Archives of Iranian Medicine
Volume:6 Issue: 2, Apr 2003

Background – Use of narcotics in the epidural space has dramatically changed patient care after surgery because it provides suitable analgesia with fewer complications than other methods. Morphine is a narcotic widely used in the epidural space for pain management, but its use is associated with several complications such as urinary retention, nausea, and vomiting. This study was designed to determine whether the addition of fentanyl to epidural morphine would reduce the associated complications.Methods – Of patients prepared for lung surgery, 72 were selected for epidural analgesia. Twelve patients met the exclusion criteria, but the remaining patients were randomized in a double-blind manner to receive morphine plus fentanyl (n = 30) or morphine alone (control group; n = 30). Drugs were injected when requested by patients, when the visual and verbal pain scores reached 2. Vital signs were checked and complications were recorded in a predefined questionnaire.Results – At the end of the study, there was a higher prevalence of complications in the morphine group than in the morphine plus fentanyl group (p < 0.05). There was no significant difference in analgesic time between the two groups, and analgesic time was more than expected in the morphine plus fentanyl group (p < 0.000).Conclusion – The results of this study showed that adding fentanyl to morphine in epidural analgesia can reduce the complications with at least equal analgesic time. Thus, we can consider this combination as a good choice for epidural analgesia in thoracotomy patients.

Background and Objective – Punch grafting is a therapy for vitiligo but, to our knowledge, its combination with outdoor topical psoralen plus ultraviolet A radiation (PUVA) has not yet been studied. This study was designed to evaluate the efficacy of combination of punch graft and outdoor topical PUVA in recalcitrant vitiligo.Methods – The study was performed in Razi Hospital, Tehran in 2000. After obtaining informed consent, 20 patients with stable and refractory vitiligo (4 segmental, 8 focal and 8 generalized) underwent treatment with punch grafting. After 3 months, outdoor topical PUVA with 8-methoxypsoralen was instituted and continued for a maximum of 4 months.Results – After the 3 months of punch grafting, only nine patients experienced 33 – 66% repigmentation. Four months after starting topical outdoor PUVA, 13 patients experienced 90 – 100% and three patients 25 – 50% repigmentation. One focal and three generalized patients showed no response.Conclusion – The combination of punch grafting and topical PUVA may be an effective treatment in stable and intractable vitiligo, especially the segmental and localized types.

Background – Chronic low back pain is a complex condition produced by multiple factors. This study investigated the psychological aspects of low back pain in a group of patients.Methods – A total of 112 subjects participated in the study. Fifty-six patients (21 females and 35 males) had low back pain and were seeking treatment in two clinics. A control group of 56 subjects (20 females and 36 males) without low back pain agreed to participate in the study as a control group. Psychological aspects were evaluated by the Persian version of Symptoms Checklist-90-Revised (SCL-90-R). Information on relevant demographics and pain was collected by one of the investigators who created the questionnaire.Results – The patients had higher scores in all scales of the SCL-90-R. A t-test which was used to investigate a possible significant difference in SCL-90-R scale between the groups indicated significant difference in all scales but the interpersonal sensitive scale.Conclusion – These findings indicate that chronic low back pain patients have an increased occurrence of coexistent psychological distress.

Background and Objective – To assess knowledge, attitudes and behavior of middle school students (aged between 12 and 14 years) about the consequences of cigarette smoking (including social, psychological and health-related issues), the present cross-sectional study was conducted based on the concepts of the "social inoculation theory". This theory enabled the listing of appropriate and true beliefs and attitudes of students in regard to cigarette smoking. Furthermore, it identified differences between beliefs and attitudes of smokers and nonsmokers of both sexes in different age groups. This could be a strong tool to develop a health education curriculum for schools to prevent risk-taking behaviors, such as cigarette smoking, among school-aged children.Methods – A total of 5,934 boys and girls attending grades 6 to 8 were selected at random from 40 middle schools in the city of Tehran, using multistage cluster random sampling.Results – About 30.5% of male and 11.7% of female students had smoked at least one cigarette in their life. In general, 2.4% of students reported smoking daily (≥1 cigarette/day). The beliefs and attitudes of smokers towards negative consequences attributed to cigarette smoking were significantly different from those of non-smokers in the two sex groups. Both smokers and non-smokers were quite knowledgeable about the health and other consequences of cigarette smoking. However, in most cases, there was some uncertainty among students about the social, cultural, psychological and environmental factors influencing young people to start smoking. Furthermore, a sense of invulnerability to the health-related problems attributed to cigarette smoking was identified among smokers of both sexes.Conclusion – Male and female students who smoke cigarettes have quite different beliefs and attitudes toward cigarette smoking than those who do not smoke. Therefore, it is necessary to develop educational curricula for schools (based on the sex of students) to teach students about the negative (immediate and long-term) health and other consequences of smoking cigarettes. One of the main elements of such curricula should emphasize the ways to empower young students with the life skills necessary to overcome peer pressure that may encourage them to smoke cigarettes.

Background – In the cervical spine there is a relation between spinal canal dimension and the occurrence of neurologic sequelae after trauma، while at the first lumbar vertebra (L1) this relation has not been conclusively established. In this study we aimed to investigate such an association. Methods – One-hundred patients with L1 burst fracture، admitted to the Department of Neurosurgery، Kerman University of Medical Sciences between 1995 and 2002 (50 paraplegic and 50 without neurologic deficit) were included in the study. Using computerized tomography (CT) scanning، the ratio of sagittal-to-transverse diameter (S/T ratio) and the cross-sectional area (CSA) of the spinal canal at L1 were measured. Statistical analysis، comparing those patients with neurologic deficit to those without، was performed using a t-test، and a simple linear regression model between S/T ratio and CSA was designed. Results – In paraplegic patients، the S/T ratio was 39. 08 ± 6. 63 (mean ± SD) and CSA was 309. 92 ± 22. 48 mm2. In neurologically intact patients، S/T ratio was 48. 46 ± 6. 43 and CSA was 349. 34 ± 22. 35 mm2. The S/T diameter ratio and CSA were significantly smaller in paraplegic patients than in those without a neurologic deficit (p < 0. 05 for both). However، a simple Pearson bivariate correlation showed that the relation between S/T ratio and CSA of the spinal canal was not significant (p > 0. 05). Conclusion – CT parameters of spinal canal dimensions correlated with severe neurologic deficit (paraplegia) in L1 burst fracture with retropulsed bone fragments in the spinal canal، but these parameters did not significantly relate to each other.

Background – The appendix is essentially a lymphoid organ which contributes to the production of B and T lymphocytes and is supplemental to the immune system. For many years, removal of normal appendix during other intraabdominal surgeries (incidental appendectomy) was a common practice. The present experimental study was designed to find a procedure in which, while preserving the appendix, the risk of future appendicitis is reduced.Methods – Laparotomy was carried out on four groups of N-Mari rats: 1) obstruction group (n = 10)—the base of the appendix was ligated; 2) milking group (n = 31)—the contents of the appendix were milked into the cecum prior to ligation; 3) drainage group (n = 31)—the contents of the appendix were milked into the cecum prior to ligation and the tip of the appendix was cut, so that mucosal secretions could drain and be absorbed into the peritoneal cavity; and 4) control group (n = 31)—only exploration and manipulation of the appendix via celiotomy, but no surgical procedures, were performed. The blood supply to the appendix was preserved in all animals. All animals underwent a second laparotomy to remove the appendix and detect histopathologic evidence of appendicitis after 30 days. Chi-square and two-tailed Fisher’s exact tests were used to analyze the data.Results – All animals in the obstruction group developed acute appendicitis early in the 24 hours after ligation. Histopathologic evidence of inflammation was detected in 12 of 31 rats in the milking group and in three of 31 subjects in the control group after 30 days. No animal in the drainage group developed appendicitis, but two cases of mucocele were encountered. The combined ligation and drainage protocol did not lead to more inflammation than the control protocol (p = 0.7).Conclusion – These results suggest that combined appendiceal base ligation and appendiceal tip cutting (for draining mucosal secretions into the peritoneum) may be considered as an alternative to incidental appendectomy. Further validation of this technique is required before it can be recommended for application in the clinical setting.

Background – Benzodiazepines have been used with opiates to give better pain relief than opiates alone. However، the interaction between the two groups of drugs is controversial. The aim of this study was to investigate whether midazolam potentiated the antinociceptive effect of morphine. Methods – Male albino mice were used in this study. Antinociception was measured using the tail-flick test. Results – Midazolam and morphine caused dose-dependent antinociceptive effects in mice. The combination of midazolam and morphine showed an increase in analgesia. The benzodiazepine receptor antagonist، flumazenil، decreased the response induced by midazolam or midazolam plus morphine but not that of morphine alone. However، the opioid receptor antagonist naloxone، reduced the antinociception induced by morphine، midazolam، or a combination of the two drugs. Methysergide or propranolol increased the analgesic effect of midazolam; ketanserin، phenoxybenzamine and atropine did not. Conclusion – Midazolam induced antinociception through both benzodiazepine and opioid receptors.

Background – The flowers of the plant Carthamus tinctorius L are used to provide color and flavor in the food industry. They are cheaper than saffron and therefore a water extract of these flowers is used instead of saffron. C. tinctorius also initiates bleeding in delayed menstruation. Therefore, in early pregnancy when the menstrual cycle is delayed, the use of C. tinctorius flowers may lead to malformation of the embryo. This experimental study was designed to investigate probable malformations due to C. tinctorius. Methods – One hundred and thirty Balb/C mice were maintained under standard laboratory conditions; then two females were housed with one male overnight, and successful mating was confirmed by vaginal plug. Pregnant females were divided into two groups. In the experimental group (120 mice), aqueous extract (1, 10, 25 or 50 mg/kg) was injected intraperitoneally, on the 7th or 8th day of pregnancy as a single dose or on the 9th and 10th days as multidoses. Distilled water was injected into the control group (10 mice). The pregnant mice delivered on the 18th day of pregnancy and the fetuses were examined for external malformation. Each fetus was weighed, the crown-rump length was measured, and the number of live and resorbed fetuses was recorded. Results – Water extract of C. tinctorius flowers caused death and decreased crown-rump length and weight. Congenital malformations included exencephally, spina bifida and tail and limb necrosis also were seen. Conclusion – The water extract of C. tinctorius flowers has many toxic effects on early development of the embryo and its use in pregnant women must be avoided.

Background – The possibility of using high-energy accelerated heavy-ion beams in radiotherapy of malignant tumors is an exciting development. Also, heavy ions comprise an important component of cosmic rays. The DNA molecule should be an important candidate target in heavy ion-induced cell lethality. Poly (ADP-ribose) polymerase (PARP) and tumor suppressor p53 are two important nuclear proteins that recognize heavy ions as a DNA damage signal. We studied the expression of PARP and p53 in cultured mammalian cells exposed to accelerated heavy ions (Fe or Ar).Methods – Chinese hamster ovary cells (CHO) and Mongolian gerbil fetal (MGF) cells were exposed to iron (Fe) or argon (Ar) ions, which are heavy ions accelerated by a ring cyclotron in Riken, Japan. We studied PARP and p53 expression as DNA strand-break recognition signal markers by immunohistochemistry assay in exposed cells to heavy ions and control cells. Results – The fraction of cells showing an elevated level of PARP in their nuclei compared to control cells after 1.5 hours of exposure to 4 Gy heavy ions was about 80%. The difference between PARP expression in CHO and MGF cells was negligible. In the immunohistochemistry assay for p53, which was performed in the Mongolian gerbil fetal cell line only, about 80% of cells showed an elevated level of p53 within the nucleus after 4 hours of exposure to 4 Gy heavy ions. However, the increase in PARP expression occurred earlier than p53 in nuclei of Mongolian gerbil fetal cells after exposure to heavy ions. About 20% of cells did not have increased PARP and p53 expression after exposure to either Fe or Ar ions. This 20% might represent a population of cells that did not receive nuclear DNA damage. Conclusion – These findings suggest that the probabilities of DNA damage after exposure to heavy ions could be evaluated based on PARP or p53 expression. The variation in expression can be related to the traversal of heavy ions through the cell nucleus and induce DNA strand-break as well as key structural components during apoptosis.

Although extremely rare, cauda equina syndrome caused by lumbar disc herniation can occur during pregnancy. The author report a case of cauda equina syndrome due to lumbar disc disease occurring during pregnancy, confirmed by magnetic resonance imaging (MRI), where a delay in diagnosis led to persistent neurologic deficit despite surgical treatment. The advent of MRI and modern surgical techniques to treat lumbar disc herniation allow safe management of this condition at any stage of gestation.