001 respectively).The patients(GII)had higher levels of serum TG, TC, LDL-C, ApoB and lower levels of serum HDL-C than control group (GI) . Conclusion: Patients with Nephrotic Syndrome have multiple abnormalities in lipid and Lipoproteins (LP) metabolism .The elevated serum TC, TG, LDL-C and ApoB levels and reduced serum HDL-C levels in patients (GII) may explain their higher rate of cardiovascular disease and as consequence ,the concept that atherogenesis might be accelerated by Nephrotic Syndrome.