Archives of Iranian Medicine
Volume:9 Issue: 2, Apr 2006

The coexistence of recipient''s and donor''s hematopoietic systems after allogeneic marrow transplantation is called mixed chimerism. The objective of this study was to evaluate the effects of MC on graft-versus-host disease (GVHD), disease recurrence, and survival after HLA identical marrow transplantation in a transplant center in Iran. The association of MC with acute GVHD, disease recurrence, survival, and relapse-free survival was investigated in 91 patients who underwent either bone (n = 12) or peripheral blood (n = 79) HLA-identical marrow transplantation. Chimerism was assessed using multiplex amplification of short tandem repeats (STR). Patients had thalassemia (n = 19), acute myelogenous leukemia (AML) (n = 29), acute lymphocytic leukemia (ALL) (n = 20), chronic myelogenous leukemia (CML) (n = 18), and other diseases (n = 5). The median age was 21 (range: 3 – 50) years. There were 38 (42%) female and 53 (58%) male participants. Conditioning was made through busulfan plus cyclophosphamide in 34 patients; busulfan plus fludarabin in 51 patients; and busulfan plus fludarabin plus antithymocyte globulin in 6 patients. The median follow-up was 13 months. On day +30, complete chimerism (CC) was observed in 72 (79%) patients, MC in 15 (17%), and no chimerism in 4 patients. The incidence of acute GVHD was significantly (P = 0.01) lower in mixed chimeras than in complete chimeras. There was no significant difference in acute GVHD grade (I, II vs. III, IV) between the two groups. The incidence of relapse was 18%. There was no difference in relapse rate between MC and CC groups. Overall survival was 89%. There was no significant difference in the overall survival between MC and CC group (96% vs. 85%, respectively). Relapse-free survival was 80% that was not significantly different between the two groups. Despite some previous reports, we found no significant difference in the survival and relapse rates between MC and CC groups.

Background/ Considering the importance of mental health in adolescents, we studied the prevalence of obsessive-compulsive disorder (OCD) in this age group and determined its relationship with their religious attitudes. In this survey, 293 students at different grades were selected using a multiphasic cluster sampling method. Subjects were asked to complete demographic, Yale-Brown scale, and religious attitude questionnaires. Those with scores higher than the cutoff value were inter­viewed by a psychiatrist, based on the DSM-IV criteria. Data were analyzed by c2 and Student’s t-test. The prevalence of OCD was 8.87% (5.1% in boys and 3.75% in girls). The majority of patients with OCD were from urban regions and had a positive family history in their first- or second-degree relatives. Nonetheless, there was no relationship between OCD and religious attitudes. The prevalence of OCD found in our study was higher than many of those reported earlier. Religious attitudes could only affect the contents of obsession and compulsion

It is known that there is an association between elevated total plasma homocysteine level and restenosis after percutaneous coronary angioplasty. To evaluate the effect of lowering plasma homocysteine levels on the rate of restenosis after stent-percutaneous coronary angioplasty. Folic acid (1 mg) or placebo was administered to 200 patients (mean ± SD age of 54 ± 9 years) for 3 months, after successful coronary angioplasty in a double-blind randomized clinical trial. The primary end point was restenosis within six months, as assessed by quantitative coronary angiography after positive exercise tolerance test. The secondary end point was a composite of major cardiac events. Base line characteristics and initial angiographic results after stent-percutaneous coronary angioplasty were similar in the two study groups. The rate of restenosis showed no significant difference in the two groups (5% in placebo vs. 10% in folic acid groups; P = 0.141), as there was the need for revascularization of the target lesion (4% in both groups; P = 0.766). Treatment with folic acid does not decrease the rate of restenosis and need for revascularization of the target lesion after stent-percutaneous coronary angioplasty.

There are few treatment options for patients with secondary progressive and worsening relapsing-remitting multiple sclerosis. Mitoxantrone is an antineoplastic drug, recently approved for treatment of multiple sclerosis. Mitoxantrone is, however, associated with dose-related cardiotoxicity, which limits its use. To investigate the possible cardiotoxicity of mitoxantrone in multiple sclerosis. We studied 96 patients with worsening relapsing-remitting or secondary progressive multiple sclerosis, to evaluate cardiotoxicity within one year of mitoxantrone therapy. This study was performed in the Multiple Sclerosis Clinic of Isfahan University of Medical Sciences from October 2003 through October 2004. Analysis of mitoxantrone therapy (12 mg/m2), in terms of cardiac toxicity, was conducted on patients who received at least 4 doses. Cardiac assessment was carried out every 6 months with electrocardiogram, as well as a spectral and color-flow Doppler echocardiographic examination at the time of enrollment and 6 and 12 months later. Ninety-six patients were assessed over 12 months. There was no evidence of clinically-significant cardiac dysfunction. Three patients had a left ventricular ejection fraction of <10% of the base-line value and three had <50%. Mitoxantrone (12 mg/m2) is effective and generally well tolerated by patients with worsening relapsing-remitting and secondary progressive multiple sclerosis. Our findings suggest that the risk for developing cardiotoxicity is low in patients with multiple sclerosis within one year of the treatment with mitoxantrone.

The aim of this study was to evaluate the outcome of pregnancies in Iranian women with immune thrombocytopenic purpura (ITP). In a historical cohort study, maternal and neonatal outcomes were studied in 30 pregnant women with ITP at a hospital in Tehran, from January 1994 through November 2003. Twenty-two cases were diagnosed as ITP before and 8 during pregnancy. Thrombocytopenia (platelet count <150 × 109/L) occurred in 22 pregnancies. Eleven (37%) had vaginal delivery and 19 (63%) underwent elective cesarean section. Eight women had severe post-partum hemorrhage. All live-born neonates were delivered in good condition at term. Neonatal thrombocytopenia occurred in 20 (67%) neonates. No bleeding complications occurred in any of the neonates. The outcome of pregnancy in pregnant women with ITP is generally good. Cesarean section should only be performed for obstetric indications. Postpartum hemorrhage is common in these women. Postpartum hemorrhage is unrelated to the mode of delivery. Severe thrombocytopenia and bleeding in the offspring are uncommon.

Background/ In the present study, the effect of acute lead exposure in the presence and absence of dopamine or alpha (α)-adrenoceptor agents on contractile response of rat isolated thoracic aorta was studied. Male Wistar rats were used in all experiments. Thoracic aorta was carefully removed, cleaned, and cut into 2-mm thick rings. The rings were mounted for measurement of isometric contractions in a tissue bath containing 10 mL of Kreb’s solution at 37 – 38○C. The following drugs were used: lead chloride, dopamine, phenylephrine, prazosin, clonidine, yohimbine, and SCH23390. One-way analysis of variance (ANOVA) and Student’s t-test were used for statistical analyses. P < 0.05 was considered significant. The α1-adrenoceptor antagonist (prazosin), α2-adrenoceptor antagonist (yohimbine), or dopamine D1 receptor antagonist (SCH23390), did not elicit any response. Combination of lead with dopamine, phenylephrine, or clonidine did not show any potentiation. SCH23390, prazosin, and yohimbine decreased the contraction induced by lead. SCH23390 decreased the contraction induced by dopamine, or lead plus dopamine. Prazosin reduced the contraction induced by phenylephrine or lead plus phenylephrine. Yohimbine attenuated the response induced by clonidine or lead plus clonidine. α1, α2, and D1 dopamine receptor mechanisms could have a role in lead-induced contraction.

Background/ The status of pelvic supporting organs and possible related factors in a population of Iranian women, 18 – 68 years of age, were studied in primary health care centers. In this cross-sectional study, 3,730 women were visited in three primary health care centers. The status of their pelvic supporting organs was measured according to the pelvic organ prolapse quantification system. Stages of prolapse were evaluated for trends in terms of various variables, using the Pearson c2 statistical test. Demographic and obstetric factors were tested for potential confounding variables with logistic regression analysis. The mean age was 36 (range: 18 – 68) years. The overall distribution of pelvic organ prolapse was as follows: stage 0, 47%; stage 1, 23.1%; stage 2, 18.3%; and stage 3, 11.6%. Based on logistic regression analysis, age ³50 years, menopause, gravidity >3, parity >3, number of vaginal deliveries >3, history of operative delivery, history of vaginal delivery without episiotomy, and home delivery were found to be independent risk factors for development of pelvic organ prolapse. The overall rate of prolapse was 53%, with most subjects having stage 1 or 2. Several factors influence development of pelvic organ prolapse.

Background/ In patients with severe concurrent coronary and carotid artery disease, two different treatment strategies may be used: simultaneous endarterectomy and coronary bypass surgery, and carotid stenting with delayed coronary bypass surgery after a few weeks. To evaluate the safety and efficacy of carotid stenting with delayed coronary bypass surgery after a few weeks in patients referred to Tehran Heart Center, Tehran, Iran and to determine the independent predictors that may be used to identify the appropriate treatment plan for such patients. This prospective study was performed from December 2003 through October 2004. Symptomatic patients with >60% stenosis and asymptomatic patients with >80% stenosis were included in this study. The risks and benefits of carotid stenting were explained. Patients were excluded from the study if any of the following was applicable: age ≥85 years, history of a major stroke within the last week, pregnancy, intracranial tumor or arterio­venous malformation, severely disabled as a result of stroke or dementia, and intracranial stenosis that exceeded the severity of the extracranial stenosis. Thirty consecutive patients who underwent carotid stenting were enrolled in this study. The mean ± SD age of patients was 66.3 ± 8 years. The procedural success rate was 96.7%. During a mean ± SD follow-up period of 5.6 ± 3.2 months, 4 (17%) deaths occurred; none of which were attributed to a neurologic causes. Moreover, 1 (3%) patient developed a minor nonfatal stroke with transient cognitive disorder. Most of patients (80%) with major complications acquired a score of ≥26. To reduce the rate of carotid stenting complications in high-risk patients with heart disease, to optimize the patient selections, and to determine the best treatment strategy, based on the clinical and lesion characteristics of patients, we proposed a new scoring system.

Carotid artery stenting has recently been recommended as an alternative to carotid endarterectomy by some clinicians. To evaluate success rate, as well as in-hospital and 30-day adverse events in our first experience in Iran for carotid artery stenting with protection devices. From December 2003 through July 2004, we performed 12 consecutive (9 males and 3 females) carotid artery stenting procedures. The patients had a mean age of 62 (range: 46 – 78) years. Indications for carotid artery stenting included primary lesions in all patients, stenosis ³50% in symptomatic, and stenosis ³80% in asymptomatic patients. Carotid artery stenting was technically successful in all 12 patients. The mean ± SD severity of stenosis before carotid artery stenting was 85 ± 14% as compared with 15 ± 10% after the procedure. No periprocedural death occurred. No in-hospital or 30-day minor or major stroke/death was observed. Percutaneous stenting of the carotid artery stenosis, when a cerebral protection device is used, is feasible and effective but not without technical difficulties and potential compli­cations. We, therefore, recommend carotid artery stenting for patients who are at high risk for undergoing carotid endarterectomy. Nevertheless, a long-learning curve may be needed for anyone who wishes to start this technique.

Street children are among vulnerable people in the world. They are one of the main groups in the society who affect the pattern of health. To determine the prevalence of hepatitis B, hepatitis C, human immuno­deficiency viruses (HIV), and syphilis among street children residing in southern Tehran, Iran. In a cross-sectional study, we selected 102 children aged below 15 years from southern Tehran. The selected children had an interview and were examined. From each child a blood sample was taken and tested for anti-HIV (ELISA), anti-HCV (ELISA), HBsAg (ELISA), anti-HBs, anti-HBc (radioimmunoassay [RIA]), rapid plasma reagin (RPR), and fluorescent treponema antibody absorption (FTA-ABS). We studied 39 (38%) boys and 63 (62%) girls, including 79 (77%) Afghan and 16 (16%) Iranian children. The nationality of 8 children could not be identified. The children were negative for syphilis, HIV, and HCV. Nevertheless, 3 of them were positive for HBsAg and 15 were HBsAb positive (>10 MIU/mL). The majority of street children are immigrants. Although these children did not have syphilis, HIV, and HCV, they are at risk of HBV.

Although it is well-known that postterm pregnancies are associated with the risk of perinatal morbidity and mortality, a comprehensive study on its management is lacking. The aim of present study was to determine whether ketonuria is associated with abnormal fetal test results in pregnancies >40 weeks of gestation. In this analytical cross sectional study, a total of 360 pregnant women with gestational age of >40 weeks were evaluated in two hospitals during 2003 – 2004. For each woman, urinary ketones, glucose, pH, proteins, and specific gravity were measured by total screen LSG tapes (Rapignost); in addition, biophysical profile test was recorded and the amniotic fluid index was assessed by ultrasonography. Ketonuria was found in 34 women (9.44%). Statistical analyses showed that maternal ketonuria was associated with oligohydramnios, abnormal fetal tests, and a significant increase in fetal heart rate decelerations. Patients with clinically-detectable ketonuria have higher risk for abnormal fetal tests in comparison with those without the disease.

Considering the high incidence of low weight and short stature among Iranian children as well as the high prevalence of both mild and moderate types of zinc deficiency, this study was conducted among patients who were referred to the Pediatric Clinic at Massih Daneshvari Hospital during 1997 – 1999. The aim of this study was to determine the effect of zinc supplementation on the children’s height and weight percentiles. Age, sex, and height and weight percentiles before and after administration of zinc were determined and recorded. The zinc supplement used in this project was in the form of a zinc sulfate solution in 0.1% and 0.5% concentrations. The dose was the upper limit of a tolerable dose, which was given in three divided doses per day. The serum zinc level was measured with the atomic absorption spectrophotometry method. The effect of age, sex, and initial serum zinc level on the percentile changes were determined. This study was conducted on 42 children with equal distribution of gender (21 male and 21 female patients). The mean age was 4.9 ± 4.1 years. Means of height and weight were 101.8 ± 23 cm and 16.5 ± 8.1 kg, respectively. The initial serum zinc level was 85.1 ± 31.6 µg/dL. The duration of zinc administration was 3.2 ± 2.6 months. The subjects were followed for a minimum of one month to a maximum of 10 months. The percentage of children with weight and height percentiles below the 50th percentile was reduced from 69% to 54% (P < 0.05) and from 50% to 33% (P < 0.01), respectively. Also, it was noted that children with low serum zinc levels demonstrated greater percentile changes. It was concluded that supplemental zinc increases height and weight percentiles.

Seizures are common in children and 5% of all medical attendances to accident and emergency departments are related to seizures. The role of emergent neuroimaging for those children with first afebrile seizure is, however, not well-defined. We reviewed medical charts of 125 children who were admitted with a new-onset afebrile seizure to the Pediatric Ward of Rasool Akram Hospital and underwent CT scan or MRI of the brain. Neuroimaging was performed for 95% (119/125) of these children over the first few hours of their arrival to the Emergency Department. In 90% (107/119) of them, the result was normal. There was a significant relationship between abnormal neuroimaging and focal seizure (P < 0.001), and with age under 2 years (P < 0.002). Therefore, it is recommended that CT scan or MRI to be performed in children with first afebrile seizure who present with focal seizures, abnormal neurologic findings, or age under 2 years.

A 7-year-old boy was referred to us with a 3-month history of swelling and pain on his left ankle. On laboratory evaluation, he only had an elevated erythrocyte sedimentation rate. X-ray showed an extensive lytic lesion of the talus bone. Chest roentgenogram was normal. The Mantuex skin test was negative. Histological examination of the biopsy tissue showed granuloma and caseating necrosis of tuberculosis. Talectomy with 6 months of antituber­culous chemotheraphy resulted in a good clinical outcome.

The nutcracker syndrome refers to compression of the left renal vein between the aorta and the superior mesenteric artery, which results in renal vein and left gonadal vein varices. Herein, we report our experience with left renal vein transposition for treatment of the nutcracker syndrome. To the best of our knowledge, this is the first reported case of the left renal vein transposition for treatment of the nutcracker syndrome in Iran.

We report on a young female, who received a cadaveric liver transplant from a donor who was a zero antigen match, and to whom she has had a strongly positive crossmatch. Immediately after transplantation, her panel reactive antibodies dropped from 55% to 0%, a value which remained for nearly 3 weeks. She subsequently, redeveloped her pretransplant anti-HLA antibodies, though at a lower level, with the exception of those specific to the donor HLA antigens. She also did not develop any acute rejection episodes during the 6 months of follow-up.

L-2-hydroxyglutaric aciduria is a rare and novel autosomal recessive inherited neurometabolic disorder. Since its first description by Duran in 1980, less than 100 cases have so far been reported. Occurring mostly in childhood, it is characterized by slowly progressive neurological dysfunction with cerebellar ataxia, pyramidal signs, intellectual decline, seizure, and extrapyramidal symptoms. MRI scanning is highly characteristic and screening for organic acid (L-2-hydroxyglutaric acid) in urine, serum, and cerebrospinal fluid is diagnostic. We investigated six Iranian children, aged 4, 14, 16, and 16 years, (the last one had two affected brothers and both of them died of similar illness at the ages of 20 and 22), by urinary organic acids assay and MRI scanning with suspicion of this rare disorder. Symptoms were suspicious for one of the leukoencephalopathies accompanied by macrocephaly. Affected cases were evaluated because of mild to moderate psychomotor retardation and regression. Head circumferences were above 2 standard deviations. Urine levels of L-2-hydroxy­glutaric acid were strongly increased. MRI scanning of the brain showed hyperintense signal on T2W images of the subcortical white matter and basal ganglia in all of them. Because of its inheritance pattern (autosomal recessive) and the high rate of consanguineous marriages in Iran, the prevalence of this disorder might be high among the mentally-handicapped patients, especially those with macrocephaly. Therefore, this entity should be considered in the differential diagnosis of mentally-retarded patients with macrocephaly.

There is a significant risk of disease recurrence in patients with diarrhea-negative hemolytic-uremic syndrome undergoing renal transplantation. Considering the low frequency of hemolytic-uremic syndrome among adults with end-stage renal disease, only a few reports are available on the outcome of these patients after renal transplantation. It has been suggested, though not proven, that living related transplant recipients are at increased risk of recurrence of hemolytic-uremic syndromeWe report a 23-year-old woman with end-stage renal disease, owing to postpartum hemolytic-uremic syndrome and the recurrence of the disease following live related renal transplant. Investigators believe that some cases of atypical hemolytic-uremic syndrome are familial and related donors may have a genetic susceptibility to develop hemolytic-uremic syndrome. In addition, recurrence of hemolytic-uremic syndrome in the allograft is associated with a very poor prognosis. Therefore, at present, many clinicians are reluctant to recommend live related transplanta­tion in any forms of diarrhea-negative hemolytic-uremic syndrome.