Tehran University Medical Journal
Year:2007 | Volume:65 | Issue:3|Papers Count:21

Background: Diabetic neuropathy is an incapacitating disease that afflicts almost 50 percent of patients with diabetes. A late finding in type I diabetes, diabetic neuropathy can be an early finding in non insulin-dependent diabetes. Diabetic neuropathies are divided primarily into two groups, sensorimotor and autonomic. Patients may acquire only one type of diabetic neuropathy or may present with combinations of neuropathies, such as autonomic neuropathy or distal symmetric polyneuropathy, the latter of which the most common form. Motor deficits, orthostatic hypotension, silent cardiac ischemia, hyperhidrosis, vasomotor instability, gastroparesis, bladder dysfunction, and sexual dysfunction can also result from diabetic neuropathy. Strict control of blood sugar, combined with proper daily foot care, is essential to avoid the complications of this disorder. With the potential to afflict any part of the nervous system, diabetic neuropathy should be suspected in all patients with type 2 diabetes as well as patients who have had type I diabetes for over five years. Although some patients with diabetic neuropathy notice few symptoms, upon physical examination mild to moderately severe sensory loss may be noted by the physician. Idiopathic neuropathy has been known to precede the onset of type 2 diabetes.

Background: Opiate-induced addiction is a main social problem in Iran. As treatment of this problem is a health priority among the medical community, studies on this topic are very crucial. The exact mechanism of dependence on opiates and their withdrawal, syndrome remains unclear. It seems that dopaminergic system and locus coeruleus (Lc) have an important role in the expression of somatic signs during opioids withdrawal. The LC has been shown to contain significant levels of dopamine (DA). In the present study, the effects of different D2 dopaminergic receptor agonist and antagonist administration in the LC on withdrawal sign expression in morphine dependence is investigated in rats.Methods: Adult male Wistar rats, weighing 220-280 g were divided into eight groups (n=8). Two cannulae were stereotaxically implanted bilaterally into the LC of each rat.After a one-week recovery, seven groups were rendered dependent on morphine by subcutaneous injection during a seven-day period. Non-dependent control animals received saline according to the same protocol. Animals received bilateral intra-LC injections of saline (1 mg/site) and quinpirole (0.1, 0.3 and 0.5 mg/site, a D2 agonist) 15 min and sulpiride (5, 15 and 30 mg/site, a D2 antagonist) 30 min prior to naloxone injection about 24 hours after the last dose of morphine or saline according to their respective group. To calculate the total withdrawal score, as an index of withdrawal syndrome, 20 different withdrawal signs were assessed and the scores of the intensity of these withdrawal signs were added.Results: Total withdrawal scores were significantly decreased by quinpirole (0.1 mg/site) and sulpiride (15 and 30 mg/site).Conclusion: The D2 dopaminergic system in the LC may be involved in the morphine induced dependency in rats. Further studies are needed to define the mechanism of this dependency in order to improve methods for the rehabilitation of addicts.

Background: Accurate computation of the radiation dose to the breast is essential to mammography. Various the thicknesses of breast, the composition of the breast tissue and other variables affect the optimal breast dose. Furthermore, the glandular fraction, which refers to the composition of the breasts, as partitioned between radiation-sensitive glandular tissue and the adipose tissue, also has an effect on this calculation. Fatty or fibrous breasts would have a lower value for the glandular fraction than dense breasts.Breast tissue composed of half glandular and half adipose tissue would have a glandular fraction in between that of fatty and dense breasts. Therefore, the use of a computational code for average glandular dose calculation in mammography is a more effective means of estimating the dose of radiation, and is accurate and fast.Methods: In the present work, the Sobol-Wu beam quality parameters are used to write a FORTRAN code for glandular dose calculation in molybdenum anode-molybdenum filter (Mo-Mo), molybdenum anode-rhodium filter (Mo-Rh) and rhodium anode-rhodium filter (Rh-Rh) target-filter combinations in mammograms. The input parameters of code are: tube voltage in kV, half-value layer (HVL) of the incident x-ray spectrum in mm, breast thickness in cm (d), and glandular tissue fraction (g).Results: The average glandular dose (AGD) variation against the voltage of the mammogram X-ray tube for d = 4 cm, HVL = 0.34 mm Al and g=0.5 for the three filter target combinations, as well as its variation against the glandular fraction of breast tissue for kV=25, HVL=0.34, and d=4 cm has been calculated. The results related to the average glandular absorbed dose variation against HVL for kV = 28, d=4 cm and g= 0.6 are also presented. The results of this code are in good agreement with those previously reported in the literature.Conclusion: The code developed in this study calculates the glandular dose quickly, and it is complete and accurate. Furthermore, it is user friendly and useful for dose optimizing in mammography imaging.

Background: Cortical Evoked Response Audiometry (CERA) refers to prediction of behavioral pure-tone thresholds (500-4000 Hz) obtained by recording the Nl-P2 complex of auditory long latency responses. CERA is the preferred method for frequency-specific estimation of audiogram in conscious adults and older children. CERA has an increased accuracy of determination of the hearing thresholds of alert patients with elevated hearing thresholds with sensory hearing loss; however few publications report studies regarding the use of CERA for estimating normal hearing thresholds. The purpose of this research was to further study the accuracy of CERA in predicting hearing thresholds when there is no hearing loss.Methods: Behavioral hearing thresholds of 40 alert normal hearing young adult male (40 ears) screened at 20 dB HL in 500-8000Hz, predicted by recording Nl-P2 complex of auditory evoked long latency responses to 10-30-10 ms tone bursts. After CERA, pure tone audiometry performed by other audiologist. All judgments about presence of responses performed visually. Stimulus rate variation and temporary interruption of stimulus presentation was used for preventing amplitude reduction of the responses. 200-250 responses were averaged near threshold.Results: In 95% of the hearing threshold predictions, Nl-P2 thresholds were within 0-15 dB SL of true hearing thresholds. In the other 5%, the difference between the CERA threshold and true hearing threshold was 20-25 dB. The mean threshold obtained for tone .bursts of 0.5, 1,2 and 4 kHz were 12.6±4.5, 10.9±5.8, 10.8±6.5 and 11.2±4.1 dB, respectively, above the mean behavioral hearing thresholds for air-conducted pure tone stimuli.Conclusion: On average, CERA has a relatively high accuracy for the prediction of normal hearing sensitivity, comparable to that of previous studies performed on CERA in hearing-impaired populations.

Background: Acute radiation dermatitis is a very common side effect of radiation therapy for many cancers, including breast cancer. Despite the high prevalence of acute radiation dermatitis as well as wet desquamation, only a few trials studying the prophylaxis of this complication using topical treatment have been conducted. In spite of these studies, some controversy still exists about regarding treatments for acute radiation dermatitis, as does some concern about their long-term complications. For this reason, we conducted a clinical trial for a new treatment with the same effectiveness as corticosteroids, but fewer complications.Methods: This trial included 60 patients with pathologic diagnoses of breast cancer for whom radiotherapy had been planned. Patients were 30-73 years old. Patients with radical mastectomy received 5000 cGy over five weeks, and those with conservative surgery received 6000 cGy over six weeks divided in 200 cGy fractions. Patients were divided randomly into two groups: one group received a moderately-potent glucocorticoid steroid, 0.1% betamethasone ointment (30), and the other received the new treatment, 0.1% calendula ointment (30). All patients applied their respective drugs twice daily within the tangential field from the first day of radiation treatment until one month after treatment was completed. Starting one week after radiation therapy commenced, patients were monitored weekly for symptoms of dermatitis and the degree of severity as well as possible adverse drug effects, in addition to such monitoring on the days of their appointments. Four weeks after termination of therapy, patients were again examined, at which time they completed a questionnaire about dermatologic complications.Results: The mean time to develop dermatitis was 3.7 weeks for the betamethasone group and 3.87 weeks for the calendula group. Maximal dermatitis intensity during treatment in the betamethasone group was: 0, 6.7%; I, 73.3%; II, 16.7%; III, 0%; IV, 3.3%. Dermatitis intensity in the calendula group was: 0, 13.3%; I, 67%; II, 16.7%; III, 0%; IV, 3.3%. No significant differences were observed in the incidence of symptoms such as burning, pruritus and pain between the two groups (p=0.762).Conclusion: Calendula ointment is as effective as betamethasone in reducing acute radiation dermatitis.

Background: Percutaneous Coronary Intervention (PCI) for bifurcated lesions is associated with a low rate of success and high rate of complications compared to such treatment of lesions of most other morphologies. Symptoms occurring at the time of procedure caused by PCI may require additional angiography with or without stenting through stent struts, which subsequently increases risks of restenosis and stent thrombosis. The purpose of this study was to evaluate the incidence of major side branch (>1mm) complications during PCI and their clinical, angiographic, and interventional Predictors.Methods: Of 104 consecutive patients, we evaluated 50 lesions with ostial stenos is (group 1) and 54 lesions without ostial stenosis (group 2) as a control group. Age, sex, major coronary artery disease risk factors, and left ventricular ejection fraction (LVEF), were compared between groups. Morphology, location, type of lesion, length of lesion, main and side branch diameters, interventional approach, and clinical and interventional outcomes were the main variables studied during this trial.Results: Side Branch Compromise (SBC) occurred in 41 (39.4%) of the total number of cases: 52% in group 1 and 27.8% in group 2 (p=0.01). More than 80% of SBC occurred in main branches with stenosis (p=0.02). SBC did not correlate with clinical characteristics, bifurcation location, LVEF, or stent number. Chest pain was reported in 18% of the cases during or after PCI. Three non Q wave myocardial infarctions (MI) occurred after SBC, each with >2 mm branch diameters (p=0.02). SBC was not associated with adverse clinical outcomes.Conclusion: The risk of MI after losing the side branch of a bifurcation lesion is not usually as high as it is after losing the main branch. Furthermore, it may not be a serious problem as one of the problems of the bifurcation lesion is the high rate of post procedural non Q wave MI associated with SBC. These findings demonstrate that side branch ostial stenos is>50%, and main branch stenosis >80% were important predictors of SBC. Protection of side branches >2 mm is highly recommended during coronary intervention.

Background: The Fontan operation is the definitive operation for palliation of complex congenital heart disease with single -ventricle physiology. The use of the extra cardiac conduit has recently been gaining popularity. The purpose of this study was to compare the outcomes of extra cardiac conduit Fontan procedure (off-pump technique) and that of traditional technique (lateral tunnel technique) in which cardiopulmonary bypass is routinely used.Methods: Forty one patients in different age groups underwent extra cardiac conduit Fontan procedure between April 2001 and December 2004. Data were collected from ICU sheets, files and during follow up visits. Under general anesthesia and through median sternotomy, using two temporary decompressing shunts, superior vena cava implanted on right pulmonary artery and a conduit interposed between transected inferior vena cava and main pulmonary artery.Fenestration was done in almost all patients and previous shunts were closed if there were any. Results: Of our patients, 13 were female and 28 were male. Mean age of the patients was 11.1 years (SD=7.8). In 24.4% of cases Fontan procedure was done as the first palliative surgery and in 75.6% of them there was previous history of palliative procedures. In 6 patients (14.6%) we were constrained to use cardiopulmonary bypass which was predictable or necessary in 50% of cases. There was no reoperation due to post operative bleeding. Two cases suffered from prolonged plural effusion. Our in-hospital mortality was 9.8%. During 2-24 months follow up, we found two cases who were in NYHA functional class 11 and one case in functional class I.Conclusion: Extra cardiac conduit Fontan procedure could be used in a safe way. The results of this study were comparable and even in some cases better than that of the traditional technique.

Background: Kernicterus, also known as bilirubin encephalopathy, is a neurologic syndrome resulting from the deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei. Indirect bilirubin is toxic for brain. Neurologic dysfunction (BIND) that include acute phase (hyperbilirubin encephalopathy) and chronic phase (Kernicterus) resulting from hyperbilirubinemia and disruption of blood brain barrier. In this study, the association between bilirubin encephalopathy and risk factors was evaluated.Methods: In this retrospective study, 312 icteric neonates were admitted in the neonatal ward of Children's Hospital, Medical Center, Tehran, and 305 of these cases were evaluated. Patient histories were taken and physical examinations were performed. For each patient, the age, sex, birth weight, time of discharge from the hospital and risk factors were recorded, and a questionnaire was completed.Results: In this study, of the 305 icteric neonates evaluated, 25 cases had kernicterus.Risk factors included acidosis, prematurity, hemolysis, hypoglycemia, sepsis, respiratory distress, low birth weight, ABO incompatibility and G6PD deficiency. The mean level of bilirubin in cases of kernicterus was 32 mg/dl and in the others was 20 mg/dl (p=0.001).Kernicterus was most common among high risk neonates (p<0.001). Birth weight less than 2,500 gm was also an important factor (p=0.04).Conclusion: High-risk neonates need prompt treatment for hyperbilirubinemia compared to low risk neonates.

Background: The aim of this study was to evaluate the association between atypical glandular cell (AGe) on Pap smear and significant pathologic finding to tailor management protocols.Methods: Between 2002 and 2005, Among 26893 Pap smears 122women with AGC Pap Smears (prevalence=0.45%) were referred to our colposcopy clinic. Forty one women underwent colposcopy directed biopsy, endocervical curettage, endometrial sampling and cervical conization to determine the cytologic and histologic correlations of AGC on pap smears.Results: A total of 122 women with AGC Pap smear were found. Only 41 women accepted to participate in the study and followed the workup procedures. The mean age of the patients was 46.92±11.48 years (range, 23-80 years). Of these patients 13 patients (31.7%) were post menopause and 28 patients (68.2%) were in reproductive age.We found 13 (31.7%) significant pathologic findings including 4 (9.7%) high grade squamous intraepithelial lesion (HG-SIL), 3(7.3%) low grade squamous intraepithelial lesion (LG-SIL), 2 (4.8%) Endometrial hyperplasia, 1(2.4%) Endometrial adenocarcinoma, 1(2.4%) adenocarcinoma of cervix, 1(2.4%) squamous cell carcinoma of cervix and 1(2.4%) papillary serous tumor of ovary. There was not any significant difference in the prevalence of significant pathologic findings and subtype of squamous or adenomatous lesions between pre and postmenopausal group.Conclusion: AGC on Pap smear was associated with a clinically significant diagnosis in approximately one third of our cases. The women with a diagnosis of AGC on cervicovaginal smear are needed to be evaluated at least with colposcopy, endocervical and endometrial curettage. Clinicians should be careful about the significance of AGC in pap smears

Background: Hypothyroidism is a well-documented complication after treatment of laryngeal cancer and is particularly significant among patients undergoing laryngectomy.We investigated the frequency of hypothyroidism in patients treated with total laryngectomy for laryngeal cancer. We also evaluated the effect of neck radiotherapy on thyroid function after total laryngectomy for laryngeal cancer.Methods: In a cross-sectional study, we evaluated 31 patients with laryngeal squamous cell carcinoma (mean age 53.6 years). Among these patients, 14 were treated with surgery only and 17 were treated with surgery plus radiotherapy. Laboratory evaluation included levels of thyroid stimulating hormone (TSH), free T4, free n, and antithyroid antibodies both preoperatively and postoperatively at the first day, as well as one and six months after surgery.Results: All patients had normal thyroid function before treatment; however, after 6 months, five patients (16.1%) were hypothyroid. Of these, three patients (9.6%) had subclinical symptoms, including elevated thyroid-stimulating hormone with normal free T4, and two patients (6.5%) showed clinical symptoms of hypothyroidism. Radiotherapy and neck dissection were significantly associated with higher incidences of hypothyroidism.Conclusion: Our data suggest that hypothyroidism occurs in a substantial proportion of patients undergoing surgery for laryngeal cancer. The results indicate that thyroid function studies should be routinely performed in the follow-up care of laryngeal cancer patients, especially if radiotherapy and neck dissection were part of the treatment. We suggest that this approach will improve the patient's quality of life and diminish the comorbidity associated with this kind of surgery.

Background: The incidence of riboflavin deficiency is high in women and children in developing countries and the deficiency almost invariably occurs in combination with deficiencies of other water soluble vitamins. The objective of this study was the assessment of riboflavin status of rural school children in Kerman province and its relationship with riboflavin, protein and energy intake.Methods: In this cross-sectional study, 327 primary school children were randomly selected by the stratified multistage cluster sampling method. Variables for classifications were sex and socio-economic status (according to the educational level). This study was conducted by the Department of Nutrition and Biochemistry of School of Public Health in Tehran University in the winter of 2001. A twenty-four hour recall questionnaire was completed by and 5 cc of venous blood was taken from each student. Riboflavin status was assessed by measuring the glutathione reeducate activity coefficient (EGR - AC) of the red blood cells. Chi-Square and Pearson's correlation coefficient tests were used to determine correlations. Student's t-test was used to show the differences in the mean of EGR - AC between the classifications of independent factors.Results: The relationship between riboflavin status and its independent variables including the status of riboflavin, protein and calorie intake were assessed. Outputs of the study indicated that 39.7% of the boys and 43.6% of the girls (41.8% together) were marginally riboflavin deficient. Furthermore, 37.7% of the boys, 33.4% of the girls (35.4% together) were frankly riboflavin deficient. An average of 67.2% of the children (70.1% boys, 63.7% girls) had enough intake of riboflavin, and 76.2% of the children (79.9%, boys, 72.5% girls) had adequate intake of protein. However, only 22% of the children (24.5% boys, 19.3% girls) had sufficient caloric intake. Outputs of this dietary evaluation reveal that there is a relationship between riboflavin status and protein intake status (P<0.05).Conclusion: This study shows that riboflavin deficiency is an important problem for the rural school children of Kerman province and the level of protein intake is an important factor affecting riboflavin status in these children.

Background: The effects of population aging are becoming apparent throughout the world. Diseases, such as cardio-vascular disease (CVD) and diabetes, are among the most important factors affecting morbidity and mortality, especially in the elderly. These diseases not only result in huge economic costs for treatment and care, but also results in hardship and time lost for relatives of the afflicted individuals. The association between nutritional status and disease is well known. In the present study, the effects of both under-nutrition and over-nutrition on the prevalence of disease are monitored in an urban Iranian elderly population. Thus far, no similar study has been performed in the Iran.Methods: This cross-sectional study was conducted in Isfahan, Iran, during late 2003 on 1694 elderly people (731 males, 963 females), aged 60 years and older. Subjects were randomly chosen from all urban elderly people during a door-to-door and weight and height survey. They were selected using a cluster sampling method, each containing 30 clusters. From each cluster, 58 elderly were selected at random. Using each subjects body mass index (BMI), the nutritional status was categorized as overweight (BMI greater than 25), underweight (BMI less than 19) and normal (having a BMI equal to or more than 19 and equal to or less than 25). Any illnesses known to each subject were also recorded.Results: Results showed that 4.7% of the subjects were underweight and 61.2% overweight. Women were more likely to be overweight and long periods of watching television increased the risk of overweight in all subjects. Being overweight was associated with diabetes and coronary vascular diseases, and lean people were less likely to suffer from such diseases.Conclusion: This study indicates a high prevalence of overweight among the Iranian elderly population, indicating the need for improvement in nutritional status in order to reduce the prevalence of diabetes and CVD.

Background: Infertility is a worldwide problem. Many different factors may cause infertility. Among them, bacterial infection of the reproductive system is one of the main factors. Recently, some limited investigation has revealed that H. pylori is capable of causing genital inflammation that may lead to infertility. Although known to be a causative agent of gastritis and duodenal ulcers, this species may be transferred orally to the vagina and asymptomatic infection leads to inflammation of the system and finally manifestation of infertility. In addition, infertility may be due to antibodies synthesized against H. pylori cross-reacting with the genital tissue.Methods: In the present study, 180 women consisting of 90 cases referred to IVF center of Yazd and 90 matched controls were enrolled. Serum was taken from all women for detection of IgG and IgM using the ELISA technique.Results: A total of 117 (65%) serum samples were positive for Helicobacter, of which 63.3% were from fertile and 66.7% from infertile women. The serum positive population was found to be predominantly in the age range of 25-35, although some 35-42 year olds were also serum positive. When the prevalence of Helicobacter infection status was compared with marriage duration in both groups, it was found that antibody titer in subjects from marriages with durations of greater than five years was significantly higher than those of five-year marriages. In addition, higher antibody titers were found in infertile women with fallopian tube (FT) factor and lower titers in those with polycystic factors.Conclusion: Although the results were not significant, they nevertheless indicate that the Helicobacter antibody titers in infertile women were higher than those of fertile women (P =0.6). Therefore, further studies are necessary to determine the role that Helicobacter infection plays with regard to infertility among women. Since the antibody titer in infertile cases with FT factor was higher than others, it may indicate that inflammation caused by H. pylori plays an indirect role in the induction of infertility.

Background: Staphylococcus aureus is one of the most common causes of nosocomial infections with high morbidity and mortality rate. Traditionally, methicillin resistant staphylococcus aureus has been considered a major nosocomial pathogen in healthcare facilities, but in the past decade, it has been observed emerging in the community as well, Informations regarding hospital microbial colonization could be an important step for prevention of nosocomial infections. Our objective was clarifying the prevalence of methicillin resistant and vancomycin resistant staphylococcus aureus colonization in nasopharynx. Methods: A descriptive cross sectional study was carried on 106 patients and nursing staff of surgery and hemodialysis wards in Amir-Alam hospital from April 2005 to July 2005. The samples were collected from nasal region of cases using cotton swab by two experienced technician and were sent to laboratory for culture and antibiogram. Results: Twenty six (29.5%) out of 106 cases were nasopharyngeal carriers of staphylococcus aureus. Eight cases (7.5%) had methicillin resistant staphylococcus aureus. The most frequent colonization rate was seen in hemodialysis nursing staff and in all of them methicillin resistant staphylococcus aureus was reported. Carrier rates in hemodialysis patients were twice compared to surgery ward patients. The interesting point was that no sample of vancomycin resistant staphylococcus aureus was isolated.Conclusion: Prevalence of methicillin resistant staphylococcus aureus colonization seems to be increased; therefore proper management for controlling this problem is mandatory. The results of the present study suggest that the prevalence of methicillin resistant staphylococcus aureus infections is higher than was expected. In Iran and vigorous preventive strategies should therefore be taken to stop the growth of this major health problem.

Background: Creutzfeldt-Jakob disease (C-JD) is a rare disorder characterized with rapidly progressive mental decline, myoclonic jerk and finally death. The transmissible pathogen for this disease is a proteinaceous infectious particle termed prion. The prion protein is encoded by a gene (designated as PRNP) on the short arm chromosome 20.This disorder is diagnosed based on clinical findings, course of disease, EEG, MRI and confirmed with brain biopsy.Case report: A 56- year- old woman presented with confusion, disorientation, hyper somnolence, psychiatric problems such as hallucination, progressive mental deterioration and myoclonic jerks. She had history of several times phlebotomy with traditional and non sterile methods in two past years. She had no past history of other disease. Her illness was diagnosed based on clinical findings, course of her illness, typical MRI, EEG and rule out other dementing disease. She died after one month.Conclusion: in any patients with psychiatric disorders, rapidly progressive mental deterioration and myoclonic jerks C-JD should be considered as an important diagnosis. Treatable dementing disease should be considered and ruled out at first. The significance of phlebotomy in C-JD has yet to be determined.