MEDICAL JOURNAL OF MASHHAD UNIVERSITY OF MEDICAL SCIENCES
Year:2008 | Volume:50 | Issue:98|Papers Count:22

Introduction: Systemic Lupus Erythematosus (SLE) is an autoimmune disease with unknown etiology. It can cause diverse clinical manifestations. Neuropsychiatric (NP) features may appear as the main signs and symptoms of the disease while they can be extremely severe in nature. Since the NP conditions are almost always very important, early diagnosis and aggressive treatment is mandatory. This study was aimed to evaluate the NP manifestations of SLE. Materials and Methods: This was a descriptive prospective study conducted from 2002 to 2004 at Ghaem Hospital, Mashhad University of Medical Sciences. Patients, involved in SLE according to American College of Rheumatology (ACR) criteria, entered the study. A neurologist examined all the patients clinically while paraclinical assessments were carried out in parallel when required. All the data were gathered in prepared questionnaires and analyzed statistically. Results: From 88 examined SLE patients, 27 had NP-SLE (30.6%). The mean age in this group was 25 years. The mean time between the beginning of the disease and the occurrence of the NP manifestations was 2.1 years. Central Nervous System (CNS) and Peripheral Nervous System (PNS) involvements were seen in 88.9% and 29.6% respectively. Cognitive dysfunction (55.5%), among all other NP features, was the most prevalent, and seizure with 37 % was the second common manifestation.Conclusion: NP involvement of SLE patients usually occurs in young individuals. CNS involvement (most frequently seizure and psychosis) was more common than the PNS involvement. In our study, cognitive disorders were the most widespread features, which is compatible to the results of other similar studies. The vast variety of neuropsychiatric manifestations and their effects on the prognosis of the underlying disease, necessitate routine complete neurologic examinations as soon as the diagnosis is confirmed.

Introduction: As a common symptom of brain diseases, seizure often indicates severe brain tissue involvement. The purpose of this study was to evaluate the different etiologies of seizure disorders.Materials and Methods: In this descriptive study, from Marches 2002 to February 2003 497 epileptic patients in Neurology Emergency Unit of Ghaem Hospital, Mashhad were studied. Routine laboratory tests, EEG, and brain CT-Scan was performed for all patients and brain MRI was done for some of them. Demographic data and results of laboratory tests, EEGs and brain CT-Scans were recorded in specific data collection sheets and were analyzed by SPSS software.Results: In our patients (497 cases), 51.3% were male and the others (48.7%) were female. The mean age of our population was 37.6 years and most of patients were middle aged (35-60 years). The prevalence of different seizures was as follows: Generalized seizures in 82.8%, Focal seizures in 7.5%, and focal seizures with secondary generalization in 9.7%. The prevalence of different etiologies of seizures was: idiopathic and cryptogenic in 48.5%, cerebral vascular diseases in 13.5%, brain tumors (primary or metastatic) in 6.8%, trauma in 6%, acquired metabolic diseases in 6%, drug intoxication or withdrawal in 4.8%, brain infections in 4.6%, developmental disorders in 2.6%, collagen vascular diseases in 2.2%, hypoxic-ischemic encephalopathy in 1.8%, phakomatosis in 0.8%, degenerative disorders in 0.8%, hypertensive encephalopathy in 0.6%, demyelinating diseases in 0.6%, and eclampsia in 0.2%. 65.85 of our patients had a previous history of at least one seizure attack, 25.25 had experienced their first seizure and 9.1% had been admitted because of status epilepticus. 15.3% of patients had positive family history for epilepsy. The most common cause of epilepsy in this study was idiopathic and cryptogenic and cerebral vascular diseases and tumors were the next common causes.Conclusion: Being so common as a cause of seizure and having significant morbidity and mortality, cerebral vascular diseases and brain tumors should be prevented or treated vigorously. Besides, recurrence of seizure attacks as the result of inappropriate drug intake or insufficient drug dose draws particular concern.

Introduction: Subarachnoid Hemorrhage (SAH) accounts for 5% of all strokes. Risk factors for SAH include hypertension, Cigarette smoking, alcohol and oral contraceptive pills (OCPs). In this study the risk factors of SAH in West Azerbaijan Province, Iran were evaluated. Materials and Methods: This case-control study carried out from March 2002 to March 2006 at Motahari Hospital of Urmia University. Using saved data of the patients of the hospital, 375 patients (exposed group) compared with 750 non exposed cases (Control). All of the risk factors evaluated in two groups, then were analyzed using the SPSS software. Data processing accomplished by the Chi-square test. Odd Ratios evaluated for all of the risk factors. Logistic regression model was used to find out the interaction of risk factors for SAH.Results: Of patients, 60% were women. SAH most frequently occurred between 40 to 60 years old. The Odd Ratios of cigarette smoking was 3.46, of hypertension 3.59, of alcohol use 2.69, and of oral contraceptive pills 2.19; So SAH had a relationship with these factors. Conclusion: The Results of this study were similar to other studies of this type. The important point of this study was the ability of controlling each of the risk factors which led to the decrease of prevalence of SAH in the Community.

Introduction: One of the indices that may be influenced in brain diseases is Intelligence Quotient or IQ. Since many years ago, it has been tried to provide a method in order to quantify intelligence as an index for diagnosis & prognosis of the disease. Weksler psychological tests are now of the best methods of determining Intelligence. However, weksler has some limitation such as being time consuming and also need of the individual's attention & cooperation. This Study aimed to evaluate the relationship between alpha brain rhythm and IQ.Materials and Methods: In this descriptive investigation done on 71 school boys aged 10 years in Neurology Research Center of Kerman University of Medical Sciences, WISC – R intelligence test & quantitative EEG were used. And the results of the intelligence test in 3 items of total score, practical test and verbal test compared to Alfa – rhythm in different brain regions and also mean distribution & frequency peak Alpha indices. In order to realize the relationship between IQ and Alpha – rhythm, spearman correlation test was used. Results: The results of this study showed that there was an obvious association between IQ and Brain mapping abnormalities, this means abnormal mapping related to a lower IQ. There was an obvious association between IQ, disrhythmia and EEG, it means that disrhythmia related to a lower IQ. Conclusion: Quantitative EEG findings may be used as factors for IQ interpretation.

Introduction: Complete revascularization in diabetic patients duo to small size and diffuse involvement of vessels is a problem in cardiac surgery. Duo to known complications of on-pump CABG, the off-pump CABG has been suggested in these patients. This study was carried out to assess the short term results of complete revascularization in diabetic patients. Materials and Methods: This retrospective study was done during 2002 to 2006 at Imam Reza Cardiac Surgery Ward on 500 patients who were operated by off-pump CABG. The patients were divided into two groups, a: diabetic (235 pts) and b: non diabetic (265 pts). The preoperative comorbidity, intraoperative measurement of the size of the artery at the site of anastomosis with different gauged probes, and the number of grafts per patient were recorded. Intraoperative and postoperative variables between two groups compared. The observed number of grafts (O) after surgery compared with the number of grafts predicted (P) before surgery. The O/P ratio or “completion index” of ≥1 signifies complete revascularization. Logistic regression analysis used to test possibility that diabetes was a predictor of poor outcomes. Results: Diabetic patients were older, with more comorbidity (congestive heart failure, peripheral vascular diseases, dialysis-dependent). The number of grafts per patient was 4.2±1.3 (DM) and 4.2±1.3 (non-DM). The size of 875 DM and 1068 non-DM arteries were gauged. There was no statistical difference in size between DM and non-DM (in millimeters) at each artery. All ratios ranged from 0.9 to 1.2, indicating similarity between DM and non-DM. The only significant risk factor for operative death was low left ventricular ejection fraction (P=0.001).Conclusion: patients with DM were sicker, but tolerated off-pump coronary artery bypass grafting as well as non-DM patients. The number of grafts per patient and O/P ratio signified the ability to perform complete revascularization. We were able to bypass the small target vessels, as anticipated. Diabetes is not a predictor of the outcomes.

Introduction: Video assisted thoracic surgery (VATS) is a new minimal invasive diagnostic and therapeutic method in lung diseases that provides a perfect view of pleura and pericardium to perform a diagnostic biopsy from the pathologic site. This study aimed to evaluate the diagnostic value of VATS in pleural effusion with an unknown cause.Materials and Methods: In this descriptive study, carried out from 1999 to 2007 in thoracic surgery department of Ghaem Hospital, sixty five patients with undiagnosed exudative pleural effusion underwent VATS for tissue diagnosis, and six months follow up was performed. Age and sex, pathology and diagnostic accuracy rate collected by questionnaire and processed using the SPSS software by descriptive statistics and frequency distribution table.Results: Among 65 patients, 33.8% were female and 66.2% were male. Mean age was 58.90±14.57 years. The most common clinical symptom was dyspnea which was seen in 87.7%. Pleural effusion was clear yellow in 55.4% and bloody in 44.6%. Malignant cytology was reported only in one case (1.5%). Transthoracic needle biopsy showed pleuritis in 86.2%, fibrosis in 10.8% and it was suspicious in 3.1%. VATS was diagnostic in 95.4% and exact diagnosis wasn’t obtained only in 3 cases (4.6%). Open biopsy was performed in these cases that indicated Mesotelioma in two cases, another case with the history of CABG was treated after 6 months of follow up. The most common diagnosis was metastatic carcinoma, which observed in 37 cases (56.9%).VATS diagnostic accuracy rate in this study was 95.4%. No complication was seen in 98.5% and only one case had bleeding (1.5%). Mortality rate, because of VATS complications, was not seen.Conclusion: According to the safety, high sensitivity and specificity of VATS, it is suggested as a good diagnostic method in pleural effusion with an unknown cause.

Introduction: Fentanyl, a synthetic opioid is a popular choice amongst anesthesiologists in the operating room. Preinduction IV fentanyl bolus is associated with coughing in 28-45% of patients. Coughing due to fentanyl is not always benign and at times maybe explosive requiring immediate intervention. The goal of this study was to compare the role of inhalation of salbutamol beclomethasone and IV lidocaine in preventing fentanyl induced coughing. Materials and Methods: This clinical trial study was performed in Ghaem Hospital in 2006. 320 patients aged 20-60 years, undergoing elective orthopedics surgery were randomized into four groups of 80. Group I served as control, while groups II, III, IV received an inhalation of salbutamol, beclomethasone or IV lidocaine before induction of anesthesia. Following IV fentanyl (2 mg/kg) the incidence of cough was recorded and graded as mild (1-2), moderate (3-4) and severe (³5) depending on the number of coughs observed. Patients, characteristics and coughs, and the results of using different drugs were recorded in a questionnaire and analyzed by descriptive statistical methods. A p value of =< 0.05 was considered significant. Results: The incidence of cough was 40% in the control group, 6.25%, 1.25% and 11.25% in the salbutamol, beclomethasone and lidocaine groups, respectively. Occurrence of cough was significantly low in the treatment groups; however the difference among the groups was not significant. Conclusion: The use of inhalation salbutamol, beclomethasone or IV lidocaine prior to IV fentanyl administration minimizes fentanyl induced coughing, and in conditions like corneal rupture or increased intracranial pressure, which coughing is highly dangerous, they are beneficial.

Introduction: Esophageal dysfunction occurs due to various disorders such as benign or malignant tumors, perforations, and motility disorders. Esophagectomy is considered as the final option for treatment of the diseases. Except malignant cases, in which lymphatic dissection is considered, transhiatal esophagectomy is the appropriate procedure for the esophageal cancer. Avoidance of thoracotomy and thoracic anastomosis are of advantages which reduces morbidity and mortality rate in transhiatal esophagectomy. In the procedure, pleural drainage through bilateral tube thoracostomy is routinely recommended. The aim of the study was to evaluate application of routine thoracostomy and to find specific criteria concerning chest tube insertion. Materials and Methods: This descriptive study was performed from 2001 to 2005 in General Surgery Department of Imam Reza hospital. Participants included 123 patients who underwent transhiatal esophagectomy. Blood sampling, Chest radiography, abdominal ultrasonography, barium swallow, cardiopulmonary function tests, and upper GI endoscopy was carried out for all patients. Individual, radiography and laboratory findings, post operation complications and mortality were collected in a questionnaire and analyzed by the descriptive statistics and frequency distribution tables. Results: Patients, 84 male (68.3%) and 39 female (31.7%), with mean age of 57.7 years underwent transhiatal esophagectomy. Clinical diagnosis of 94% of cases was squamous cell carcinoma (S.C.C.). Surgical complications included rupture of azygous vein in 1 case, chylothorax in 2 cases, right main bronchial injury in 1 case, anastomosis fistula in 2 cases, and wound infection in 4 cases. Chest tube insertion was performed in 41 cases (33.3%) at the end of operation, and in 19 cases (15.4%) postoperatively. Volume drainage > 400cc was reported in 29% of patients and tube duration > 4 days in 51% of patients. Conclusion: Transhiatal esophagectomy which was inaugurated in 1933 is a less morbid procedure among various approaches of esophagectomy. Bilateral chest tube insertion can cause less movement of the patient and respiratory distress, and rise surgical complications including thromboemboli, empyema, atelectasis, and lung infection. According to the results of this study, tube thoracostomy is indicated for following reasons: a. high volume of intraoperative mediastinal bleeding, b. pleural effusion irrelevant to the operation, c. postoperative respiratory distress along with pleural effusion, and d. asymptomatic high volume of pleural fluid.

Introduction: Iran with the rate of 17.9 cases in 100000 population had the seventeenth grade of tuberculosis incidence in 1998, indicating high prevalence rate of disease. Rapid diagnosis of disease is important for treatment of patients with tuberculosis and prevention of distribution in the community. This study was carried out to compare the radiologic manifestations of lung in smear negative and smear positive patients.Materials and Methods: This descriptive study performed from 2004 to 2007 on patients referring to Imam Reza Hospital, Mashhad University of Medical Sciences. Sputum smear was examined for patients suspected to pulmonary tuberculosis. Positive smear for BK cases, were considered as smear positive patients. Bronchoscopy was performed for patients whose smears were negative for 3 times. Patients whose disease was confirmed with BAL or biopsy were supposed as smear negative patients. Finally, we collected information of 58 patients with smear positive tuberculosis and 64 patients with smear negative tuberculosis and compared radiologic manifestations of the two groups by chi-square and t test.Results: In this study, there were 122 patients including 63 females (51.63%) and 59 males (48.36%). Patients' age range was 16 - 90 years old with the mean of 56.37 (SD = 18.8). The most common radiologic manifestation was Airspace consolidation, seen in 52 patients (42.6%) including 19 patients with smear positive and 33 patients with smear negative. Other radiologic features according to their prevalence consisted of: Airspace consolidation and Volume loss in 24 patients (19.7%) including 8 smear positive and 16 smear negative, Airspace consolidation and Bronchogenic spread in 17 patients (13.9%) including 16 smear positive and 1 smear negative, Airspace consolidation and Cavitationin 16 patients (13.1%) including 12 smear positive and 4 smear negative and Interstitial opacities (Miliary)in 13 patients (10.5%) including 3 smear positive and 10 smear negative. Conclusion: Generally, in 85 percent of patients with cavitary pulmonary tuberculosis, smear of sputum was positive, but just in less than 35 percent of patients with collapse and less than 25 percent of patients with interstitial pattern, smear of sputum was positive.

Introduction: Contamination of food with mycotoxin producer fungi is common problem in production and maintenance of food and can lead to primary and secondary mycotoxicosis. Information on the fungal contamination of bakeries flours is limited and this kind of contamination is important for food and therefore this survey was undertaken to determine the fungal contamination of flour in bakeries of Tabriz city. Materials and Methods: A total of 89 samples were obtained using standard 20 cm collection tube from bakeries located in different part of Tabriz city and examined according to Iranian 997 and 2393 food standards. Samples were diluted serially (10-2, 10-3, 10-4, 10-5, 10-6) prior cultured in YCGA medium and incubated at 250C for maximum 21 days and a screening survey for positive samples was carried out. Results: Of total 89 samples 61 (68.5%) were fungi free and 28 (31/5%) had fungal contamination of more than 104 colony forming units/gram (cfu/g). Aspergillus and Acremonium Spp. were the most frequently detected microorganisms throughout the survey. The average of humidity of 12/8 ± 0.76 in examined samples that was at standard frame (less than 14%).Conclusion: The results of this survey were similar to the results of other surveys in Iran and other countries. As the fungal contamination has a strong influence on the ultimate quality of flour end products and food safety as the major food of Iranian people, more attention to the quality of flours is necessary for minimizing of fungi the contamination.

Introduction: Streptokinase (SK) is the most widely used thrombolytic agent in treatment of acute STEMI in our country. Recent studies have showed the poor quality of SK products in use in the developing countries.Materials and Methods: this clinical trial study was performed between 2005 and 2006 at Ghaem and Javad-al-Aemeh Hospitals of Mashhad and Shariati Hospital of Fasaa. Two hundred sixty thrombolytic eligible acute STEMI patients were randomly assigned to Streptase, produced in Germany (group I; n=130) or Heberkinasa, produced in Cuba (group II; n=130).Dose of drugs was 1,500,000 units administrated in 60 minutes. Response to treatment were assessed by clinical (angina, re-MI, heart failure, mortality), laboratory (CK_MB), electrocardigraphy (resolution of ST elevation, arrhythmia) and echocardiographical (LVEF, MR) parameters .All data were analyzed by the SPSS version 11 and comparison between the treatment groups was performed using the chi-square and Z-test.Results: the patients in two groups were similar in age, sex, risk factors, site of MI and killip class. More than 50% decline in the sum of ST elevation was observed in 76.9% of group I and 53.1% of group II, (p=0.000). Peak of CKMB at 6th hour was higher in group I than II, 70.8% vs 60%, (p=0.01). Occurrence of re-MI was not significantly different, 1.53% vs 0.76% (p=0.56). Superiority of Streptase to Heberkinasa was shown also in the rate of pulmonary edema, 9.2% vs 19.2% (p=0.02) and cardiogenic shock, 6.9% vs 19.2% (p=0.003). Mean LVEF was higher in group I, 50.8% vs 40.5% (p=0.0001) and significant MR (mitral regurgitation) was lower, 3.3% vs 8.3% (p=0.03). Mortality rate wasn't different in two groups.Conclusion: According to clinical and Paraclinical parameters streptase was significantly more effective than Heberkinasa in the treatment of patients with acute STEMI.

Introduction: In the treatment of patients with severe burns, it is a matter of urgency to achieve definitive and total wound closure in order to avoid the metabolic abnormalities and septic complications of an open wound. In the absence of autologous skin, allograft skin is the best alternative for wound coverage. The purpose of this study was to evaluate survival of allograft in major burn injuries.Materials and Methods: This cross- sectional descriptive study, carried out from 2004 to 2006 on seventeen female patients with severe burns, ranged from 60% to 90% total body surface area in Imam Reza Burn Center. Allograft was used for wound coverage from first degree relatives, and patients were followed up for six months. Data were recorded in a questionnaire and analyzed by descriptive statistics and frequency distribution tables.Results: Twenty two allografts were used in the course of treatment of 17 severely burned patients. Five patients (29%) had two allografts and 12 patients (71%) had one allograft. In 9 patients (53%) rejection of transplanted skin was observed. In 3 cases (18%), rejection in one of the allografts was observed, while in 5 patients (29%) the total transplanted skin was rejected.Conclusion: allograft is an effective alternative treatment to resurface major burns in case of limited auto skin graft donor site, and the percent age of rejection was much lower than the other studies.

Introduction: Eye surgery especially cataract surgery is done at an ambulatory basis under local or general anesthesia. Remifentanyl is an ultra-short-acting opioid and propofol is a short-acting anesthetic. They may be used for maintenance of anesthesia. The aim of this study was evaluating and comparing the hemodynamic changes, recovery time, and complications between these drugs and topical anesthesia in non-complicated cataract phaco surgery.Materials and Methods: This clinical trial study was carried out in a 6 months period in 2006 at Khatam Hospital, Mashhad. Patients with non-complicated cataract surgery were divided into 3 groups of 25: control, remifentanil & propofol groups. Topical anesthesia was used in the first group. In the second & third groups induction was done by propofol, Atracorium & LMA. Maintenance of anesthesia in second group was done with propofol 5 mg/kg/h and in third group with remifentanil 0.25 mg/kg/min. All the procedures were done by a surgeon. Patients were monitored on NIBP, HR, Spo2 continuously and recovery complications were checked .The patients with cardiopulmonary disorders, hypertension and b-blocker usage were excluded from this study. Data was analyzed by Spss 13 software, ANOVA, Chi-square, fisher exact test & regression. P< 0.05 was considered significant.Result: One patient in the first group and two patients in the second group were omitted due to cancellation of surgery & arrest. There was no demographic difference among the groups. Hypotension & bradycardia in remifentanil group was more common than propofol group (P=0.005). Recovery time in remifentanil was shorter than propofol (P=0.000) and recall in propofol was more common than remifentanil (P=0.024). There was no significant difference among groups in nausea & vomiting (P=0.38).Conclusion: In this study local anesthesia with conscious sedation had less complications & more rapid discharge, therefore is better than general anesthesia. If using general anesthesia, Due to fast recovery and less recall, remifentanil is more suitable than propofol for eye surgery but because of hypotension and bradycardia it is better be used in low doses.

A 54-year-old woman Para 5 was admitted to the hospital because of increasing abdominal enlargment. She felt well until a year ago, when abdominal distention gradually developed.In abdominal ultrasongraphy a coarse, echogenic liver and ascites was detected, the spleen was enlarged and other intraabdominal organs were normal. Abdominal paracentesis was performed. Serum-ascites albumin gradient was greater than 1.1 gr/dl (high serum-ascites albumin gradient).Laboratory-tests for evaluating the etiology of cirrhosis revealed: HBs Ag: Neg , HBc Ab: Neg , Hcv Ab: Neg , Anti HBs: Pos.ASMA (anti smooth muscle antibody):NegANCA (anti neutrophilic cytoplasmic antibody):NegANA (anti nuclear antibody):NegAMA (anti mitochondrial antibody):NegSPEP (serum protein electrophoresis):Normal range The patient had no history of hepatotoxic drug usage.In upper GI endoscopy two columns grade II varicose veins were seen.Based on the history and para clinic evaluation cryptogenic cirrhosis was the most probable diagnosis.The patient underwent medical therapy with furosemide and spironolactone, and in regular follow up amount of ascites was under control.A month ago the amount of ascites increased and several therapeutic paracentesis were performed.Ascites analysis showed high serum-ascite albumin gradient and negative cytology for malignancy.Ultrasonography reported multiple focuses on peritoneal surface with seeding like appearance, cirrhotic liver, enlarged spleen and massive ascites, normal kidneys and uterus and ovaries. Tumour markers measurement revealed:CEA=0.3 (Normalrange=0 - 5ng/ml)aFP=0.4 (Normalrange=0 - 10IU/ml)CA 125=244 (Normalrange= 0 - 35 IU/ml)Abdominal and pelvic CT scan didn't show any tumoural lesion and no paraaortic lymphadenopathy. Trans vaginal sonography reported normal uterus and ovaries. Further tumour marker analysis revealed:Elevated serum level of CA 125to 414 IU/ml CV'CA 15- 3 = 27 (normal = up to 40 IU/ml)JLJCA 19- 9 = 25 (normal = up to 40 IU/ml)A week later level of CA 125 decreased to 262. Therefore we obtained fluctuating level of CA 125, normal CT scan and normal level of other tumour markers.We found in papers from other countries in the same situation that they performed laparotomy but they found nothing except cirrhosis (l).In some articles CA 125 presented as a marker of ascites in patients with liver cirrhosis (2). Some authors suggested that quantification of CA 125 in peritoneal fluid (PCAI25) and serum (SCA125) can differentiate between cancer cases and non cancer disease, and they found that ratio of PCA125 to SCA125 (PIS CA125) was significantly lower in non cancer patients than that in cancer ones. (lf the ratio is upper than five the risk of malignancy increased) (3). We quantified CA125 level simultaneously in peritoneal fluid and serum: PCA125 = 210, SCAl25 = 250, PIS CA125 = 0.84.The ratio of 0.84 was predictive of a benign disease. In an overview to our patient, we had one sonography that reported seeding like appearance in peritoneal surface, but in CT scan no lesion was detected. Fluctuating level (increase decrease) of CA125 and low PIS ratio, normal level of other tumour markers, made us to come to the final step oflaparoscopic examination and biopsy to determine whether it is malignant or benign.In laparoscopic examination no cancerous lesion or fibrin deposit or tuberculosis granolurna with normal omentum and cirrhotic liver detected.Multiple biopsies were taken from peritoan beside liver which reported normal (no: 159104).We came to this conclusion that in cirrhotic patient with ascites the elevated level of CA125 with normal level of other tumour markers and low PIS ratio and no malignant finding in imaging is suggestive of a benign process, as described in other articles.More studies on this matter should be performed in order to prevent the unnecessary laparatomies.

Introduction: Merkel cell carcinoma(MCC) is a rare primary neuroendocrine carcinoma of the skin in elderly individuals, on sun exposed areas of the body, with the head and neck being the most common sites. Excessive ultraviolet exposure may play an etiologic role in the development of it. Exposure to mustard gas can cause skin reactions and increase risk of skin neoplasms and probably MCC. The Aim of this study was to report this interesting case and review the published literature on MCC.Case report: In this article a 60 year old man with a history of exposure to chemical warfare sulphur Mustard gas in Iraq-Iran conflict and development of a hemorrhagic nodular mass with a duration of 3 months on his scalp, that based on histology, immunohistochemical staining and was diagnosed as MCC is presented.Conclusion: This was the first reported case of merkel cell carcinoma in Iran exposed to sulphur Mustard gas. Sulphur Mustard gas can be an etiologic factor for this tumour.

Introduction: Chronic granulomatous disease (CGD) is a rare immunodeficiency disorder characterized by recurrent infections with catalase positive bacteria. The cause is some defect in bactericidal activity of neutrophils and fungal organisms.Case Report: In this study a 23 years old man with history of recurrent pulmonary and lymph node infection has presented. He was misdiagnosed for TB three times and received anti- TB treatment. Finally the Chronic Granulomatous was confirmed. Conclusion: This case study demonstrated that CGD should be considered in adults with unexplained recurrent infections to prevent wrong treatment due to misdiagnosis and to reduce the disease severity by prophylactic treatments.

Introduction: Ventricular rupture following myocardial infarction (M.I) is a serious clinical problem with a high mortality. The aim of this study was to present a case with this disorder.Case Report: A 73 year-old man with left ventricular rupture and cardiac tamponade following myocardial infarction was managed successfully by emergency surgery. The procedure was accomplished with the use of cardiopulmonary by pass. A large PTFE patch was sutured according to the Nunez technique. Patient survived during a mean follow-up of 12 months.