Archives of Iranian Medicine
Volume:6 Issue: 3, Jul 2003

Background – Growth assessment is an essential component of pediatric health surveillance because almost any problem within physiologic, interpersonal, and social domains can adversely affect growth. The growth chart is the most powerful tool in growth assessment. Standard growth charts are based on the data collected by the American National Center for Health Statistics (NCHS).Growth percentiles require periodic revision because of the changes in the ethnic mix of the population as well as socioeconomic and environmental conditions. This paper describes the new reference percentile curves for weight, height, and head circumference in an Iranian population between birth and 6 years of age.Methods – Fifteen-hundred and forty children (808 boys and 732 girls) were studied using cross-sectional method. Based on the primary data, 5 percentiles (5, 25, 50, 75, and 95) were determined for each sex and age group separately. The smoothed curves were then prepared. The smoothed curves of the 50th percentiles in our study compared to those of NCHS. Results – Using Run test, there were no significant differences between the percentiles found in our study and those in NCHS except for three groups: the height of males at birth (p = 0.0268), the weight of females at 18th month (p = 0.0456), and the weight of males at 4 ½ years of age (p = 0.0109). However, after 36th month, Iranian children were found to be generally lighter and smaller than the subjects in NCHS references. Conclusion – The new reference smoothed curves are similar to NCHS curves. The means, NCHS/WHO standards are appropriate for growth assessment in our community in this range of age (0 – 6 years). Nevertheless, for determination of standard growth charts especially for weight and height, more extensive studies on other age groups and in different locations of Iran are recommended.

Background – In the interest of efficiently using limited resources, it is important to optimize the throughput of cardiac surgery patients. Accordingly, the present study was performed to estimate the bed occupancy rate and throughput of patients in cardiac surgery departments using simulation models.Methods – In this paper, the typical Heart Surgery Department of Freeman Hospital in Newcastle upon Tyne, England was considered, where there were some beds in the ward, theater, and intensive care unit (ICU). For a set of data, a computer program for Monte-Carlo simulation of the department using Fortran-77 software (Fortran Company, USA) was developed in order to observe the behavior of the department as a queuing system. Different number of beds in the ward and ICU were simulated in order to observe the bed occupancy rate in the ward and ICU and also the throughput of patients in the system.Results – Bed occupancy rates in the ward and ICU for the case of 2 beds in the ICU and 11 in the ward were 78% and 81%, respectively. In this case, the throughput of 500 patients in the system could take 513 days. For 3 beds in ICU and 16 in the ward the mean bed occupancy rate was 84% in the ward and 79% in ICU. The throughput of 500 patients in the system with 9 beds in ICU and 39 in the ward could take 130 days.Conclusion – To prevent disinvestment prior to building a hospital or a new ward, especially in developing countries, it is suggested to perform simulation studies to observe the behavior of system in advance.

Background – To evaluate the feasibility, efficacy, and toxicity of the combination of carboplatin plus docetaxel as a first-line treatment in advanced epithelial ovarian cancer. Methods – Between February 1999 and December 2001, a prospective nonrandomized open study was done. Of the patients referred to two cancer clinics in Tehran, those in stage Ic-IV were selected. Combination of carboplatin plus docetaxel was given every 3 weeks for 6 cycles. Forty-two eligible patients (median age, 49 years; age range, 24 to 72 years) were given a total of 224 cycles of chemotherapy with carboplatin at AUC = 5 and docetaxel 80 mg/m2. Thirty-five patients completed 6 cycles. Results – The major toxicity was hematological with 50% of the patients developing grade II-IV neutropenia. Three patients developed grade IV thrombocytopenia. Four patients experienced clinical (sensory) neuropathy. Fluid retention was a significant clinical problem in 5 patients. The overall response rate was 71% (25/35). Four out of 12 previously inoperable cases showed complete pathologic remission in their second laparotomy. From the onset of the study the median follow-up for living patients was 21 months and the survival rate at 1 year was 80%. Conclusion – This combination looks well tolerated and in addition to offering less toxicity, its efficacy seems comparable to the other standard regimen.

Background – Scintigraphy remains the gold standard to study gastric emptying. We used this method to demonstrate the impact of delayed gastric emptying on gastroesophageal reflux disease (GERD), one of the most common gastrointestinal disorders. Methods – Scintigraphy was performed for 16 patients with documented GERD and 16 asymptomatic normal volunteers. The test meal was composed of two labeled fried eggs with two slices of bread, and 150 mL of nonlabeled water. Images were obtained in anterior and posterior projections in 30-minute intervals for a total period of two hours. Gastric emptying curves, the estimated time required for the stomach to empty one-half of its original meal (T1/2), and gastric retention activity at 120 minute (RA120) were used for gastric emptying evaluation.Results – Seven (44%) of patients had deviation in their gastric emptying curves compared to normal limits. The mean ± SD of T1/2 and RA120 of the patient group were 95.74 ± 54.00 minutes and 33.03 ± 15.92 percent, respectively; the corresponding figures for the asymptomatic control group were 64.94 ± 14.48 minutes, and 20.31 ± 8.41 percent. There was a significant difference between the means of the two groups (p < 0.05 for T1/2 and p < 0.01 for RA120) using Student t-test. Five (31.25%) patients demonstrated an abnormal T1/2 and the same number revealed an abnormal RA120. Relying upon at least one of these factors, 9 (56.25%) of the patients had evidence of delayed gastric emptying compared to the asymptomatic individuals. Conclusion – We concluded that delayed gastric emptying could be considered as a predisposing factor of GERD. Therefore, we recommend gastric emptying study in all patients suffering from this disease.

Background – Superstition, the belief in supernatural causes of events, is common in our society and is sometimes associated with religious beliefs. Some psychiatric patients attribute their mental illness to supernatural causes, which can prevent them from benefiting from appropriate medications. They either discontinue medication and refer to Doa-Nevees, a person who writes prayers and amulets, and is known as a traditional healer, or seek superstitious treatments prior to psychiatric treatment. This study was performed to determine the frequency of beliefs in superstitious causes of mental illnesses among the psychiatric patients hospitalized in Beheshti Hospital, Kerman, Iran. Methods – In this descriptive study, 99 consecutive psychiatric in-patients were selected in Beheshti Hospital, Kerman, Iran from April 2000 to July 2000. Patients aged 17 to 70 years old (mean age ± SD, 32.2 ± 8.9 years). The goal of the study was explained to all patients and they were enrolled into the study with complete consent. Subjects were questioned using a researcher-made questionnaire consisting of 15 items, which had been based on the researcher’s clinical experience with psychiatric patients, and whose validity and reliability had been proved. Statistical analysis was done using Epi-info 6 computer application and Chi-square test.Results – The ratio of male/female was 1:1. Of all studied patients, 77.8% believed in superstitious causes of their illnesses and 60.7% had received some superstitious treatment. Forty-six (88.4%) of male and 31 (65.9%) of female patients believed in superstitious causes of their mental illness showing a significant difference in this regard between males and females (p < 0.008). Similarly, 37 (71.1%) of male and 23 (48.9%) of female patients had sought superstitious treatments, which showed a significant difference between these two groups in seeking superstitious treatments (p < 0.003). Nonpsychotic patients showed a higher inclination for superstitious treatments compared with psychotic ones. The rate of superstitious beliefs and seeking of related treatments were lower in patients with higher levels of education. Conclusion – Superstitious beliefs regarding the nature and treatment of mental illnesses may postpone effective psychiatric treatment and damage patients.

Background – Numerous studies in various countries have documented comorbidity of mood disorders and substance use disorder, but little have been published on this subject from Iran. This study was performed to investigate such comorbidity in patients with substance use disorder.Methods – The subjects of the study were 1,017 opioid-dependent patients referred to or taken care of in Razi Psychiatric Hospital and Private Psychiatric Clinic of Tabriz University of Medical Sciences, Tabriz, Iran. They were assessed by means of Symptom Check List-90 Revised (SCL-90 R), the fourth edition of diagnostic and statistical manual of mental disorders (DSM-IV) criteria and Beck test which had been translated to Persian in three years (from August 1998 to July 2000). All of the subjects were unpaid and volunteers. We used SPSS 11.5 for our statistical analysis and ethical principles were considered in all stages of the study.Results –The comorbidity rate of all types of mood disorders with every substance use disorder was found in 71.2% of all subjects. Of the studied subjects, 31.2% were of low education (could only read and write). The frequency of dysthymic disorder was 6.6% and the mean score of global assessment function was 57.6%.Conclusion – The comorbidity of psychiatric disorders, especially mood disorders, with substance use disorder is frequent, with the most potent and generous substances having the highest comorbidity rates.

Background – The emergence and spread of penicillin and multidrug resistance in Streptococcus pneumoniae has become a major concern worldwide. Consequently, clinical laboratories should consider screening-selected isolates to determine whether they are susceptible to cefotaxime as well as to penicillin. The aim of this study was to survey drug resistance among clinically important isolates of S. pneumoniae recovered from patients in Tehran.Methods – The drug susceptibility of 130 isolates of S. pneumoniae cultured from severely infected patients from 1998 to 2000 was determined using both agar disk diffusion and macro broth dilution tests. Isolates were grown from clinical specimens including blood (60%) and cerebrospinal fluid (20%) from patients with pneumonia, bacteremia or meningitis. The remaining isolates were recovered from sputa (10%) and sinus exudates. Bacterial cultures were sent to Pasteur Institute for conformational and drug susceptibility tests. Results – Sixty-eight percent of isolates were resistant to penicillin, 10% to erythromycin, 52% to cotrimoxazole, and 56% to tetracycline. Of the 25% of the organisms that were found to be resistant to cefotaxime, 1% were highly resistant. None of the isolates were resistant to vancomycin. The minimum inhibitory concentrations (MICs) of cefotaxime corresponded to the MICs of penicillin (being the same or different by only 1 or 2 dilutions).Conclusion – Resistance to penicillin and cefotaxime increased over the study period. Penicillin-resistant strains of S. pneumoniae cultured from patients in Tehran were also more likely to be resistant to other beta-lactams such as cefotaxime. The increasing trend of antibiotic resistance among strains of S. pneumoniae in Iran is alarming, and the treatment of infections with this organism will be more difficult in the future.

Objective – Conservative treatment of medial epicondylitis including splinting, physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), and local injection of steroids has been reported to be successful in most reported cases. In the present study, we evaluated the effectiveness of local injection of steroids.Methods – Over a period of 5 years (1997 – 2001), we randomized 38 patients (40 elbows) seen in our private clinics into two groups. The treatment group (20 elbows) received one injection of 40 mg methylprednisolone and 1% lidocaine, and the control group (20 elbows) received one injection of normal saline and 1% lidocaine. Patients in both groups were given standard NSAIDs, physical therapy, and splinting. Pain severity was assessed at 2, 4, and 12 months. Results – The severity of pain in both groups was same before the treatment and there was no significant difference between the two groups. The difference in pain score between the two groups at 2 months was statistically significant (p = 0.01). At 4 months, the mean pain scores in the two groups were similar (p = 0.673) and there were no significant differences between the two groups at 12 months (p = 0.942, Mann-Witney test).Conclusion – Since local injection of a steroid had only short-term benefits, we do not recommend it for the treatment of medial epicondylitis. NSAIDs, splinting, and physical therapy provide the best conservative approach in this condition; steroid injection near a sensitive nerve (ulnar nerve) is not justified.

Background – Weakening of the inferior oblique muscle is the procedure of primary importance in the treatment of patients with superior oblique palsy, Knapp’s classes I and III. In this study, the effectiveness of anterior transposition of the inferior oblique muscle in the treatment of these patients was evaluated. Methods – Twenty three patients with superior oblique palsy, Knapp’s classes I and III underwent anterior transposition of the inferior oblique muscle. These patients had 10 to 25 prism diopters (PD) hyperdeviation in primary position. The tip of the disinserted muscle was sutured to the sclera parallel and adjacent to the lateral border of the inferior rectus muscle insertion. The prism and alternate cover test measurements were performed in all cardinal positions of gaze before and six months after surgery. Results – The mean reduction of hyperdeviation measured 14.9 PD in the primary position, 23 PD in adduction, 25.2 PD in elevation and adduction, and 18.1 PD in depression and adduction. There was no hypotropia in the primary position or limitation of upgaze. Postoperative hyperdeviation in the primary position was 5 PD or less in 21 out of 23 patients. Conclusion – The anterior transposition of the inferior oblique muscle is very effective in eliminating hyperdeviation in patients with superior oblique palsy, Knapp’s classes I and III. Up to 25 PD of hyperdeviation reduction in the primary position can be achieved. If this type of anterior transposition is used, hypotropia in the primary position or limitation of upgaze will possibly not occur.

Background – The immunophenotyping of lymphocyte subsets in bronchoalveolar lavage (BAL) is of importance in the differential diagnosis of interstitial lung diseases. The main intent for lymphocyte population subtyping in BAL fluid is finding those diseases with increased lymphocytic cell infiltration in the affected organ such as sarcoidosis and asbestosis.Methods – A dual color flow-cytometric analysis was performed to identify the percentages of total T (CD3+) lymphocytes, T-helper (CD4+) lymphocytes, cytotoxic (CD8+) T-lymphocytes, CD4/CD8 ratio, CD19+ B-lymphocytes, and CD16+56 natural killer cells in the BAL fluid of untreated patients with sarcoidosis, tuberculosis, and other interstitial lung diseases. Lymphocytes were gated on the basis of their expression of CD45 and their side scatter properties. T-lymphocyte subsets were analyzed in 37 patients with sarcoidosis, tuberculosis, nonsarcoidosis, and nontuberculosis. A p value of less than 0.05 was regarded as statistically significant for the results obtained.Results – The results presented here show that a high percentage of CD3+ and CD4+ T- lymphocytes as well as a high CD4/CD8 ratio were observed in the BAL fluid of the patients with sarcoidosis when compared with other interstitial lung diseases. An analysis of CD4/CD8 ratio exhibited that a CD4/CD8 ratio of 4:1 had a positive predictive value of 95% in distinguishing sarcoidosis from other pulmonary diseases.Conclusion – The high specificity of the procedure suggests that it may be used routinely for the analysis of lymphocytes in BAL fluid for the differential diagnosis of sarcoidosis.

Background – Reexpansion pulmonary edema (RPE), a rare complication of the reexpansion of a collapsed lung, typically follows the evacuation of a massive pleural effusion or complete pneumothorax. The aim of this study was to determine the clinical features, outcome, and effective treatment approach of RPE and also to evaluate the correlation of this phenomenon and its outcome with the underlying cause of lung collapse. Methods – This retrospective descriptive study was carried on 389 cases of chest intubation in 4 subsets of patients with the following underlying conditions: pneumothorax (200 patients), pleural effusion (100 patients), chylothorax (9 patients), and atelectasis (80 patients). Demography and data of variables were extracted from the hospital case records of the patients admitted within a 67-month period (from January 1993 to March 1998) in Thoracic Surgery Department of Razi Hospital and Cardiac Surgery Department of Heshmat Cardiovascular Center, Rasht, Iran. The statistical significance of the association between RPE and its underlying condition or treatment was assessed using c2 analysis and Fisher’s exact test; p < 0.05 was considered significant. Results – Among 389 cases of lung collapse including 200 pneumothorax, 100 pleural effusion, 9 chylothorax, and 80 atelectasis patients, 20 cases (5.1%) were complicated with RPE. Fifteen patients (75%) had severe and 5 patients (25%) showed mild tachypnea. All pleural effusion cases, 70% of pneumothorax, and 50% of atelectasis cases severe tachypnea. In eighty percent of the RPE cases the complication appeared within the first hour of chest tube insertion while in the remaining 20%, RPE occurred within the first 24 hours. One of the patients with RPE who was a case of pneumothorax died (5% mortality). All patients were given oxygen and 14 patients (70%) received corticosteroids. Indomethacin suppositories were administered to 11 (55%) patients. Twenty-five percent of RPE cases required bronchodilators while only one case (5%) had received a bronchodilator drug. Conclusion – We concluded that RPE is not a rare complication. Early diagnosis and appropriate approach can reduce mortality. For patients with progressive hypoxemia and respiratory distress, the main aim of the treatment should be slowing the blood flow towards the involved lung; the simplest and quickest way to achieve this is lung recollapse. Meanwhile, appropriate hemodynamic monitoring, adequate fluid replacement, use of diuretics, and mechanical ventilation would be helpful.

Disseminated peritoneal leiomyomatosis (DPL) is a very rare condition that almost always occurs in young women subjected to an altered hormonal milieu, usually pregnancy. To the surgeon, DPL may appear as metastases; the possibility of DPL should be considered whenever peritoneal nodules are encountered in a young woman, particularly if she is pregnant. Here we present the case report of a 35-year-old woman with DPL, spontaneously regressing after total hysterectomy and bilateral salpingo-oophorectomy.

Cerebral tuberculomas account for a large proportion of space occupying brain lesions, especially in the developing countries. The authors describe a patient with paradoxical progression of intracranial tuberculomas four months after successful treatment of tuberculous meningitis, and the possible immunological mechanisms of this phenomenon are discussed.

A 16-year-old male with headache, vomiting, fever, neck stiffness, and a positive Kerning’s sign was referred to Boali Medical Center. The cerebrospinal fluid examination revealed a lymphocytic meningitis, and the blood smears was positive for Borrelia. He was successfully treated with doxycycline.