مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و ششم شماره 9 (پیاپی 213، آذر 1397)

Hepatitis B virus (HBV) is an etiological agent of hepatitis B infection. Hepatitis B is a life-threatening disease that affects the liver. The clinical outcomes of the disease are varied from asymptomatic disease to serious complication such as cirrhosis and hepatocellular carcinoma (HCC). Despite availability of the vaccine and appropriate treatment, hepatitis B infection still remains a major public health problem worldwide. Based on WHO reports, over 887.000 people die annually from hepatitis B complication including cirrhosis and hepatocellular carcinoma. Hepatitis B is very contagious and spreads through infected blood, body fluids, mother to baby during birth, contaminated needle and between sexual partners. HBV uses sodium taurocholate cotransporting polypeptide (NTCP) receptor to enter hepatocytes and by replicating in these cells interferes with liver functions. In fact liver damage is as result of virus multiplication and activation of immune responses especially virus-specific cytotoxic T lymphocytes (CTLs) against infected cells. CTLs and CD4Th1 cells by killing infected cells and releasing antiviral cytokines control virus replication in infected individuals. Also, the functions of these cells in patients who successfully clear the infection are potentially strong. In contrast to acute self-limited HBV infection in persistent HBV infection, these cells are exhausted. Several studies have showed that the great challenge in clearance of the HBV infection is related to stability of covalently closed circular DNA (cccDNA). cccDNA produce in viral life cycle and remains inside the infected cells for a long time and act as a template for generating new pre-genomic RNA and virus propagation. So far, no antiviral treatment has been effective in the complete elimination of this structure. Prevention of the disease can be achieved by using effective vaccine. Previous studies indicated that neutralizing antibodies against surface antigen of the virus known as S antigen have protective properties. Therefore, a subunit vaccine containing S antigen is available. Currently S antigen is produced in recombinant form and WHO recommended the first dose should be given within a day of birth. Pegylated IFN-γ and nucleotide-nucleoside analogues are effective drugs against HBV infection, but they may have severe side effects. Ineffectiveness of the vaccine on premature infants and immunocompromised people and also drug side effects has made HBV infection a great trouble.

Genetic polymorphism is responsible for variations and individual differences. Polymorphism is a major factor of complex diseases with unknown etiology and cancer. Inconsistency in the symptoms of polycystic ovary syndrome (monthly disorder, hirsutism, obesity, diabetes, infertility) is one of the major pathological complications of this syndrome. The present study was conducted to evaluate the polymorphism gene β2 and β3 adrenergic receptors in women with polycystic ovary syndrome. This cross-sectional study was performed on 200 patients with polycystic ovary syndrome (PCOS) in Imam Khomeini Hospital, Vali-e-Asr Infertile Clinic in Tehran, Iran, from March 2016 to April 2017. Blood samples in two groups (study and control) were obtained for genomics approved by the DNA Company based on the gene bank. Polymerase chain reaction (PCR) samples were extracted and then the primer design was performed by using Primer Express software, version 3.0 (Applied Biosystems, Foster City, CA, USA) and confirmed by using of the primer blast tool at the NCBI site in terms of compliance with the beta 3 adrenergic receptor gene. Analysis of protein changes was performed by using CLUSTALW (https://www.genome.jp/tools-bin/clustalw). Polymorphism was investigated on codons 16, 27, 113 and 164 from the beta2 adrenoceptor gene and codon 64 of the beta3 adrenergic receptor gene. The study of the codon beta2 of adrenoceptors showed that only codon 164 (Thr164Ile) polymorphism (44.4%) was significant (P<0/002) in study group. Homozygote and heterozygote ratios also show a significant difference between the study and control groups (P<0/004). Polymorphism exon 1 in codon 64 of beta3 adrenoceptor; which codes the amino acid tryptophan, indicates that the nucleotide T has changed to C. This finding confirms that mutagenic genotype can raise chance of getting to the polycystic ovary syndrome in women. OR: 2.546 (95% CI: 1.02-5.367) (P=0.012). These results show that polymorphisms of codon 164 (Thr164Ile) of beta2 receptor gene and beta3 adrenergic receptor gene polymorphism Thr164Ile (rs 4994) associate with polycystic ovary syndrome and the risk of PCOS are significantly increased in mutation genotype women.

Approach to treat empyema following pulmonary infection, especially in the second stage, is disputed. Therefore, this research aimed to compare the effect of simple tube thoracostomy versus surgical debridement in complicated parapneumonic empyema management. This prospective randomized trial was conducted in Thoracic Surgery Department of Imam Khomeini Hospital of Tabriz and Dr. Shariati Hospital of Isfahan cities, Iran from March 2003 to September 2015. 104 patients with stage II empyema, divided into two groups (52 patients in each group). Group 1 was treated with simple tube thoracostomy and group 2 with surgical debridement with thoracotomy or thoracoscopy and patients had at least 2 referral after discharge. Personal information, medical history and information of complications and recurrence were recorded in two forms. Finally, data analysis was done by SPSS software version 22 (IBM SPSS, Armonk, NY, USA) and methods of Chi-square test and independent sample t-test. The age-mean of patients under study was 48.17±11.13 years in group 1 and 46.21±13.58 years in group 2 and the most patients were middle-aged (between 40 to 50 years). The number of men in both groups was more than women. 44.23% of patients in group 1 and 38.46% of patients in group 2 had a history of smoking. Duration of hospitalization (P=0.005), a chest tube duration (P=0.004) and duration of treatment (P=0.005) in group 2 was significantly higher than group 1. The complications (P=0.172) and recurrence (P=0.324) in group 2 are non-significantly more than group 1. The complications of treatment, after a week in group 1, are non-significantly higher than group 2 (P=0.690), but complications of treatment after a month in both groups were equal (P=1). Duration of hospitalization, chest tube insertion time and duration of treatment in simple chest tube drainage treatment is shorter than surgery treatment (thoracoscopy or thoracotomy) and simple chest tube drainage treatment is more effectiveness way to treat patients with complicated parapneumonic empyema in stage 2.

Identifying the best species of medicinal plants and extracting effective substances can be effective in preventing oral and dental illness. The Malva sylvestris L. is among these plants. Malva sylvestris L. belongs to Malvaceae family from which A great deal of (Malvone A: 2-methyl-3-methoxy-5,6-di- hydroxy-1,4-naphthoquinone) anthocyanin and important natural pigments have been extracted. Anthocyanins and other substances of Malva sylvestris own antibacterial properties. Antibacterial properties of Malva sylvestris were investigated on the bacterial species. The purpose of this study was to investigate the antibacterial effects of the Malva sylvestris L. extract on the Streptococcus mutans and compare it with the effect of chlorohexidine (0.12%). This experimental study was carried out at the Shahed University of Medical Sciences, Tehran, Iran in the field of microbiology in January 2016 to September 2016. Methanolic aqueous extract of Malva sylvestris L. was prepared by decoction extraction method. The presence of polyphenol trepnoid, saponine, anthocyanins compounds in the extract was approved by high performance thin layer chromatography. Chromatographic and spectral fingerprint analysis plays an important role in the quality control of complex herbal medicines. The antimicrobial effect of the Malva sylvestris L. on the growth of Streptococcus mutans was evaluated. Extract at different concentrations (16.8-4.2 mg/ml) had an antibacterial effect and compared with commonly used chlorohexidine in dentistry. The non-growth halo against Streptococcus mutans showed an average of 1.66 mm. The minimum inhibitory concentration against Streptococcus was 2 mg/ml. The presence of polyphenols, troponides of saponin, was characterized by high performance thin-layer chromatography (HPTLC). However, antibiotics play an important role in human health, with the increasing occurrence of bacterial resistance against available antibiotics. The results of this study showed that the aqueous-methanolic extract of the Malva sylvestris L. plant has antimicrobial activity affecting Streptococcus mutans. The flowers extract also showed high antibacterial effects against some human pathogen bacteria strains. This property of polyphenolic compounds of the plant, identified by fingerprint analysis, was less susceptible to chlorohexidine than gold standard.

Gestational diabetes is one of the common causes of maternal and fetal complications. Due to fetal and maternal complications of diabetes, it is very important to reduce the prevalence of diabetes and its consequences. The relationship between vitamin D deficiency and type 2 diabetes has been reported. There is little information about the relationship between serum vitamin D levels and the risk of gestational diabetes mellitus (GDM). The aim of this study was to determine the relationship between the levels of vitamin D and gestational diabetes. This case-control study was conducted in health centers of Urmia University of Medical Sciences in May 2015 until March 2016. A total of 100 pregnant women with gestational diabetes and 100 healthy pregnant women were entered into the study by nonrandom and available sampling. The level of vitamin D was measured and levels were divided into three levels. Vitamin D levels were considered less than 20 ng/ml, 20-30 ng/ml and more than 30 ng/ml as deficiency, insufficiency and sufficient, respectively. Exclusion criteria include pre-pregnancy glucose tolerance, history of medical disease, and supplementation with vitamin D. The mean age of women in the study group was 30.31±5 years and in the control group was 28.83±4.95 years (P=0.06). The vitamin D levels in GDM and control groups were 7.25±4.76 ng/ml and 11.93±16.12 ng/ml, which is lower in the gestational diabetes than the control group (P=0.01). The severe deficiency of vitamin D in the gestational diabetes group and in control group were 34% and 27% respectively (P<0.0001). There was a significant difference in mean fasting plasma glucose level between gestational diabetes group and healthy pregnant group (P<0.001). There was no relationship between vitamin D levels and body mass index of pregnant women (P=0.1). In this study, the majority of patients had vitamin D deficiency and in the gestational diabetes group, vitamin D deficiency was significantly higher than the control group. The severe deficiency of vitamin D in the gestational diabetes group was higher than patients without gestational diabetes.

Adding morphine as adjuvant intrathecal drug for cesarean section is a gold standard for post-operative analgesia according to literature, but because of frequent incidence of nausea, vomiting and pruritus, it has limited popularity. Various mechanisms have been demonstrated for the opioid-induced pruritus, with a variety of medications with different mechanisms of actions for prevention and treatment. The aim of this study was to determine the effect of intramuscular promethazine on intrathecal morphine-induced pruritus after cesarean delivery. In a retrospective descriptive-analytical study, recorded data of two thousand American Society of Anesthesiologists (ASA) I or II women undergoing elective cesarean delivery at the Bahman Hospital of Tehran, Iran, during the period of 2008 to 2013 were reviewed. Participants were divided into two groups of one thousand for each theme; the initial group underwent spinal anesthesia by employing intrathecal morphine as part of a standard anaesthetic regimen without prophylactic administration of promethazine, the subsequent group received 25 mg intramuscular promethazine after intrathecal drug administration. The incidence and severity of pruritus (absent, mild, moderate or severe) and intensity of pain using numeric rating scale (NRS) and also the incidence of nausea and vomiting were examined as main variables. All data were analyzed using SPSS software, version 22 (IBM SPSS, Armonk, NY, USA) and P values of less than 0.05 were considered as statistically significant. The incidence of nausea (P=0.025) and vomiting (P=0.046) was different in two groups; with statistical significance. The mean score of pain according to numeric rating scale (NRS) was similar in both groups (P=0.46). The frequency of pruritus was statistically similar in both groups, (P=0.302); but the severity of itching showed statistically significant difference between two groups (P<0.001). The severity of pruritus was significantly reduced by intramuscular administration of 25 mg promethazine, shortly after spinal morphine administration but it was shown to be ineffective to reduce the incidence of pruritus. Also, the incidence of post-operative nausea and vomiting (PONV) was less by intramuscular promethazine application.

Cystatin C (Cys C) as a cysteine protease inhibitor is produced in a constant level from all nucleated cells. The purpose of this study was to investigate the correlation between serum levels of Cys C and coronary slow flow (CSF) and body mass index (BMI) in men. This investigation is in the form of a descriptive-analytical study. The statistical population was all non-active male aged 34-73 years with CSF candidate for angiography referring to Seyedoshohada University Hospital, Urmia, Iran, from March 2015 to February 2017. After obtaining an inform consent, 74 male patients (mean age 54.77±9.00 years, height 1.74±0.12 cm, weight 73.13±6.85 kg, and BMI 26.98±3.83 kg/m2) were selected by convenience non-random sampling as the sample size (patients were eligible for diagnostic coronary artery angiography for the first time and referring to Seyedoshohada University Hospital in Urmia). Then all the patients were placed under angiography with one mobile angiography system. Patients were assessed for coronary blood flow with a quantitative method using corrected thrombolysis frame count in myocardial infarction (CTFC). All the patients with TFC larger than two standard deviation pre-published area for a specific vessel were counted as CSF. Demographic characteristics of age, height, weight, and BMI in male patients were measured by wall-meter with an accuracy of one millimeter, digital scale with precision of 100 g, and weight/hieght2 formula, respectively. The traditional risk factors including smoking, diabetes mellitus (DM), high blood pressure (HBP), dyslipidemia, and family history were also assessed using a checklist. Serum levels of Cys C were measured by ELISA machine. The mean demographic and physiological variables of subjects were: age 54.77±9.00 yr, height 1.74±0.12 cm, weight 73.13±6.85 kg, and BMI 26.98±3.83 kg/m2. Also, the results of this study showed that there were no significant correlations between serum levels of Cys C with CSF and BMI in male patients’ candidate for angiography referring to Seyedoshohada University Hospital (P=0.871 and P=0.494, respectively). The results of this study suggest that serum levels of Cys C had no significant correlations with the CSF and BMI in male patients’ candidate for angiography aged 34-73 years.

Escherichia coli (E. coli) is one of the most important infectious agents in patients undergoing prostate biopsy. It belongs to a large family of gram-negative rods, Enterobacteriaceae. This family includes members of the normal flora of the intestine that are only occasionally pathogenic. Recent considerations of rectal colonization with fluoroquinolone-resistant E. coli shows the need to change strategy of treatment of infection in patients undergoing prostate biopsy. Therefore, the purpose of this study was to determine molecular typing of fluoroquinolone resistant (FQR) E. coli rectal isolates and associated infections in patients undergoing prostate biopsy. In this prospective cohort study, rectal swabs were collected from 158 male patients before prostate biopsy at the Urology Research Center of Sina Hospital, Tehran, Iran, from March 2015 to February 2016. The FQR organisms were isolated using selective media, and antibiotic susceptibility pattern was determined for following antibiotics, ampicillin, levofloxacin, cotrimoxazole, amoxicillin-clavulanate, cefazolin, ceftazidime, cefepime, gentamicin, piperacillin-tazobactam, nitrofurantoin, amikacin, fosfomycin, imipenem. In general, phylogenetic background, prevalence of E. coli sequence type 131 (ST131) and its subclones (H30 and H30-Rx ST131) were compared in two groups of FQR E. coli rectal colonization and clinical isolates. In total, 73 patients had a positive rectal culture for FQR gram-negative bacteria, the most prevalent isolate of which was E. coli. Phylogenetic group B2 was most predominant, followed by A, E, C and D, B1 and F. The antibiotic susceptibility patterns for the FQR organisms showed high levels of resistance to ampicillin and trimethoprim-sulfamethoxazole, while the resistance to amikacin, fosfomycin and imipenem remained very low. In general, antibiotic resistance to several antibiotic was mainly detected in group B2 and with ST131 genotype. Despite the increase in infections among patients colonized with strains of E. coli ST131, its frequency was almost statistically significant between colonized and infected groups. The ST131 pathogen has a high prevalence in rectal colonization and post prostate biopsy infections, which showed widespread resistance to common antibiotics.

Today, several vaccines have been developed to prevent infectious diseases. The older first-generation vaccines may have many problems. In this regard, genetic engineering plays an important role using tools such as shuttle vectors to develop recombinant DNA vaccines that usually include plasmid constructed so that can propagate in two different host species. The present study reviews a variety of shuttle vectors, their structures, productions, pathogenicity and more importantly their applications in the production of novel vaccines. A systematic review was performed based on search in international databases with no time limit including Scopus, PubMed and Google Scholar. All databases were searched using the standard (English and Persian) keywords. Relevant articles from 1996 to 2018 were collected from search of international databases including Science Direct, Google Scholar, and PubMed using keywords such as “shuttle vectors”, “recombinant plasmids” and “DNA vaccines”. In this study, a total of 31 full texts were used. A shuttle vector typically contains similar components to replication origins and promoters and can propagate in various hosts. Nowadays, they are used in designing and constructing of new vaccines against infectious diseases including tuberculosis and viral hepatitis. Also, Multi-epitope peptide DNA vaccines are effective against some viruses and they are potentially effective against some bacteria such as Helicobacter pylori. Shuttle vectors as a powerful genetic engineering tool have a high ability to study the mechanisms of pathogenic microorganisms and make new vaccines such as DNA vaccines and multi-epitope vaccines. The hope is that such multi-epitope DNA vaccines might induce immunity against multiple antigenic targets, multiple strain variants, and/or even multiple pathogens. However, the ability of DNA vaccination to co-deliver a series of antibody and/or CD4 T cell epitopes remains largely unexplored.

Twin pregnancy consist a healthy fetus, and hydatidium molar pregnancy is unusual and very rare. Its incidence is in about 1,22,000 to 1,100,000 of all pregnancies. This type of pregnancy is commonly associated with several obstetric complications requiring early termination of pregnancy. Managing a twin mole pregnancy with normal and live fetuses is controversial, although this unusual type of abnormalities in most cases leads to abortion or intrauterine fetal death. In other hand, due to the high probability of obstetric complications during pregnancy, such as preeclampsia in 25% of cases, metabolic complications such as hyperthyroidism and vaginal bleeding pregnancy is terminated. Survival of the normal coexisting fetus is variable and depends on whether the diagnosis is made, and if so, whether problems from the molar component. Present study reported a case of coexisting mole and live fetus twin pregnancy with successful outcome. A 35 years old woman, G2ab1 which was diagnosed to have twin pregnancy with mole and coexisting live fetus in 11 weeks of gestational age was referred to obstetric department of Ghaem Hospital, Mashhad University of Medical Sciences, Iran in January 2017. Close follow-up and obstetric surveillance had performed for her and at the last her pregnancy was terminated in gestational age of 36 weeks; a healthy male infant. The β-human chorionic gonadotrophin (BhCG) levels still is undetectable after one year. Twin pregnancy with one normal fetus and a co-existing molar pregnancy could be continued under close surveillance if the live fetus has normal karyotypes and no structural anomaly and decreasing level of serum BhCG level during the time. Close monitoring necessary even after termination due to increasing risk of persistence trophoblastic disease after termination, what was performed in this case also.