Tehran University Medical Journal
Year:2008 | Volume:66 | Issue:3|Papers Count:16

Background: Aeromedical transport provides immediate advanced medical treatment for certain critically ill and injured patients, bringing about rapid treatment and decreasing the time of hospitalization. With the great expense of helicopter emergency medical services (HEMS), research and review of experience is conducted to determine areas in which the enforcement of standards will enable the effective and optimal use of HEMS.Methods: We examined peer-reviewed published articles in French, English and Persian journals and medical texts to determine the best use of, and standards for, HEMS.Results: We found that HEMS effectively improves health care in three categories of services: the rapid transportation of medical personnel/equipment to an accident and of patients to the hospital (primary response); meeting road ambulances at an intermediate point coming from a hospital or accident to transport patients to a hospital (secondary response); the planned urgent inter-hospital transfers of critically ill patients for specialized care (tertiary response). HEMS standards have been set for: the flight equipment and crew, the types of emergencies to which HEMS should respond, the optimal length of time for each part of the mission (call out time, response time, on-scene time, transport time, and total rescue time) and the affect on patient survival. Some other standards include: algorithms for patient screening, flight heights for different diseases and injuries, rooftop and parking garage helipad at hospital, approach of flight paths and the facility at the touchdown area. HEMS standard medical equipment includes those needed for telemedicine and basic and advanced life support. Standard drugs on board the HEMS vehicle depends on the type of the missions selected for HEMS. The area of medical crew members, as well as their fundamental and the continuing training, also has standards that must be met. The standard scoring system for severity of injury, and finally, the standard method for the annual calculation of the cost and benefit of using HEMS in a specified region have also been considered.Conclusion: As trauma is a common reason for requesting HEMS in Iran, the decrease in “Golden Hour” response time for trauma patients is a priority. HEMS is expensive and enforcing standards also requires increased effort and expense. Nevertheless, both can reduce the morbidity, mortality and expense for longer hospital stays. Thus, the proper telemedicine and life support equipment and drugs, as well as algorithms for patient screening can improve HEMS efficacy. Furthermore, enforcing proper communication and record keeping regarding trauma severity for HEMS missions allows hospitals to predict the proper immediate treatment for incoming patients and its future need for HEMS services.

Background: Amino acids have different effects on the growth of some dermatophytes. Some may encourage growth, while others inhibit it. The concentrations of some amino acids also are an important factor for their effect. To investigate the effects of amino acids on the growth of dermatophytes, the dermatophytes Trichophyton schoenleinii and Microsporum canis, obtained from Iran.Methods: In this study, two concentrations (1g/dL and 0.1g/dL) of 23 amino acids were added to the Sabouraud glucose agar media of these dermatophytes. The experiment was carried out three times. After two weeks, the means of the colonies were compared with the control, which had no amino acids added to the Sabouraud glucose media.Results: The results showed that L-cysteine hydrochloride, L-cysteine, L-aspartic acid, Lglutamic acid and DL-tryptophan and L-tyrosine had the most inhibitory effects on the studied dermatophytes, while arginine L-lysine and L-methionine had moderate effects and the rest of amino acids had less inhibitory, or even stimulatory, effects on the growth of the dermatophytes. M. canis and T. schoenleinii has a different sensitivity to amino acids. This data indicates that sulfur-containing amino acids and acetic amino acids have greater inhibitory effect against these two dermatophytes.This may be an indicator that such amino acids used in, for example, sweetener may have an important role in immunity to these dermatophytes. Thus, some amino acids may be used as a possible treatment for dermatophytosis.Conclusion: Among the amino acids L-cysteine hydrocholoride, glutamic acid, aspartic acid, and tryptophan are the most inhibitory effect s against of T. schoenleinii and M. canis.

Background: The health risk associated with chronic exposure to organic solvents investigated in several epidemiologic studies indicates a significant relationship between solvent exposure and glomerulonephritis. Solvents are the most commonly used chemicals in industry. According to European statistics 43% of all solvent consumption takes place in the painting industry, 10% in metal cleansing, 6.7% in adhesives and 3.9 percent in the laundry (dry cleaning) industries. Although BUN and creatinine indicate massive loss of glomerular function, microalbumin is a sensitive urinary marker for nephrotoxins in the early detection of solvent-induced effects on the glomerulus. The purpose of our study was to use microalbumin, serum BUN and serum creatinine levels to identify occupational solvent-induced effects on the glomerulus.Methods: Renal dysfunction was monitored by microalbumin, BUN and creatinine serum levels in a cohort study of 92 workers currently exposed to solvents (solvent group). A control group of 92 individuals were selected from parts of the same factory not exposed to solvents. All individuals in the study were men, without diabetes or hypertension. The percentage of smokers was equal between the two groups. The solvent group was selected using environmental monitoring of organic solvents in different parts of the painting room. The individuals were chosen by simple random selection. Exclusion factors included less than one year of work in the painting room, use analgesic or aminoglycoside one month before the study and medically diagnosed renal disease, such as glomerulonephritis or renal failure. Data was gathered using a questionnaire requesting demographic information, history of present and past diseases, present and past occupational history, drug history, history of illness in their colleagues and safety conditions at work (use of safety gloves, masks, clothing, goggles and general and local ventilation). The results analyzed with SPSS 11.5.Results: Several studies showed that solvents cause renal disorder (tubular and glomerular), although glomerulonephritis is more prevalent. The mean age of the solvent group was 28.6 ±2.7 years and was 33.7 ±7 years in control group (p<0.05). The mean duration of solvent exposure was 4.8 ±1.5 years. Statistically meaningful differences were found between solvent and control groups for microalbuminuria, increased serum BUN and creatinine levels (p<0.05), although there was no significant correlation between these parameters and the duration of exposure (p>0.05).Conclusion: The results suggest that kidney dysfunction results from chronic occupational exposure to solvents at levels found in automobile painting rooms in Iran.We recommend increased monitoring of workers using solvents and increased review and enforcement of safety regulations regarding such use of solvents.

Background: Early diagnosis of bacteremia and its complications is the most important part of care and management of the patients. The utility of polymerase chain reaction (PCR)techniques have been shown to identify pathogens in less and more optimal time. The aim of our study was to evaluate prevalence of bacteremia using universal PCR in febrile patients admitted in Pediatric Medical Center comparing other routine methods like blood culture. Methods: One hundred febrile children suspected to septicemia who were admitted in Pediatric Medical Center, were included. From all patients whole blood samples were obtained for blood culture and PCR. Results: Of all patients, 65%were 3 to 36 months old. The frequency of male and female patients was 45 and 55, respectively. The prior oral and parental antibiotic therapy had been taken for 45 and 12 patients. The mean temperature of body was 38.98 ±0.57at presenting time. Twelve patients were positive blood culture. Nineteen patients had positive PCR test which consisted of 11 patients with positive blood culture. The severity of fever and laboratory findings such as WBC, ESR, and CRP had no significant difference between patients with positive and negative blood culture and PCR. Conclusion: universal PCR technique is more sensitive and specific than conventional blood culture and other methods to diagnose bacterial infection.

Background: For the purpose of ascertaining myocardial infarction (MI) and ischemia, the sensitivity of the initial 12-lead ECG is inadequate. It is risky to diagnose posterior MI using only precordial reciprocal changes, since the other leads may be more optimally positioned for the identification of electrocardiographic changes. In this study, we evaluated the relationship between electrocardiography changes and wall motion abnormalities in patients with posterior MI for earlier and better diagnosis of posterior MI.Methods: In this prospective cross-sectional study, we enrolled patients with posterior MI who had come to the Emergency Department of Shariati Hospital with their first episode of chest pain. A 12-lead surface electrocardiogram using posterior leads (V7-V9) was performed for all participants. Patients with ST elevation >0.05 mV or pathologic Q wave in the posterior leads, as well as those with specific changes indicating posterior MI in V1-V2, were evaluated by echocardiography in terms of wall motion abnormalities. All data were analyzed using SPSS and p<0.05 were considered statistically significant.Results: Of a total 79 patients enrolled, 48 (60.8%) were men, and the mean age was 57.35±8.22 years. Smoking (54.4%) and diabetes (48%) were the most prevalent risk factors. In the echocardiographic evaluation, all patients had wall motion abnormalities in the left ventricle and 19 patients (24.1%) had wall motion abnormalities in the right ventricle. The most frequent segment with motion abnormality among the all patients was the mid-posterior. The posterior leads showed better positive predictive value than the anterior leads for posterior wall motion abnormality.Conclusion: Electrocardiography of the posterior leads in patients with acute chest pain can help in earlier diagnosis and in time treatment of posterior MI.

Background: Total laryngectomy is the mainstay of treatment for laryngeal cancer. Fistula is one of the most common complications after total laryngectomy. In patients without risk factors such as prior radiotherapy, diabetes mellitus or chronic renal disease, the incidence of pharyngocutaneous fistula is related to wound healing and duration of operation. We have developed a new method that is both simple and without the complication of pharangocutaneous fistula. Herein, we report the efficacy of this innovative method for the closure of total laryngectomy compared to the conventional method for closure.Methods: In this clinical trial, we included 40 patients with grade T3 or T4 squamous cell carcinoma of the larynx. The total laryngectomy of all patients was performed by the standard method. Twenty patients (case group) were repaired by the new method for closure and 20 patients (control group) were repaired by the standard method. Duration of surgery and hospital stay, bleeding, hematoma, seroma and fistula formation were characterized for every patient and statistically analyzed.Results: The mean age was 59.8 ±7.8 years for the control group and 61.3 ±6.4 years for the case group. Duration of surgery was 150 ±23.2 minutes and 130 ±18.7 minutes for the control and case groups, respectively (p<0.001). Duration of hospital stay was 10.5 ±1.6 and 3.1 ±0.2 days in the control and case groups, respectively (p<0.002). Bleeding, hematoma or seroma were not seen in either group. Pharyngocutaneous fistula occurred in three patients in control group and was not observed in case group.Conclusion: This new method for closure shortens the duration of surgery and hospital stay. Furthermore, the patients in the case group avoided the psychological and traumatic side effects of tube feeding associated with fistula. In addition, no other complications were observed with this method. We recommend the use of this simple and efficient method for wound closure after total laryngectomy.

Background: Laparoscopic techniques for the placement of peritoneal dialysis catheters are becoming increasingly popular. Recently, with the improvements in laparoscopic surgery, various methods for the insertion of peritoneal dialysis catheters have been reported, indicating that the laparoscopic insertion is preferred over the open and percutaneous techniques. The aim of this study was to introduce and assess a simplified laparoscopic method for the insertion of peritoneal dialysis catheters in continuous ambulatory peritoneal dialysis (CAPD) patients.Methods: We enrolled 79 consecutive end-stage renal patients (46 men and 33 women) with a mean age of 50 years (range: 19-83 years) in this study. During the surgery, a 5-mm trocar was placed in the left upper quadrant for the optics and another 5-mm trocar was placed to the left of the umbilicus. Using the second trocar, a tunnel was formed 2 cm left of the umbilical plane for the insertion of a Tenckhoff catheter. Under direct vision, the catheter was advanced into the abdomen. The catheter was tested for patency.Catheters of all subjects were capped for two weeks before dialysis initiation.Results: The mean duration of the operation was 15 minutes. Ten patients died during the follow-up period, all due to other medical problems, and six patients underwent renal transplantation; however, no deaths or complications were observed during surgery. Early onset complications were seen in 12 patients (15.1%). The most frequent late-onset medical and mechanical complications were peritonitis (6.3%) and hernia (3.7%). During a follow-up period of four years, removal of the catheter was required in two patients as a result of peritonitis.Conclusion: We obtained a low complication rate and a high catheter survival rate with this laparoscopic insertion of the Tenckhoff catheter. We believe future experience will encourage the use of this safe, simple and quick procedure.

Background: Neural Tube Defect (NTD) characterized by failure of neural tube to close properly be the second most common born defect after congenital heart disease. The most prevalent forms of NTD are Anencephaly and Spinal-bifida. Many factors are involved in this anomaly. New researches suggest environmental factors like radiation, hyperthermia, Vitamin A and acid folic deficiency, anti epileptic drug like Carbamazepine, Phenobarbital, phenytoin, Folic acid antagonist like Sulfasalazine, Triametherine and systemic disease like diabet mellitus, obesity, genetic factors, the most schance 40 to 70 percentages.Methods: In this survey cross sectional study was conducted in five hospitals depend to Tehran university during three years. Study subject identified through review of admission and discharge at major hospital through regular contact with newborn nurseries and birth hospital.Results: In 38473 reported cases, 143 cases have neural tube defect. Among NTD cases, 11.9% of mothers had medical diseases in their previous history such as diabetes mellitus, epilepsy-psychiatric, and disorder-heart diseases. In this study group, 5.6% have preclampsia during pregnancy period. The most common NTD anomaly in this study was anencephaly and meningomyelocele that was different from studies in literature.Conclusion: NTD result from failure of neural tube close threats fetus health up to 28 days after conception. When is often prior to the recognition of pregnancy since many pregnancy are unplanned NTD prevention is best achieve by adequate daily folic acid intake thought of reproductive ages .educational effort to promote daily intake of folic acid supplemental by women of reproductive age and NTD risk factor should be done.Early diagnostic procedure for high risk pregnancy advised.

Background: The aim of this survey is to compare the emotional and behavioral problems of children with only one parent versus those from two-parent families. We analyzed behavioral problems such as aggression, delinquency and socialization issues, as well as emotional problems such as depression, anxiety, and somatic complaints.Methods: Using a multi-stage cluster sampling, 10 of the 20 geographic regions covered by Imam Khomeini Relief Foundation were selected. Using systematic random sampling, 460 families with children aged 4-18 years were selected. All children were evaluated using the Child Behavior Check List (CBCL) to determine behavioral and emotional problems. Logistic regression tests were conducted to measure the effects variables, including age, gender, number of parents in the family, psychiatric history of each child and history of parental psychiatric treatment, on the internalizing, externalizing and total CBCL scores. A cut-off score of 64 was used to convert raw scores.Results: No differences were observed in CBCL subscales between single-parent children vs. children of two-parent families.Conclusion: Regarding the two-parent families among the study population, the results could not be generalized. As these families have qualified for assistance, the father cannot manage the family because of his disability, such as physical or mental problems.This minimizes the effect of having a father in a two-parent family, rendering them similar to single-parent families. Thus, differences were not observed between the two types of families. Further studies are necessary to compare single-parent families with two-parent families among the community.

Background: The aim of this study was to statistically evaluate the hypothesis that the presence of meconium-stained amniotic fluid is associated with postpartum maternal infection.Methods: This prospective cohort study included 573 term pregnant women in labor, with no other medical problems, that underwent cesarean section for pregnancy termination.Women with prolonged active-phase labor, prolonged rupture of membranes, complicated cesarean section and pre-operative infections were excluded from this study. The subjects were divided into two groups: 280 women with meconium-stained amniotic fluid (M group), and 293 women with clear amniotic fluid (C group). A comparison was done regarding postpartum fever, endometritis and wound infection between the two groups. Student’s t-test and chi square test were used for data analysis, along with linear regression, with p<0.05 indicating significance.Results: Among the 573 women, a total of 82 women (14%) had fever after cesarean; 42 women from the M group, and 40 women from the C group (p= 0.3). Among the 82 women who had fever, 33 women had continuous fever, 6.5% in group M and 2.7% in group C (p<0.05, RR: 1.98, 95% CI 1.3-3.1). Among the 573 women, 4% developed endometritis 5% in group M and 2% in group C (p<0.05, RR: 2.3, 95%, CI 1.3-3.4).Similarly, among the 573 women, a total of 5 women (1%) developed wound infection, 1.7% in group M and 0.68% in group C (p=0.7).Conclusion: Meconium-stained amniotic fluid is associated with increased postpartum infection independent of other risk factors for infection.

Background: Preterm labor is a major contributor to neonatal morbidity and mortality and results in increased obstetric and pediatric care costs. The purpose of this study was to assess the effects of vaginal progesterone for maintenance therapy following treatment of threatened preterm labor for preventing preterm birth.Methods: The study included 70 singleton pregnant women with preterm labor with intact membranes. Patients were randomized to receive either maintenance vaginal progesterone therapy (n=37) administered (400 mg) daily or no treatment (controls, n=33) after discontinuation of acute intravenous tocolysis.Results: The two groups were similar with at respect to maternal age, race, parity, gestational age at admission, bishop score, and preterm delivery risk factors .Compared to the control group, the mean ±SD time gained from initiation of maintenance therapy to delivery (36/11±17/9 versus 24/52±27/2) (mean±SD) days, p=0.037) and the gestational age at delivery (36.07±1.56 vs. 34.5±1.3 weeks, p=0.041) were higher in the vaginal progesterone maintenance therapy group. No significant differences were found with recurrent preterm labor 13 (35.1%) versus 19 (57.6%), p=0.092. Respiratory distress syndrome 4 (10.8%) versus 12 (36.4%) p=0.021, Low birth weight10 (27%) versus, 17 (51.5%) p=0.04, birth weight (3101.54±587.9gr versus r 2609.39±662.9gr, p=0.002) were significantly different between the two groups.Conclusion: The gestational age and time gained from initiation of maintenance therapy to delivery were longer in women receiving vaginal maintenance tocolysis with progesterone and improve perinatal outcomes. However, maintenance therapy did not decrease the recurrence of preterm labor episodes.

Background: Poisoning is one of the major causes of seizure in emergency medicine. Because of the varying availability of drugs in different areas and insufficient control of the sale of some dangerous industrial substances, the causes of seizure in poisoned patients may be differ in our society. In this study, we examine the causes of seizures in poisoned patients in Iran, and their outcomes.Methods: This retrospective and analytical-descriptive study investigated the sex, age, type of poison, presence and type of seizure, seizure treatment and outcome from the records of 2,220 hospitalized poison victims from 2001 to 2003 in poison emergency departments in Noor Hospital. Data was analyzed by one-way analysis of variance and chi square tests using SPSS.Results: Of the 2,220 patient records examined, 66 patients developed seizure. Seizure was more common in men (33 patients), and most common in the 15-40 year age group (28 patients). The most common causes of seizure were tricyclic antidepressants (TCA) (39.7%), organophosphates (17.5%), carbamazepine (7.9%) and organochlorines (6.3%).However, status epilepticus was more common in organochlorine (25%), organophosphate, TCA (18.75%), and carbamazepine (12.5%) poisoning. There was a negative relationship between age and type of seizures. Seizure was not related to previous history of seizure. Midazolam alone (25%) was the most effective drug for controlling seizures. Death occurred in six patients with or without renal complication. The mortality rate among poisoned patients with seizure was 37.5%. Conclusion: The incidence of seizure in our study reflects the availability of certain drugs and toxins that require more steadfast control. Midazolam, with its low side effects, may be the drug of choice for the treatment of status epilepticus in poisoning.

Background: Although it is not a new disorder, in recent times we have attained a greater understanding of auditory neuropathy (AN). In this type of hearing impairment, cochlear hair cells function but AN victims suffer from disordered neural transmission in the auditory pathway. The auditory neuropathy result profile often occurs as a part of that of the generalized neuropathic disorders, indicated in approximately 30-40% of all reported auditory neuropathy/auditory dyssynchrony (AN/AD) cases, with approximately 80% of patients reporting symptom onset over the age of 15 years. In the present report, the results of audiologic tests (behavioral, physiologic and evoked potentials) on two young patients with generalized neuropathy are discussed.Case report: Two brothers, 26 and 17 years old, presented with speech perception weakness and movement difficulties that started at 12 years of age and progressed as time passed. In their last examination, there was a moderate to severe flat audiogram in the older patient and mild low tone loss in the younger one. The major difficulty of the patients was severe speech perception impairment that was not compatible with their hearing thresholds. Paresthesia, sural muscle contraction and pain, and balance disorder were the first symptoms of the older brother. Now he can only move with crutches and his finger muscle tonicity has decreased remarkably, with marked fatigue after a short period of walking. Increasing movement difficulties were noted in his last visit. Visual neuropathy had been reported in repeated visual system examinations for the older brother, with similar, albeit less severe, symptoms in the younger brother.In the present study of these patients, behavioral investigations included pure-tone audiometry and speech discrimination scoring. Physiologic studies consisted Transient Evoked Otoacoustic Emission (TEOAE) and acoustic reflexes. Electrophysiologic auditory tests were also performed to determine Auditory Brainstem Response (ABR), Auditory Middle Latency Response (AMLR) and Auditory Late Response (ALR). The results of these examinations for these two siblings are discussed and compared with the results of other studies.Conclusion: Distinguishing auditory neuropathy from other speech perception disorders can be performed by conducting audiologic evaluations as a battery of tests. The probability of generalized neuropathy must be considered in patients with auditory neuropathy symptoms.