TEHRAN UNIVERSITY MEDICAL JOURNAL (TUMJ)
Year:2006 | Volume:64 | Issue:8|Papers Count:17

Paget’s disease is a chronic non-metabolic bone disorder that is characterized by increased bone resorption, bone formation and remodeling. This unbalanced process may lead to osseous deformities, structural weakness and altered joint biomechanics all of which can make surgical reconstruction difficult. Although few patients with Paget’s disease ever require surgical treatment, successful surgical management of severe orthopedic complications has improved the quality of life for these patients. Surgical options include osteotomy to restore long bone deformity and arthroplasty to correct altered joint mechanics. Patients are at increased risk for surgical complication such as blood loss and heterotopic bone formation. Issues relating to the surgical management of patients with Paget’s disease such as appropriate preoperative diagnosis, technical challenges of surgery, and strategies to improve the long-term outcome of surgical intervention are discussed.

Background: Surgical wound infection surveillance is an important facet of hospital infection control processes. There are several surveillance methods for surgical site infections. The objective of this study is to evaluate the accuracy of two different surgical site infection surveillance methods.Methods: In this prospective cross sectional study 3020 undergoing surgery in general surgical wards of Imam Khomeini hospital were included. Surveillance methods consisted of review of medical records for postoperative fever and review of nursing daily note for prescription of antibiotics postoperatively and during patient’s discharge. Review of patient’s history and daily records and interview with patient’s surgeon and the head-nurse of the ward considered as a gold standard for surveillance.Results: The postoperative antibiotic consumption especially when considering its duration is a proper method for surgical wound infection surveillance. Accomplishments of a prospective study with postdischarge follow up until 30 days after surgery is recommended.Conclusion: The result of this study showed that postoperative antibiotic surveillance method especially with consideration of the antibiotic usage duration is a proper method for surgical site infection surveillance in general surgery wards. Accomplishments of a prospective study with post discharge follow up until 30 days after surgery is recommended.

Background: Despite advances in medical science and modern technology, epilepsy remains as a stigmatized condition and negative public attitude toward epilepsy is a common phenomenon especially in developing countries such as Iran. It is the major factor causing serious social discrimination against people with epilepsy which in turn may be more devastating than the disorder itself. Thorough understanding of the knowledge and attitudes toward epilepsy is essential to modify these negative attitudes.Methods: We conducted a face-to-face questionnaire interview survey in crowd locations of Tehran in August, 2004-April 2005. A total of 1079 persons all more than 15 years old were asked to fill the questionnaire.Results: Eighty eight percent of respondents had heard about epilepsy before, 42.2% of them knew one person with epilepsy. However, out of responses about the causes of epilepsy, 52.4% said it was caused by brain damage, 26.4% said it was an inherited disease,, 14.3% said it was due to fever, 34.8% believed stress as the cause of it and1.1% said evil spirits was the cause. 56.9% considered pregnancy to be appropriate for epileptics. 94% believed children with epilepsy could go to school and have normal education.Conclusion: According to this survey, public knowledge and attitudes about epilepsy in study population is not satisfactory. It is suggested that additional efforts must be made to increase the knowledge of the general population through education programs especially among school children.

Background: The Composite International Diagnostic Interview (CIDI) is a comprehensive, standardized diagnostic interview for the assessment of psychiatric disorders. There have been few studies on the validity of the CIDI. The objective of present study was to assess the validity of a Farsi translation of the complete CIDI and its psychosis/mania module in five referral clinical psychiatric settings.Methods: Two hundred and three as well as 104 consecutive admissions were interviewed using the complete and the psychosis/mania module, respectively. Within two days of the CIDI interview, two last year residents of psychiatry or psychiatrist who were blind to the CIDI diagnosis completed the Clinical diagnostic checklists (based on DSM-IV and ICD-10 criteria) simultaneously and reached the consensus diagnosis. Data analysis was performed using SPSS 11 to determine the validity of CIDI.Results: The sensitivity and specificity for the diagnosis of schizophrenia was 0.12 and 0.96 using DSM-IV criteria. According to ICD-10 criteria, the results were the same with 0.19% sensitivity and 0.96% specificity. The sensitivity for the diagnosis of bipolar I disorder was low (0.21 using DSM-IV criteria and 0.17% using ICD-10) and specificity, high (0.90 compared to DSM-IV and 0.89 compared to ICD-10 criteria). The results were rather similar for the psychosis/mania module of CIDI.Conclusion: This study suggests that the Farsi translation of both the complete CIDI and the psychosis/mania module of CIDI have good specificity, but poor sensitivity for the diagnosis of schizophrenia and of bipolar I disorder.

Background: Drug abuse has been known as a growing contributing factor to all types of trauma in the world. The goal of this article is to provide insight into demographic and substance use factors associated with trauma and to determine the prevalence of drug abuse in trauma patients.Methods: Evidence of substance abuse was assessed in trauma patients presenting to Sina trauma hospital over a 3-month period. They were interviewed and provided urine samples to detect the presence of drug/metabolites of opium, morphine, cannabis and heroin by “Morphine Check” kits. Demographic data, mechanisms of injury, history of smoking and drug abuse were recorded.Results: A total of 358 patients with a mean age of 28.4 years were studied. The Patients were predominantly male (94.7%). There was a history of smoking in 136 cases (38%). 58 cases (16.2%) reported to abuse drugs (91.5% opium). The commonest route of administration was smoke inhalation (37.2%). Screening by Morphine Check test revealed 95 samples to be positive (26.5%). The preponderance of test-positive cases was among young people (of 20-30 years of age) with a history of smoking. Victims of violence and those with penetrating injuries also showed a higher percentage of positive screens (P=0.038 and P<0.001, respectively). Conclusion: These results suggest that drug abuse is a contributing factor to trauma especially in violent injuries and among the young. Regarding the considerable prevalence of drug abuse among trauma patients, it’s highly recommended that all trauma patients be screened for illicit drugs.

Background: A variable hematological value without clinical sign of sepsis or hematological disorder is often observed in newborns. The purpose of this study was to investigate hematological measurements in umbilical cord vein of newborns delivered spontaneously or by cesarean section. Methods: We studied 150 pregnant women who delivered term normal infants. The patients were divided into two groups according to the route of delivery: vaginal (n=75) and cesarean section (n=75). Immediately after delivery, umbilical cord blood samples were collected. Any possible relationship between mode of delivery, gestational age, gravidity, parity, sex, weight of the new born infant, and the duration of different phase of labor with the hematological parameters was investigated.Results: We observed a significant increase in all hematologic parameters including hemoglobin and hematocrit levels and WBC, platelet and RBC counts in newborns delivered spontaneously (p<0.001). The lymphocyte counts were similar in two groups. Male infants and newborns with higher gestational age showed a higher hemoglobin and hematocrit levels. Increased parity and gravidity correlated with a decrease in all hematological values of umbilical vein blood except of lymphocyte count (p<0.001). Prolonged duration of first and second stage was associated with higher mean leukocyte, neutrophil, platelet, hemoglobin and hematocrit values.Conclusion: The mode of delivery, gestational age, parity, gravidity, sex and weight of newborn, and the duration of first and second stage of labor can influence on hematological parameters of umbilical cord blood.

Background: Psychological debriefing has been widely advocated for routine use following major traumatic events. Cognitive Behavioral Interventions, art supportive therapies, and sport and recreational support activities are other interventions for reducing posttraumatic stress disorder. We assessed the effects of theses methods individually and in combination on reduction posttraumatic stress disorder symptoms in adolescents who had experienced Bam earthquake.Methods: In a field trial, we evaluated the efficacy of psychological debriefing, group cognitive-behavioral therapy, art and sport supportive interventions in 200 adolescents with PTSD symptoms who survived of Bam earthquake and compare it with a control group. Patients were randomly assigned to one of intervention programs including: group cognitive behavioral therapy; group CBT plus art and sport interventions; art and sport interventions without group CBT; and control group.Results: Thirty one individuals were excluded because of migration. A statistically significant reduction in overall PTSD symptoms as well as in avoidance symptoms was observed after group cognitive-behavioral therapy. There was no significant difference in reduction of overall PTSD and avoidance symptoms between the other groups.Conclusion: Psychological interventions in form of group cognitive behavioral therapy can reduce the symptoms of PTSD symptoms but we couldn't find the art and sport supportive therapy alone or in combination with group CBT to be useful in this regard.

Background: Autosomal-dominant polycystic kidney disease (ADPKD), a common hereditary disease, is characterized by the progressive development and enlargement of multiple cysts in both kidneys, and typically resulting in end stage renal disease (ESRD) by the fifth decade of life. Post-transplant diabetes mellitus (PTDM), a common complication after transplantation with an incidence rate of 2.5-20%, is associated with poor graft and patient survival. In few studies, PTDM has been more frequent in ADPKD transplanted patients. In the present study, we investigated whether there is any association between PTDM and ADPKD in our patients.Methods: In this prospective study, 140 non-diabetic and nonsmoker successfully transplanted patients (27 ADPKD and 113 non ADPKD patients) were enrolled during three years. Both groups were matched for age, sex, body mass index (BMI), duration of renal replacement therapy before transplantation and also immunosuppressive protocols after transplant. Post-transplant diabetes mellitus was defined as Clinical Practice Guidelines advocated by Canadian Diabetes Association. All patients were followed for 12 months.Results: PTDM occurred in 11.1% of ADPKD patients and in 13.1% of control group which was statistically insignificant (P>0.05). The development of PTDM in ADPKD group was not related to sex, age, and hypertension, duration of renal replacement therapy before transplantation, BMI and serum creatinine levels (P>0.05).Conclusion: Post-transplant diabetes mellitus appears not to be associated with autosomal-dominant polycystic kidney disease as an etiology of end stage renal disease.

Background: Rheumatoid arthritis (RA) is an autoimmune disorder with unknown etiology. In recent years, a great number of studies have investigated the possible role of reactive oxygen species in the etiology and pathogenesis of Rheumatoid Arthritis. The aim of this study was to analyze the level of activities of catalase, glutathione peroxidas (GSH-Px), Super oxide dismotase (SOD) in patients with RA compared with the healthy subjects.Methods: In a case-control study sixty rheumatoid arthritis patients 18-75 years old and 60 healthy sex and age-matched controls were selected, Catalase activity was measured by determining the constant rate (k) of hydrogen peroxide decomposition. GSH-Px activity of plasma was measured with spectrophotometer by Glutathione oxide generation due to GSH-Px. SOD activity is measured by degree of inhibition effect of SOD in generating super oxide radicals by xanthine and xanthine oxidase. C-reactive protein and rheumatoid factor values were determined by agglutination and latex tests.Results: The plasma activity of catalase (p<0.001), GSH-Px (p<0.01), plasma level of hemoglobin and hematocrit (p<0.05) were significantly lower in patients with RA comparing with controls. The reduction in SOD activity was not significant (p>0.05). There was a negative significant relation between Creactive protein and Rheumatoid factor values with the erythrocyte activity of catalase and GSH-Px (p<0.01).Conclusion: These results suggested that oxidative stress plays a very important role in the inflammation and pathogenesis of RA.

Background: Community-acquired pneumonia could be a life-threatening condition especially in elderly patients. The factors influencing the outcome in elderly patients are thought to be different from those in young adults. We compared the clinical and paraclinical profiles in elderly and nonelderly patients with community-acquired pneumonias.Methods: In this cross-sectional study, seventy nine patients who were hospitalized with community acquired pneumonia over a period of one year were included. Patients' medical records were reviewed; and data related to comorbid conditions, signs and symptoms, laboratory and radiographic findings were gathered using a checklist.Results: The clinical features, laboratory parameters and complications from pneumonia were almost similar in 41 elderly (group I, age ≥65 years) and 38 young (group II, age <65 years) subjects. Delirium was seen more in elderly group (p=0.05). The average body temperature and pulse rate were significantly higher in nonelderly group. Sixty one percent of elderly patients and 21% of young patients have Po2 less than 60 (p=0.02). Smoking (29.1%), neurological disturbances (19%), congestive heart failure (15.2%), chronic obstructive pulmonary disease and diabetes mellitus (13.9%) were associated comorbidities in both groups. In non elderly group, immune compromise and IV drug use were more common as underlying comorbid conditions. Two of three mortalities were due to elder patients.Conclusion: Community acquired pneumonia could have more serious clinical and abnormal laboratory features in the elderly than younger patients. Mortality rate may be higher in older patients. Comorbid conditions are frequently seen in both elderly and nonelderly patients with community acquired pneumonia, but IV drug use and immune compromise are more frequent in nonelderly patients.

Background: The early diagnosis of acute appendicitis before progression to gangrene or abscess formation is recognized as important to minimize morbidity from this common disease process. The aim of this study was to assess the value of different risk factors in the diagnosis of perforation.Methods: This descriptive-analytic and retrospective study was conducted to investigate epidemiological characteristics in patients with perforated and nonperforated appendicitis. A series of 1311 patients who were operated on for acute appendicitis between years 1380-1382 in Shahid Beheshti and Yahyanejad hospitals were reviewed. Data gathered included age at operation, gender, care sought prior to admission for appendectomy including antibiotic and analgesic therapy, time of presentation in the year, duration of symptoms, signs and symptoms at the time of admission, and the patient’s living area. Results: One hundred twenty one of 1311 patients (9%) had perforated appendicitis and 1190 patients (91%) had unperforated appendicitis. Presentation and referral in the first 6-month was associated with higher perforation rate. Patients from rural area showed a higher rate of perforations. The perforation rate was significantly higher in elderly patients (>65 year). When the duration of symptoms was more than 12 hours at presentation, the risk of perforation showed a five-fold increase. 30.7% of perforated cases had used antibiotic or sedative before referring to the hospital. Conclusion: Appendiceal perforation continues to be a complication in patients with acute appendicitis and increased in the frequency as the age of the patients increase and the duration of symptoms lengthen. We also found that the perforation rate is higher in patients from rural area and in whom present in the first 6-month of the year, a finding that was not reported so far.

Background: Celiac is one the most common causes of malabsorption and is an autoimmune disorder resulting in damage to intestinal epithelial cells by self T lymphocytes. The main culprit is gluten. The aim of our study was to assess the histopathologic findings of patients suspicious to have celiac disease in their first admission and compare them with serologic findings (endomyosial antibody test: EMA).Methods: The study is a prospective descriptional type and 95 patients suspicious to have celiac disease were included who went under upper endoscopy and sampling and also serologic studies. Histopathologic findings were grouped by Marsh classification. Specimens in Marsh stage 0 and 1 were also stained for leukocyte common antigen by immunohistochemistry Results: Ninety five patients, 49 males and 46 females, ranging from 9 months to 17 years (mean: 6.3 ys) were included in the study the most common complaint was abdominal pain. EMA test was positive in 43 patients. Most specimens were categorized as Marsh stage IIIA (51 cases) by histopatholgic examination, which can be seen in many other conditions. Only 16 patients were categorized as Marsh stage IIIB & IIIC, which are seen in established celiac patients No significant correlation was found between histopathologic and serologic findings. No difference was found between H&E staining and immunohistochemical staining in counting of intra- epithelial lymphocytes.Conclusion: Most of our patients had mild partial villous atrophy which is also seen in many other disorders and also EMA test was negative in this group. It appears that current assessment of celiac disease has many drawbacks and necessity of more specific methods is highly appreciated.

Background: A plan for management of infected arterial pseudoaneurysm has evolved from our experience with forty two cases of such aneurysms treated between 1378 and 1382. Methods: Clinical data of 42 patients with femoral pseudoaneurysm resulting from addictive drug injection who presented in emergency department of Sina Hospital between 1378 and 1383 were retrospectively reviewed.Results: All patients were men with the mean age of 36.9 years. Twenty eight patients were referred from other medical centers. The mean time of delay in presentation was 17.3 days. The mean duration of drug injection was 14 months. Primary repair and emergent vascular bypass were performed in 3 (7.1%) and 2 (4.8%) patients, respectively. 5 (11.9%) patients undergone delayed revascularization. Thirty two (76.2%) patients returned to their normal lifestyle without any vascular bypass. One patient required amputation and one patient died due to sepsis and acute renal insufficiency.Conclusion: Management of infected femoral pseudoaneurysms is simple ligation of the external iliac or femoral artery. When Doppler is not available “Operation Room and postoperative Direct Observation” is recommended in such patients to avoid unnecessary revascularization surgery.