TEHRAN UNIVERSITY MEDICAL JOURNAL (TUMJ)
Year:2008 | Volume:66 | Issue:2|Papers Count:19

Background: Total spinal anesthesia is a complication of lumbar epidural anesthesia following undiagnosed subarachnoid or subdural injection of local anesthetic. Although many achondroplastic dwarfs have a normal spine, catheter insertion may be more problematic with a narrow epidural space making a subarachnoid tap more probable.Other malformations associated with achondroplasia, such as prolapsed intervertebral discs, reduced interpedicular distance, shortened pedicles, and osteophyte formation, combined with a narrow epidural space may make identification of the space difficult and increases the risk of dural puncture. Furthermore, subarachnoid tap or dural puncture may be hard to recognize if a free flow of CSF is difficult to achieve due spinal stenosis. Yet, for those who meet the criteria, epidural regional anesthesia is frequently preferred over other forms, which often have more or more dangerous side effects in this type of patient.Case report: A 22-year-old achondroplastic male dwarf patient was scheduled for pelvic mass resection and was considered a candidate for continuous epidural anesthesia. The anesthesia became complicated by total spinal anesthesia, which was reversed following supportive management for about two hours.Conclusion: There is significant debate over the composition and volume of the test dose, especially for patients with achondroplasia. We nevertheless recommend repeated testdoses during the accomplishment of epidural anesthesia to exclude unintended intravascular, intrathecal or subdural injection, keeping in mind that a test dose of local anesthetic does not completely prevent complications.

Background: Transrectal ultrasonography guided needle biopsy of prostate frequently used for early detection of cancer has faced the pathologists with a major diagnostic challenge.In recent years P504S has been used as a tumor cell marker for definitive diagnosis of prostatic cancer in small biopsy specimens.Methods: 70 prostate needle biopsies and 6 transurethral resections (TURP) containing atypical foci as well as 40 morphologically unequivocal prostate cancer biopsies, including 8 with foamy features, were stained with P504S.Results: 36 specimen out of 40 biopsies with unequivocal cancer, showed variable P504S staining (sensitivity, 90%); 2 minute cancer and 2 foamy cancer lacked P504S staining. of 76 cases with atypical foci (70 biopsies, 6 TURP), 18 were diagnosed as high-grade prostatic intraepithelial neoplasia (HGPIN) - 16 of them showing diffuse moderate P504S staining - and 58 had foci of atypical small acinar proliferation. 14 of the latter cases were highly suggestive of cancer, 4 of which lacked P504S staining. In 44 cases with benign atypical foci, 2 out of 14 cases with atypical adenomatous hyperplasia (AAH) and 1 of 2 postradiation atypias showed focal weak P504S staining with remaining 28 cases being negative.Conclusions: P504S has slightly lower sensitivity for detection of prostate cancer than that found previously. Heterogeneous expression patterns may explain negativity in some biopsy specimens with minute cancer. In atypical small acinar proliferations, diffuse positive P504S staining in atypical glands strongly supports cancer diagnosis, but negative staining does not exclude it. P504S seems to have low sensitivity for detecting minute and foamy prostate cancers. Most HGPINs show diffuse moderate P504S staining. AAH and benign glands may show focal P504S staining. We recommend using P504S along with morphologic examination and conventional basal cell markers.

Background: Sentinel lymph node (SLN) biopsy has become the standard of care in malignant melanoma, it is commonly identified by intradermal injection of both radiocolloid tracer and Patent Blue Dye (PBD) around the tumor. This study aims to evaluate the efficacy of PBD in identifying inguinal SLN and also the accuracy of SLN mapping performed by peritumoral injection of PBD without combined radioisotope in malignant melanoma of lower extremity.Methods: Thirty consecutive patients with primary melanoma of lower exteremity who were referred to Cancer Institute of Tehran University of Medical Science between March 2003 to March 2006 were enrolled in this study. All patients had a preoperative pathologic diagnosis of malignant melanoma, median breslow thickness (range 1-4 mm) and none had clinical or radiologic evidence of nodal involvement or distant metastases.At surgery PBD was injected around the lesion or scar of excisionl biopsy. Subsequently with a 5cm groin incision SLN Biopsy and complete lymph node dissection was done and all lymph nodes were sent for histopathologic examination. SLN examined by both hematoxylin-eosin and immunohistochemical staining.Results: SLN identification rate was 100%. No complication directly related to PBD injection was seen. Forty-eight sentinel lymph nodes and 195 non sentinel lymph nodes were harvested. Nineteen SLNS were found to be metastasic in 13 patients (47%). In these patients metastases were found in other inguinal lymph nodes.In the remaining 17 patients, both the SLN itself and the other removed nodes were negative for the metastatic involvement.Conclusions: Patent blue dye may be enough to identify superficial inguinal SLN in lower extremity melanoma.

Background: The aim of this study was to assess the efficacy and safety of a new minimally-invasive surgical procedure using trans-obturator Tape (TOT) to treat female stress urinary incontinence.Methods: This clinical trial study was performed from 2003 to 2004 in the Gynecology Department of Imam Hospital, Vali-e-Asr, Tehran, Iran. A total of 35 women with stress urinary incontinence underwent the TOT procedure. All patients underwent pre-operative clinical examination, cough-stress test (full bladder), uroflowmetry and post-voiding residual volume assessment.Results: The mean age of patients was 50 years, ranging from 26 to 74 years, with average urinary stress incontinence duration of six years. The mean time of follow-up was 14 months (at 1, 6, 12 and 24 months) and the average duration of surgery was about 20 minutes. The perioperative complication rate was 9% with no vascular, nerve or bowel injuries. The rate of hemorrhagic side effects (spontaneously-absorbed hematoma and blood loss not requiring blood transfusion) was 2.9%. Post-operative urinary retention and vaginal erosion occurred in one case each; the former was treated by intermittent selfcatheterization.In total, 91.4% of patients were completely cured and 8.6% were improved without failure of treatment.Conclusions: The present study confirms the results obtained by Delorme and coworkers, and allows us to consider TOT as a safe, minimally invasive and efficient short-term surgical technique for the treatment of female stress urinary incontinence, alone or in combination with prolapse repair. Following this study, a randomized control trial is recommended to compare TOT with the gold standard surgery for women with urinary incontinence.

Background: Acute appendicitis is one of the most common abdominal emergencies.Many studies comparing the two routes of open and laparoscopic appendectomy have been performed comparing the duration of each operation, duration of hospitalization, amount of post-operative pain medication required and infectious complications were the most commonly evaluated factors.Methods: This clinical trial study, performed between March 2005 and March 2006 at Golestan and Imam Khomayni hospitals in Ahvaz, Iran, included 100 patients. Open appendectomy and laparoscopic appendectomy were carried out on 50 patients each.Duration of surgery and hospitalization, amount of pain medication and infectious complications were compared, with chi–square, ANOVA and t-test used for statistical analysis.Results: The average length of hospital stay for laparoscopic appendectomy was 44.48 hours and for open appendectomy was 54.80 hours (p<0.01). The average of amount of pain medication for laparoscopic appendectomy was 2.40 doses and for open appendectomy was 30.46 doses (p<0.01). The laparoscopic and open procedures averaged 31.8 and 35.2 minutes, respectively (p=0.5). Only one (2%) laparoscopic case had infection, while four (8%) open appendectomy subjects suffered from this complication. Patients who underwent laparoscopic appendectomy had no intra-abdominal abscesses.Conclusions: Duration of hospitalization was statistically much shorter using the laparoscopic appendectomy than that of the open procedure (P<1%). The amount of pain medication administered was also statistically less in the laparoscopic procedure (P<1%).However, the amount of time to complete each procedure was not statistically different.Most importantly, complications such as wound infection and intra-abdominal abscess were remarkably less using laparoscopy. We recommend laparoscopic appendectomy over open appendectomy.

Background: Cirrhosis and portal hypertension influence the hepatic circulation. The purpose of this study was to evaluate the diagnostic accuracy of liver Doppler ultrasonography parameters in cirrhosis.Methods: This case-control study involved 118 subjects. All case subjects had biopsyproven hepatic cirrhosis. The controls were healthy people, case-matched for age and gender. All cases and controls underwent Doppler ultrasonographic evaluation. We compared the area under the ROC curve of each parameter for cases vs. controls using Fisher’s exact test, with p <0.5 indicating significance.Results: The means of the following parameters for case vs. control subjects were: frequency of portal venous flow inversion, portal vein diameter 12.67±2.72 vs. 10.59±1.69, and hepatic arterial resistance index 0.81±0.07 vs. 0.74±0.09. The mean hepatic artery pulsatility index (1.87±0.48 vs. 1.34±0.23), was significantly higher among the case subjects (P=0.001). The maximum flow rate of the portal vein was also significantly lower in the case subjects (16.50±5.59 vs. 36.74±8.74 cm/s, P=0.001). We did not observe significant differences in the means of the hepatic artery maximum flow rate and end-diastolic flow rate. For diagnosing cirrhosis, the application of 24.1 cm/s as the cutoff point for the portal vein maximum flow rate, we obtain an accuracy of 95.45% (91.23%-97.70%, CI=95%), whereas a cutoff point of 1.54 or more for the hepatic artery pulsatility index yields an accuracy of 85.71% (79.48%-90.29%, CI=95%). Utilizing a hepatic arterial resistance index of 0.765 or greater is associated with an accuracy of 71.05% (62.81%-78.11%, CI=95%) in diagnosing cirrhosis.Conclusions: Doppler ultrasonography and assessment of hepatic artery and portal vein parameters are accurate methods in the diagnosis of cirrhosis.

Background: Childhood nephrotic syndrome is frequently characterized by a relapsing course. Due to their adverse effects, the use of corticosteroids for the management of frequently relapsing nephrotic syndrome is limited. Levamisole, a steroid sparing agent, has been found to have low toxicity. This study was conducted to evaluate the efficacy of levamisole in steroid-sensitive nephrotic syndrome (SDNS).Methods: In this retrospective study from January 1988 to September 2006, we included data from 305 pediatric SDNS patients at the Children’s Medical Center clinics in Tehran, Iran. Nephrotic syndrome was diagnosed using classic criteria. None of the patients had any signs or symptoms of secondary causes of nephrotic syndrome. All had received prednisolone 60 mg/m2/day. After remission, prednisolone administration was reduced to every other day and the steroid was tapered over the next three months. With every recurrence, prednisolone was prescribed with the same dosage, but after remission it was continued at a lower dosage for another six months or longer if there was risk of recurrence. Levamisole was administered to all patients at a dose of 2 mg/kg every other day.Results: Patients ranged in age from 1 to 20 years (mean±SD: 4.84 ±3.1) and 70.8% were male. At the last follow up, 84 (27.5%) were in remission, while 220 (72.1%) patients had relapsed or needed a low dose of steroid. Levamisole was effective in reducing the prednisolone dosage and long-term remission in 68 (22.3%) and 90 (29.5%) cases, respectively. A comparison of before vs. after levamisole treatment revealed a had significant decrease in the number of relapses (2.05±0.88 vs. 1.1±1.23; P<0.0001) and the prednisolone dosage (0.74±0.39 vs. 0.32±0.38 mg/kg/day; P<0.0001). Only one patient developed levamisole-induced neutropenia.Conclusions: In childhood steroid-dependent nephrotic syndrome, levamisole is an efficacious, safe initial therapy in maintaining remission while decreasing steroid dose, in addition to reducing the rate of relapse.

Background: Medical induction abortion is an acceptable alternative to surgical abortion for pregnancy termination. Misoprostol is an inexpensive PGE1 analogue that can be used easily and safely as a single agent for first- and second-trimester pregnancy termination.The objective of this study was to evaluate the efficacy of two different doses of vaginal misoprostol for pregnancy termination with gestational age up to 16 weeks.Methods: This clinical trial included 100 pregnant women with gestational age up to 16 weeks requesting legal termination of pregnancy. The subjects were randomized in two equal groups, and received either 200 (group 1) or 400 mg (group 2) misoprostol vaginally every 6 hours with a maximum of four doses. Response to treatment was defined as complete or incomplete abortion within 48 hours after initial dose. Curettage was performed for patients with heavy bleeding or incomplete abortion. The abortion outcome and side-effects were assessed.Results: The groups were similar in maternal age, gestational age, parity and obstetrical history and indication for pregnancy termination. The side effects in group 2 were significantly higher than in group 1 (P<0.05). There were no statistically significant differences between the two groups regarding completeness of the abortion and mean time to abortion induction.Conclusions: In the termination of pregnancies up to 16 weeks, the 200 mg per dose regimen of misoprostol was as effective as the 400 mg regimen; however, side-effects were more common with the higher dose.

Background: Premedication is widely used in pediatric anesthesia to reduce emotional trauma and ensure smooth induction. The rectal route is one of the most commonly accepted means of drug administration. The aim of our study was to investigate and compare the efficacy of rectally administered midazolam versus that of ketamine as a premedication in pediatric patients.Methods: We performed a prospective randomized double-blinded clinical trial in 64 children, 1 to 10 years of age, randomly allocated into two groups. The midazolam group received 0.5 mg/kg rectal midazolam and the ketamine group received 5 mg/kg rectal ketamine. The preoperative sedation scores were evaluated on a three-point scale. The anxiolysis and mask acceptance scores were evaluated separately on a four-point scale, with ease of parental separation, based on the presence or lack of crying, evaluated on a two-point scale.Results: Neither medication showed acceptable sedation (<75%), with no significant difference in sedation score between the two groups (P=0.725). Anxiolysis and mask acceptance using either midazolam or ketamine were acceptable, with midazolam performing significantly better than ketamine (P=0.00 and P=0.042, respectively). Ease of parental separation was seen in both groups without significant difference (P=0.288) and no major adverse effects, such as apnea, occurred in either group.Conclusions: Rectal midazolam is more effective than ketamine in anxiolysis and mask acceptance. Although they both can ease separation anxiety in children before surgery, we found neither drug to be acceptable for sedation.

Background: Resulting from the rough flow of air through the nose and throat during sleep, snoring can arise from transitory obstruction at various levels, rendering the sufferer feeling sleep deprived. A relatively new method using radiofrequency technology, called palatoplasty (somnoplasty), can be used to reduce the size of obstructive tissues in the nose and throat. In this study, we assess radiofrequency palatoplasty in the treatment of snoring.Methods: This nonrandomized prospective quasi-experimental study included 28 patients who snored at a level considered bothersome to their bed partner. Snoring and drowsiness were each subjectively scored using 20-point visual analogue scales before and after treatment. Radiofrequency energy was delivered to the soft palate either at the midline or in the lateral soft palate; 21 patients were treated once and seven patients twice with an interval of at least seven weeks.Results: The mean age of the patients was 47 (SD=10.7) years, with a range of 25-65 years, 57% were men, and the mean body mass index was 29 (SD=4.5). Sleep apnea in these patients was subjectively rated mild to moderate. After seven weeks of treatment, snoring was improved in 71.4% of patients (p<0.005). The tongue versus pharyngeal size was improved in 34.4% (p<0.005). The mean patient snoring score was significantly improved from 17.39 (SD=3.02) to 11.50 (SD=6.46) (p<0.005). The mean drowsiness score was also significantly reduced from 6.8 (SD=6.9) to 3.93 (SD=4.19) (p<0.005). No persistent negative impact was observed in speech or swallowing. Pain and bleeding was limited.Conclusions: Radiofrequency palatoplasty is effective in the treatment of snoring and its consequent drowsiness.

Background: Approximately 10 percent of all pregnancies continue to 42 weeks’gestation.The true prevalence of pregnancies lasting longer than 41 or 42 weeks’gestation has been difficult to establish because many such diagnoses occur as a result of an inability to accurately establish time of conception. Several studies indicate that menstrual dating is often inaccurate and can lead to induction of labor for a presumed but inaccurate diagnosis of postterm pregnancy. It is now widely accepted that a more precise method of determining gestational age is the first trimester measurement of crown-rump length of the fetus.Methods: We carried out a cross- sectional study on patients who were referred for a prenatal care to Arash hospital, Medical Sciences/University of Tehran. Women in the first trimester of pregnancy who presented to the center during the study period with precise date of last menstrual period were eligible to enroll. They underwent an ultrasound dating scan between 8 and 12 weeks, measuring crown-rump length. The estimated date of delivery (EDD) was changed if there was a discrepancy of more than 5 days from the gestation, calculated from the last menstrual period (LMP). For the remaining women (noscan group), gestation was determined using the LMP. Data were analyzed using SPSS, 11.Statistical significance was assessed with Chi-square, student t-test and Anova, using a significance threshold of < 0.05.Results: Of 217 women who were enrolled, 10.6% of the patients who underwent an ultrasound dating scan were postdate versus 3.7% of the patients whose gestational age calculated from LMP (p=0.005).Conclusions: The application of first trimester sonographic measurement of crown-rump length of the fetus results in a significant reduction of the diagnosis of postterm pregnancies.

Background: Chlamydia trachomatis (CT) is an obligate intracellular bacterium that causes genital disease and the most common sexually transmitted infection in the world. The most frequent risk factors associated with chlamydial infection are related to sexual behavior, multiple partners, and inconsistent condom use. Presenting primarily as urtheritis in men and cervicitis in women, CT a major cause of chronic pelvic inflammatory disease and subsequent infertility in women, eye and lung infection in newborns and other manifestations. Identification of CT-infected patients may prevent its spread and thereby reduce the high morbidity associated with CT infections. Polymerase chain reaction (PCR) is a sensitive and specific method for the detection of small quantity of bacterial DNA in clinical samples. The aim of this study was to determine the frequency of C. trachomatis by PCR in genital samples from patients in the city of Kerman.Methods: A total of 130 genital samples including 64 endocervical and 66 urethral swab samples were collected by physicians. Nucleic acid was extracted from each sample using a commercial DNA extraction kit. PCR primers specific for a conserved region of the C. trachomatis omp2 gene, encoding an outer membrane protein, were used for amplification.Results: A total of 9.2% (6.25% of cervicitis and 12.1% of urethritis) of the samples were found positive for CT using this PCR method.Conclusions: The present study shows a high prevalence of CT infection, especially in men with urethritis. Such patients should be referred to genitourinary clinics for treatment and partner notification. Given its worldwide prevalence, further CT studies on more populations are needed to assess potential public health implications of these infections.

Background: Hypertension is a very common and important disease. There are conflicting reports about mercury, a trace element, in the genesis of hypertension.Methods: In this study we examined the relationship between blood mercury levels and hypertension prevalence in a population-based sample of hypertensive and normotensive patients at the Shariati Hospital and the Tehran Heart Center in Tehran, Iran. A cross sectional sampling of 224 patients, aged 40-80 years, who participated in physical examinations conducted in 2006 were included in this study. The population that participated in this study were sample of hypertensive (n=112) which had essential hypertension and normotensive (n=112) patients which had no history of essential hypertension at the Shariati Hospital and the Tehran Heart Center in Tehran. The consent of all the patients was taken in the written form before the experiments. After selecting the patients the range of blood mercury levels were measured with Flame atomic absorption.Results: The range of blood mercury levels was 0 to 39.55 mg/dL. The mean blood mercury level of hypertensive patients (10.75 +1.23 mg/dL) was higher than that of normotensive patients (1.6 +1.02 mg/dL). There was a significant difference in the mean blood mercury level of normotensive men (1.74 +1.56 mg/dL) versus that of hypertensive men (11.9 +1.38 mg/dL). The mean blood mercury level of normotensive women (1.5 mg/dL) was also significantly different from that of hypertensive women (9.65 +0.53 mg/dL) (p<0.001).Conclusions: In this population, there is a positive relationship between the concentration of blood mercury levels and the presence of hypertension.

Background: Measuring anxiety level in clinical and non-clinical population needs valid and reliable tool. This research examined the validity and reliability of Beck Anxiety Inventory in Iranian normal population as well as clinically anxious patients.Methods: First, a two-session course was run to train research workers. After they were sufficiently prepared, they were dispatched to different regions of the city, Tehran, referring to residential places for men and women volunteer to take part in the research. At the end, 1513 respondents were randomly recruited and tested using Beck Anxiety Inventory (BAI). Of this population, 112 respondents were randomly selected and re-tested in order to measure test-retest reliability with a one-month interval time between first and second tests. Meanwhile, 261 clinically anxious patients (from clinics and mental health centers) were tested. In order to measure validity, 150 patients were interviewed by two parallel clinicians and the anxiety level was rated based on a 10-point scale from 0 (the least) to 10 (the most). The two raters were blind to the BAI scores of the patients.Results: For data reduction and analysis, the SPSS for Windows-edition 14, was conducted.Findings showed that the Persian version of BAI proved a good reliability (r=0.72, p<0.001), a very good validity (r=0.83, p<0.001), and an excellent internal consistency (Alpha=0.92).Conclusions: The results support the applicability of BAI in Iranian population and suggest the use of this inventory for clinical and research aims. Persian version of BAI not only can help clinicians in assessment and diagnosis, but also assist researchers to evaluate anxiety level when needed.