Archives of Iranian Medicine
Volume:16 Issue: 5, May 2013

This prospective study aimed to evaluate the detailed outcomes of diabetic patients with critical limb ischemia, six months after percutaneous transluminal angioplasty and appropriate multidisciplinary wound care. Totally, 45 consecutive patients (50 limbs) were enrolled and then divided into two groups according to the healing of ulcers. The endpoints were ulcer healing and major adverse events including amputation, mortality, and cardiac or cerebral morbidities, during a six- month follow-up period. During six months follow-up, major amputation was performed for four of 50 limbs (8.0%). A total of nine (20%) patients died and the leading cause was cardiac death (13.3 %). Also, stroke and non-fatal myocardial infarction occurred in three (6.7 %) and one (2.2 %) of the patients, respectively. Among the 29 (59.2 %) healed wounds, 22 (44.9 %) were completely closed. The patients with nonhealing wounds had a higher rate of dialysis (40% vs. 0 %, P-value < 0.001) and more ulcers with stage of D3 according to the Texas Wound Classification (60% vs. 31 %, P-value = 0.016). Other demographic, clinical, ulcer characteristics and procedural characteristics such as number and level of the treated lesions did not differ significantly between the two groups. Based on our findings, it seems that along with current usual therapeutic routines which focus on wound healing and limb salvage, more attention should be paid to simultaneous diagnostic assessments and treatment of cardiovascular disease in this group of patients during short-term follow- up.

Intrathecal injection of fluorescein is a useful adjuvant method for localization of fistulas in endoscopic endonasal repair of cerebrospinal fluid (CSF) leakage. Although being neurotoxic in commercial doses, a low dose of diluted fluorescein seems to be safe on the basis the existing data in the literature. The purpose of this study was to investigate the role of a low- dose intrathecal fluorescein injection in detection of CSF fistula and potential adverse effects of this technique. CSF rhinorrhea was repaired in 20 patients with an endoscopic endonasal technique. Intraoperative intrathecal fluorescein injection was used for localization of the site of the CSF leak. The accuracy rate of leakage site identification and the incidence of complications and recurrences were recorded. Intrathecal administration of fluorescein demonstrated CSF leakage in 18 of the 20 patients (90%). There were no intraoperative complications. Definitive closure of the CSF leakage site was achieved in 16 patients (80%) after the initial reconstruction. Recurrence occurred in four cases and all patients were free of CSF leakage after the second surgical attempt. The present study suggested that a low dose of intraoperative intrathecal fluorescein administration is a safe and sensitive method for localization of CSF leakage sites.

The aim of the present study was to investigate the chromosomal abnormalities and to identify the most prevalent or frequent type of chromosomal abnormalities in cases of amenorrhea from the southern region of India. A total of 637 cases with amenorrhea were analyzed using G- banding, C-banding, Silver staining, and fluorescence in situ hybridization was done wherever necessary. Out of the 637 cases involved in our study, 132 abnormalities were detected. The incidence of chromosomal abnormalities in cases with primary and secondary amenorrhea was around 20.7 %. In addition to the numerical anomalies, various structural aberrations of the X chromosome like deletions, isochromosomes, duplications, ring chromosome, and also male karyotype were detected. Review of the literature and overall incidence of chromosomal abnormalities in patients with amenorrhea suggests the need for cytogenetic analysis to be performed in all the cases referred for amenorrhea with or without short stature. Precise identification of chromosomal abnormalities helps in confirming the provisional diagnosis; it helps the secondary amenorrhea patients in assisted reproduction and to understand the clinical heterogeneity involved and in efficient genetic counseling.

Estrogen is the major sex steroid affecting the growth, remodeling, and homeostasis of the female skeleton. Estrogen loss in postmenopausal women leads to osteoporosis. The aim of this study was to evaluate the early and long- term effects of estrogen loss on bones, tendons, muscles, and menisci in ovariectomized rats. Fifteen rats were randomized into three groups of five animals each. The first group was the control group with no additional surgical procedure, but the rest (groups 2 and 3) were bilaterally ovariectomized. All animals in the group 2 were sacrificed at 14th week to evaluate the short- term effect, and all of other animals in the groups 1 and 3 were sacrificed at 28th week to analyze the long- term effect of estrogen loss in the ovariectomized group and to control with the group 1. Quadriceps muscles, Achilles tendons, menisci, and femur cortical bones from both lower extremities were taken. The amount of apoptosis was measured. There was a significant increase in cell apoptosis in bones, muscles, and tendons with insignificant increase in cell apoptosis in menisci at early and late periods in rats with ovariectomies than the control. The results indicated that estrogen loss after ovariectomy does not only affect bones; it may also increase cell apoptosis in different tissues such as muscles, tendons, and menisci.

Total colonic aganglionosis (TCA) is present in 4% – 5% of the patients with Hirschsprung''s disease and has a high surgical mortality rate between 13% – 23%. Diagnosis and treatment of TCA is still a major challenge for pediatric surgeons. Many techniques with several advantages and disadvantages were established for its treatment. We have performed State’s pull-through as total colectomy and ileo-proctostomy with long posterior rectal myotomy in TCA and severe dysmotility disorders. In this retrospective study, 13 patients with TCA were evaluated from1992 through 2012 in two pediatric surgery centers, which consisted of 10 TCA, one intestinal neuronal dysplasia (IND), and two chronic intestinal pseudo- obstruction syndrome (CIP). All patients underwent total colectomy, resection of part of the involved small intestine, and rectal anastomosis in one layer with 4/0 vicryl with long posterior rectal myotomy. All patients had preoperative barium enema and rectal biopsy for diagnosis. Leveling ileostomy was performed in 12 patients and mid-jejunostomy in one patient. In two of 13 children, proximal diverting loop ileostomy was established after definitive operation. In three patients, trans-rectal myotomy was needed two weeks after the initial operation. All patients were females with the age ranging from six months to six years. State’s pull-through was carried out for all (the mean age of definitive procedure was 5.1 months). Rectal biopsy of 10 patients reported no ganglion cells of which one had extended aganglionosis to mid- jejunum, one had IND, and two had ganglionicbowel bowel with clinical presentation of CIP. The follow- up period was from six months to 10 years (the mean follow- up period was 10 months). There were no significant complications in 12 patients except episodes of diarrhea and severe dehydration which needed hospitalization. One patient with mid- jejunum aganglionosis had severe failure to thrive and needed repeated hospitalization for parenteral nutrition. All patients had acceptable bowel function following operation (two to six times a day). Now, five of the 13 patients are above the age of toilet training, having voluntary bowel movement with little or no medication (Leopromid). State’s pull-through is recommended in all cases of TCA and severe dysmotility problems of the colon. This technique is less difficult to perform, and avoids the complications and disadvantages of removal of the rectum and has satisfactory results.

BACKGROND: The amygdala is the key brain structure for anxiety and emotional memory storage. We examined the involvement of β-adrenoreceptors in the basolateral amygdala (BLA) and their interaction with morphine in modulating these behaviors. The elevated plus-maze has been employed for investigating anxiety and memory. Male Wistar rats were used for this test. We injected morphine (4, 5, and 6 mg/kg) intraperitoneally, while salbutamol (albuterol) (1, 2, and 4 μg/rat) and propranolol (1, 2, and 4 μg/rat) were injected into the BLA. Open- arms time percentage (%OAT), open- arms entry percentage (%OAE), and locomotor activity were determined by this behavioral test. Retention was tested 24 hours later. Intraperitoneal injection of morphine (6 mg/kg) had an anxiolytic-like effect and improvement of memory. The highest dose of salbutamol decreased the anxiety parameters in test session and improved the memory in retest session. Coadministration of salbutamol and ineffective dose of morphine presenting anxiolytic response. In this case, the memory was improved. Intra-BLA administration of propranolol (4 μg/rat) decreased %OAT in the test session, while had no effect on memory formation. Coadministration of propranolol and morphine (6 mg/kg) showed an increase in %OAT. There was not any significant change in the above- mentioned parameter in the retest session. Coadministration of morphine and propranolol with the effective dose of salbutamol showed that propranolol could reverse anxiolytic-like effect. We found that opioidergic and β-adrenergic systems have the same effects on anxiety and memory in the BLA; but these effects are independent of each other.

Oral cavity has been proposed as an important reservoir of H.pylori, being implicated in bacterial transmission through oral-oral route. However, some investigators believe that the newborn acquires H.pylori from mother through vaginal delivery. In this study, oral and vaginal yeasts were examined for the intracellular occurrence of H.pylori and their possible role in bacterial transmission. Sixty nine oral and vaginal yeasts from expecting mothers (39 oral and 30 vaginal) and seven oral yeasts from neonates(6/46 vaginal delivery, 1/43 cesarean) were identified and studied by light and fluorescent microscopy for observing the intracellular bacterium-like bodies(BLBs). Whole DNAs of yeasts were recruited for detection of H.pylori-specific genes. Urea breath test (UBT) was performed for detection of H.pylori infection in mothers. Stool antigen test (SAT) was used for detection of H.pylori antigens in infants’ stool at birth and six months of age. Oral yeasts were isolated more frequently from normally-delivered neonates. The frequency of H.pylori genes in mothers'' vaginal yeasts was significantly higher than in mothers'' oral yeasts. A significant correlation was found between the occurrence of H.pylori genes in vaginal yeasts and that in neonates'' oral yeasts, occurrence of H.pylori genes in mothers'' vaginal yeasts or neonates'' oral yeasts, and UBT+ results in mothers. C.albicans which colonizes the oral cavity of neonates through vaginal delivery or contact with environment or healthcare workers could be an important reservoir of H.pylori. Vaginal yeasts are more potent in accommodating H.pylori than oral yeasts. Accordingly, vaginal yeast is proposed as the primary reservoir of H.pylori which facilitates H.pylori transmission to neonates.

This paper discusses the statistical principles, methods, and software programs used to calculate sample size. In addition, it reviews the practical challenges faced in calculating sample size. We show that because of such challenges, statistical calculations often do not provide us with a clear-cut number for the study sample size; rather they suggest a range of reasonable numbers. The paper also discusses several important nonstatistical considerations in determination of sample size, such as novelty of the study and availability of resources.

Negative ulnar variance can be a risk factor in Kienböck’s disease, wrist instability, and scaphoid bone fracture. This study focused on the ulnar variance in wrists with scaphoid bone nonunion. We retrospectively reviewed posteroanterior wrist radiographs of 65 patients who were diagnosed as established scaphoid nonunion and underwent open reduction and bone grafting between 2005 and 2010. We used reference radiographs from contralateral wrists of 65 consecutive skeletally- mature patients with distal radius fracture as the control group and then measured ulnar variance and compared it in both groups. Ulnar variance was measured in standard posteroanterior wrist X-rays of 65 scaphoid nonunion and 65 normal controls. Twenty five patients (38.5%) in the scaphoid nonunion group had negative ulnar variance, and the mean value was -0.26 (± 1.24) mm (range: -3, +2). In the control group, 15 subjects (23.1 %) had an ulnar minus wrist, and the mean ulnar variance was + 0.54 (± 1.47) mm (range: -3, +4). The difference in ulnar variance was significant between the two groups (P-value = 0.001). Ulnar variance may influence developing of nonunion process in scaphoid bone fracture.

Disseminated cryptococcosis is rare in immunocompetent hosts and hepatic manifestations as the presenting feature is further rare. We report a case of disseminated cryptococcosis with hepatic involvement as an initial manifestation in a previously healthy, immunocompetent adult. A young married female presented with progressive jaundice, anorexia, weightloss, cough with expectoration, and hepatosplenomegaly. Biochemical profile showed liver function derangement with increased transaminases, alkaline phosphatase, bilirubin with deranged coagulation assay, and decreased albumin. The patient was treated initially for disseminated tuberculosis with associated sepsis, but she succumbed on the third day. Diagnosis of cryptococcosis was made on the basis of sputum culture, serology, and liver histopathology.

Congenital homocysteinemia is a genetic disease with various clinical manifestations such as thrombosis, lens dislocation and mental retardation and osteoporosis, so early diagnosis is important for decreasing the mortality and morbidity especially in pediatric populations. Here we describe a child with a presentation of coma with a past history of lens operation with unfortunate fatal clinical course, and a final diagnosis of congenital homocysteinemia.

A 31-year-old athlete was admitted to our hospital for previous inferior myocardial infarction (MI), diagnosed by transthoracic echocardiography, myocardial scintigraphy, and cardiac magnetic resonance, while coronary angiography revealed normal coronary arteries. Laboratory investigations excluded acquired or inherited thrombophilia, immunologic disorders, cardiotropic agents infection, and drug abuse. Antiplatelet therapy was started but, after 15 days, he was rehospitalized with diagnosis of multiple left renal infarctions. A transesophageal echocardiography (TEE) was so performed which excluded a right-to-left shunt, suggestive of patent foramen ovale, or other cardioembolic sources in heart chambers and valve apparatus. Antiplatelet therapy was replaced with oral anticoagulants without any further embolic event at one-year follow-up. This case raises two important questions regarding young patients with cryptogenic MI. First, if TEE should be part of a complete diagnostic pathway; second, if oral anticoagulants should be preferred over antiplatelets for secondary prevention particularly when the cause of MI remains unknown.

Coronary arteriography performed in a 42-year-old male patient showed communications from the left anterior descending artery to the right ventricle one month after a myocardial infarction. The area of communication did not correspond to the site of the infarction as established by electrocardiogram and previous angiography. Exactly how the fistula developed in our case remains unknown. Angiogenesis also suggests that myocardial infarction can lead to spontaneous formation of these coronary anomalies.