TEHRAN UNIVERSITY MEDICAL JOURNAL (TUMJ)
Year:2008 | Volume:66 | Issue:1|Papers Count:19

Background: Multiple sclerosis (MS) is an inflammatory disease of the central nervous system with multifocal areas of demyelination. Despite an increased understanding of the mechanisms causing MS, immunological factors that indicate disease activity are only starting to be discovered. Chronic brain inflammation is often associated with an increase in production of IgG in the CSF as determined by the IgG index (normal£0.77) and oligoclonal bands (OCBs). Different studies have found variable correlations between these two factors and disease progression. We herein evaluate the correlation of IgG index and OCB with disease progression in Iranian MS patients.Methods: The IgG index was measured in 54 patients with multiple sclerosis. The progression index (PI), type of disease course and the presence of OCBs were compared in patients with normal, high and very high IgG index.Results: PI was higher in patients with very high IgG indexes (0.10±0.13) vs. patients with high (0.06±0.05) and normal IgG indexes (0.05±0.07; p>0.05). Secondary progressive (SP) patients had higher IgG indexes than those with relapsing-remitting (RR) courses (2.04±1.24 for SP vs. 1.78±1.45 for RR; p>0.05). The PI was higher in OCB-positive MS patients (0.08±0.10) vs. OCB-negative patients (0.05±0.04) (p>0.05).Conclusion: Although the findings of this study need to be treated with some caution since this is not a prospective evaluation, the results indicate a trend toward better prognosis of the disease in patients with lower IgG index values. We think that the IgG index is a useful marker of disease activity in MS. Patients with IgG indexes above 1.1 could have an increased risk of progression and they would benefit from early treatment with immunomodulator agents. Our results did not reveal statistically significant prognostic value for IgG index in patients with multiple sclerosis. Thus the results warrant prospective studies to verify the prognostic value of intrathecal IgG synthesis in multiple sclerosis.

Background: Hypomagnesemia is commonly encountered in patients with a wide variety of diseases including subarachnoid hemorrhage (SAH), cardiovascular emergencies, head trauma, migraine attacks, seizure and preeclampsia. It seems to be associated with a poor clinical outcome. This study considers the prevalence and temporal distribution of hypomagnesemia after aneurysmal SAH and its correlation with the severity of SAH, delayed cerebral ischemia (DCI) as well as the neurological outcome after a period of three months.Methods: Between 2003 and 2008, 60 patients were admitted to the emergency ward of Imam Khomeini Hospital with acute SAH. Serum magnesium levels were measured during the first 72 hours, days 4-7, and second and third weeks after SAH. The threemonth outcome was assessed according to the Glasgow Outcome Scale (GOS). Clinical SAH grading was performed according to the criteria of the World Federation of Neurological Surgeons (WFNS) and the patients were allocated to “Good” (GOS = 4, 5) and “Poor” (GOS= 1-3) outcome groups. The prevalence of hypomagnesemia was assessed in both patient groups. Fisher exact test was used to analyze data.Results: Hypomagnesemia occurred in 22% of patients during the first 72 hours after SAH. It was associated with more prevalent DCI (p<0.05), whereas low serum magnesium levels during days 4-7 17% of patients) and the second week (22% of patients) after SAH were correlated with poor clinical outcome (p<0.05). No correlation was found between first 72 hour-hypomagnesemia and poor clinical outcome at three months.Conclusion: Hypomagnesemia occurs after aneurysmal SAH and it may predict the occurrence of DCI, while low serum magnesium levels during days 4-7 and within the second week of event predict poor clinical outcome at three months. Treatment of this electrolyte disturbance may have a favorable effect on the clinical outcome of patients with aneurysmal SAH.

Background: The risk of atherosclerosis and cancer is high in hemodialysis (HD) patients. There is evidence that HD causes oxidative stress. However, the causative factors of oxidative stress are unknown. It has been suggested that HD imposes an additional oxidative stress on patients with chronic renal failure by activation of granulocytes on dialyzer membranes resulting in an imbalance between oxidants and antioxidants. In this regard, a number of reports, either measuring specific analytes or enzymes, or estimating the total antioxidant activity of the plasma have given contradictory and inconclusive results. To investigate the oxidative stress status in Iranian HD patients, in this study, we evaluated GSH and FRAP levels along with Ca and pH in the blood of these patients.Methods: Along with 20 healthy age and gender matched control subjects, 24 patients underwent dialysis, three times per week, for four hours in each session. Before and after dialysis, blood was taken for biochemical and liver function tests and to evaluate oxidative stress markers and measure Ca and pH levels.Results: There was a significant decrease in FRAP and GSH levels after dialysis compared to those before treatment. Dialysis caused an increase in pH and Ca levels compared to levels in control subjects after dialysis.Conclusion: In general, before dialysis, there is a balance between oxidants and antioxidants; however, due to higher levels of oxidants as well as the possible binding of antioxidants to the dialyzer membrane during dialysis, an imbalance occurs. The instability in the balance of oxidants and antioxidants may be the major cause of cellular oxidative damage found in HD patients. This study indicates that there is a significant level of oxidative stress in renal chronic patients and this stress is augmented by dialysis. Antioxidant therapy should be considered in these patients.

Background: The induction of anesthesia, laryngoscopy and endotracheal intubation can be associated with hemodynamic responses such as tachycardia, bradycardia, hypertension, hypotension and so forth. Changes in arterial pressure (>25%) can be associated with cardiovascular complications and impairment of cerebral perfusion. The aim of this study was to evaluate hemodynamic responses to laryngoscopy and intubation after propofol versus thiopental anesthesia.Methods: One hundred and eighty ASA class I patients, aged 20-50 years, were enrolled in a randomized clinical trial (RCT), divided into propofol and thiopental groups and evaluated for hemodynamic response to induction of anesthesia and to laryngoscopy/ intubation. Data collection parameters included systolic pressure (sp), diastolic pressure (dp), mean arterial pressure (map) and heart rate. Analysis was performed using SPSS version 13.5, t-test and c2 test to determine the significance of the results.Results: From a total of 180 patients, 91 (50.6%) were male and 89 (49.4) were female. There were no differences in age, weight or gender between the two study groups (p>0.05). Changes in the hemodynamic indices on the operation table from before induction to those after premedication had no significant difference. There were no significant differences in the decrease of sp/dp ratio or map between the two groups. Mean changes in heart rate were 11.5 ±5.43 and 5.37 ±3.5/min in the thiopental versus the propofol group, respectively. The only significant difference between the two groups was the increase in heart rate after intubation for the thiopental group.Conclusion: The only difference in the hemodynamic indices of normal healthy patients after induction of anesthesia or those after intubation while using propofol versus thiopental Na was in the tachycardia reflex to laryngoscopy and intubation, which was less after propofol induction. For this reason, propofol may be the better choice for anesthesia induction, especially for coronary patients.

Background: Whatever its etiology, the inflammatory reactions of preeclampsia lead to the activation of endothelium and result in vascular damage. CRP is considered a sensitive index of systemic inflammation, so it is used as predictive factor for disease. This study was carried out to test the screening and predictive abilities of the CRP test in order to detect and diagnose pregnant women prone to preeclampsia prior to the onset of symptoms.Methods: In this prospective cohort study, conducted in Arash Hospital between 2005 and 2006, we determined the CRP levels of 201 pregnant women at 10-16 weeks of pregnancy. Based on exclusion criteria and illness, 31 patients were excluded and 170 patients were followed until the end of their pregnancies.Results: In this study, the mean serum CRP values of those who had preeclamptic and those who had normal pregnancies were compared and the statistical differences were significant: 6.18 mg/L for preeclamptic patients compared with 4.12 mg/L for normal patients (p=0.003). Using a chi-square test, we found that patients whose CRP level was ³4 were six times more likely to have preeclampsia than those with CRP levels <4 (k=9.4; p=0.002; OR=6.15; 95% CI=0.69-22.28).Conclusion: This study confirms the results of previous reports indicating a significant relationship between rising serum CRP in the first trimester of pregnancy and preeclampsia at third trimester. More studies consisting of other inflammation factors are necessary to find an acceptable and reasonable screening test to diagnose pregnant women who are prone to preeclampsia.

Background: The presence of increased numbers of nucleated red blood cell (NRBC) in the umbilical cord blood has been associated with states of relative hypoxia. Nucleated red blood cell counts are a potentially useful tool in estimating the degree and timing of intrauterine hypoxia. This may have important implication in determining causality in case of compromised infant. Cord blood NRBC counts may be obtained noninvasively from an otherwise discarded specimen and analyzed by personnel on equipment readily available in most hospital laboratories. Since the aim of monitoring of fetal heart is early diagnosis of hypoxia, we studied the relationship between abnormal fetal heart rate with the number of nucleated red blood cells (NRBC) in the umbilical cord blood.Methods: We performed this research at Hazrat Zeynab Hospital on 130 full-term newborns (65 cases of fetal distress and 65 normal cases) between July 2005 and July 2006. The NRBC counts of newborns with abnormal fetal heart rate were compared with those of normal newborns and correlations with other parameters including Apgar score, hemoglobin level, and condition of newborns in the first 24 hours of the birth and birth weight.Results: The mean NRBC count in the fetal distress group was 9.45 ± 8.75 and that of the normal group was 9.17 ± 8.76 per 100 white cells (p=0.89). The mean duration between diagnosis of fetal distress to birth was equal to 1.2± 0.77 hours. Furthermore, there was no meaningful correlation between number of NRBC and Apgar score, hemoglobin, birth weight and condition of newborns in the first 24 hours.Conclusion: If the fetus is born a short time after the diagnosis of distress with no risk factors for hypoxia, the NRBC count for cord blood is not elevated.

Background: The most common cause for acute onset of thrombocytopenia in an otherwise well child is (autoimmune) idiopathic thrombocytopenic purpura (ITP). The incidence of ITP appears to be greater in children than in adult. The incidence of ITP in children is estimated to be approximately 46 new cases per million populations per year. Prednisolone, typically given as a single dose of 1-4 mg/kg/day, is indicated for all patients with symptomatic thrombocytopenic purpura and probably for all patients with platelet counts below 30000-50000/mL who may be at increased risk for hemorrhagic complication. An alternative to corticosteroid therapy for ITP is IVIG, but is much more expensive, has significant side effects, and is not significantly superior to steroid therapy to justify the expense and side effects of its use. In acute ITP, 80% of patients respond initially, with more rapid increase in platelet counts compared to steroid treatment. To the best of our knowledge, this is the first study in Iran comparing the efficacy of prednisolone and IVIG in the treatment of ITP.Methods: In this retrospective study, 202 ITP patients were treated with either prednisolone or IVIG between 1995 and 2005 at the Children’s’ Medical Center, Tehran, Iran. We compared the efficacy of prednisolone and IVIG in increasing the platelet counts of ITP patients. In addition, we collected the following patient data: seasonal incidence, age distribution, gender, parental consanguinity, and platelet count on admission.Results: There were no meaningful differences between IVIG and prednisolone in the treatment of ITP (z test with p<0.05). ITP was more common in males, with the highest incidence in the age range of 2-8 years old.Conclusion: Because there was no statistical difference between the outcome of the IVIG and prednisolone treatments, we recommend that prednisolone be the drug of choice to treat ITP.

Background: To evaluate the possibility that prolactin is involved in the pathogenesis and flare-up of systemic lupus erythematosus (SLE).Methods: In this cross-sectional study we determined serum prolactin levels in sixty (60) serum samples from sixty patients diagnosed with SLE by the criteria of the American College of Rheumatology (ACR). All patients were females between 13-64 years of age. Disease activity was defined according to lupus activity criteria count and scored by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Serum prolactin concentrations were determined by immunoradiometric assay (IRMA) [125I]. Patient blood samples were taken between 10 a.m. and 12 p.m. Serum was separated and kept frozen at -20oC.Results: Hyperprolactinemia (>21 ng/mL) was found in 7 (11.7%) patients. SLEDAI scores of <4 were considered inactive disease, >15 active disease and 4-15 moderate activity. Accordingly, 6.7% of our patients had active disease. Normal serum prolactin levels range from 2 to 21ng/mL. Among those with active disease, prolactin levels were higher, with mean prolactin levels of 18.15, 15.11 and 11.5 ng/mL for active, moderate and nonactive groups, respectively. Increased prolactin levels correlated with activity of SLE disease (p=0.019, r=0.305). No correlation was found between tissue involvement and prolactin level (p=0.24) and no significant correlation was found between prolactin level and age (p=0.19).Conclusion: Hyperprolactinemia, detected in patients with SLE by IRMA, was associated with disease activity. Our findings suggest that prolactin may play a role in the pathogenesis of SLE.

Background: The kidney is a complex and vital organ, regulating the electrolyte and fluid status of the human body. In clients with a chronic disease, such as end-stage renal disease, functioning status and hematologic indexes are different than among the general population. Electrolyte and hematologic changes may induce many illnesses for such patients. The purpose of this study is to determine the effects of applying the continuous hemodialysis (HD) the blood test results of HD patients.Methods: This quasi-experimental, before-after study included 38 HD patients from Hamedan, Iran in 2005. Subjects were selected using simple randomized sampling and were assigned to one group for the purpose of this research and investigated over a period of six months. Data collection tools included demographic questionnaire and control check lists. The first phase of the research involved orientation of the control group, which was limited to completion of the questionnaires and control check lists. Immediately after, the same patients became the case group, upon which continuous HD was applied and hemoglobin, hematocrit, blood urea nitrogen (BUN), potassium, sodium, and albumin tests were performed. Statistical analysis of the data employed SPSS (version 13), descriptive statistics, paired t-test and the Friedman test.Results: In this group, 47.2% of the subjects were male and 52.8% female. Data analysis shows that, using repeated measurement ANOVA test, a significant relationship between application of the continuous HD and improvement in hemoglobin, hematocrit, BUN, potassium, sodium, and albumin levels (p<0.05).Conclusion: Application of continuous HD causes a significant improvement in the blood test results of HD patients. We recommend that continuous HD be used, whenever appropriate, to resolve the common causes of complications in HD clients, including abnormal levels of electrolytes, especially potassium and phosphorus, as well as BUN and creatinine.

Background: This study have conducted in order to determine of direct or indirect effective factors on mortality of neonates with low birth weight by path analysis.Methods: In this cohort study 445 paired mothers and their neonates were participated in Tehran city. The data were gathered through an answer sheet contain mother age, gestational age, apgar score, pregnancy induced hypertension (PIH) and birth weight. Sampling was convenience and neonates of women were included in this study that was referred to 15 government and private hospitals in Tehran city. Live being status of neonates was determined until 24 hours after delivery.Results: The most changes in mortality rate are related to birth weight and its negative score means that increasing in weight leads to increase chance of live being. Second score is related to apgar sore and its negative score means that increasing in apgar score leads to decrease chance of neonate death. Third score is gestational age and its negative score means that increasing in weight leads to increase chance of live being. The less changes in mortality rate is due to hypertensive disorders in pregnancy.Conclusion: The methodology has been used could be adopted in other investigations to distinguish and measuring effect of predictive factors on the risk of an outcome.

Background: Over the years, Trans Urethral Resection of Prostate (TURP), as a treatment modality for obstructing benign prostatic hyperplasia (BPH), gained popularity throughout the world. It is considered the gold standard for the surgical management of BPH. However, there is not the same pattern in our country and open prostatectomy is more common. Specific evaluation should be done preoperatively. Cystoscopy is one of them that have special limited indications. The aim of this study was to define the rate of pathological findings in routine urethrocystoscopy before open prostatectomy.Methods: In a prospective study from 2003 to 2005 in Dr Shariati hospital 120 patients prepared for open prostatectomy underwent routine cystoscopy, without absolute indications for cystoscopy.Results: There was no special pathology observed in routine cystoscopy. The results of this study revealed that the mean of age in patients with meatal stricture was significantly lower than those without stricture (59.5±0.7 vs. 49.9±5.5 years, p=0.008). Also, the results of present study showed that in patients with meatal stricture serum creatinine level was significantly higher (2.2±1.34 vs. 1.2±0.42 mgr/dL, p=0.003). Furthermore, it was revealed that the mean of age in patients with bladder diverticulum was significantly higher compared with those without bladder diverticulum (76.3±3.1 vs. 68.4±4.9 years, p=0.001).Conclusion: Routine cystoscopy is not necessary before open prostatectomy.

Background: Sleep has a major role in daily cycles and reconstruction of physical and mental abilities. Regarding the importance of this feature, we decided to determine sleep quality in medical students.Methods: A questionnaire containing demographic data, Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index was prepared. We distributed the questionnaires using a census method to every student at the Zanjan Faculty of Medicine. The completed questionnaires were collected and the data was analyzed using SPSS.Results: A total of 224 students answered the questionnaire, with 133 (59.4%) students evaluated to have good sleep quality and 91 (40.6%) poor sleep quality. Of these 91 students, 38% were female and 44.8% were male (p=0.307). The prevalence of poor sleep quality according to the four stages of medical training was 24.6% of those in basic sciences, 42.9% of those in physiopathology, 41.7% of externs, and 53.5% of interns (p=0.008). According to residential status, the prevalence of poor sleep quality was 61.5% among students living with their spouse, 44.6% for students living in their own private homes, 37.6% among students living in the dormitory, and 20.8% for those living with their parents (p=0.024). According to marital status, 35.8% of singles and 64.9% of married students had poor sleep quality (p=0.001). According to financial status, 57.9%, 46.9%, and 33.9% of those from low, moderate and high economic classes, respectively, were sleep deprived (p=0.049). Among those with average grades of under 16 and over 16 out of 20, 47.5% and 32%, respectively, were suffering from poor sleep quality (p=0.047). There was no obvious relationship between sleep quality and BMI, sex, or history of depression or anxiety.Conclusion: Poor sleep quality was significantly associated with lower grades, economic status, living arrangement and type of training. A large number of students quality of life and work may suffer because sleep deprivation.

Background: Juvenile xanthogranuloma is a benign, normolipemic, dendrocytic histiocytosis that usually affects young children. It presents clinically as single or multiple yellow-brown papulonodular lesions in the upper part of the body, especially the head and neck. In adults, xanthogranuloma is not common and usually presents as a single lesion. Multiple xanthogranuloma in adults is rare. For the most part, cutaneous lesions are self-limited and seldom necessitate treatment. Here we report an adult patient with multiple xanthogranuloma.Case: A 45-year-old woman presented with multiple papulonodular lesions around the eyes and over her breasts and back. Biopsy showed giant cells with a wreath-like arrangement of nuclei (Touton giant cell) and diagnosis of juvenile xanthogranuloma was made.Conclusion: Although juvenile xanthogranuloma is a disease of children, it can rarely occur in adults. These patients should be evaluated for involvement of other organs to prevent complications. With ocular involvement, the risk of morbidity is high, and complications can include glaucoma, retinal detachment, cataract, vascular occlusion, hyphema, and corneal blood staining.