نشریه پژوهش در پزشکی
سال بیست و سوم شماره 4 (پیاپی 93، زمستان 1378)

Considering conflicting reports on the success efficacy of health services, this study was carried out to determine the sty le of utilization of health and treatment services in health centers of rural areas in 1996. The descriptive and cross-sectional strategy of this research study was performed in health centers of 11 provinces and their villages were classified into high, intermediate, and low groups according to the quality of presented services. For this purpose, six physicians were involved with the project using similar questionnaires and methods of evaluation. In this regard, every one of them studied one or two provinces for a period of 1-3 months. They referred to 196 villages and had interview with 1064 families, 62 health assistants, and 27 physicians and completed the questionnaires. It was found out that the first place of refer for the villagers was rural health centers and then in order of impo11ance were doctorchr('39')s office and health and tremment centers. In well-conditioned regions, the villagers rarely referred to rural health and treatment centers (6%) and the greatest reference was the office of physicians (34%). In this regard, most of them expressed the closeness of health center as the major cause of refer. The existence of free services especially drng, having trust to health assistants, and observance of referral system were the other causes ofrefer. On the basis of their views, the availability of the necessary drugs was 45.5%, 76.6% and 57.2% in poor, moderate and well-conditioned regions respectively. The suggestions of health assistants for the improvement of health service presentation in order of frequency were the availability of the approved drugs, holding courses of training and re-education, establishing the rural health and treatment centers in line with the existing health centers and continuous or intermittent presence of physicians in rural areas. According to the views of physicians in less than half of the cases, there is enough supply of the necessary drugs and in 74.1 % of cases, the existence of the necessary equipments has satisfied the physicians. Meanwhile, in none of the studied villages, there did not exist all of the 41 approved drugs completely, but the contraceptive pill existed in 96.5% of cases. Furthermore, considering the list of necessary equipments, the necessary items did not exist in many of the cases.

Considering the different clinical symptoms of leishmaniasis in Iran, and the wide distribution of its agent and the little information in this regard, this study was performed to characterize the responsible variants using monoclonal antibodies. A total of 156 isolates of Leishmania from patients with cutaneous leishmaniasis and one isolate from rat were characterized using the standard monoclonal antibodies using ELISA and IF A tests. Geographic distribution of 156 isolated Leishmania was 30 in Shiraz, 28 in Kerman, and 98 in Tehran. In this study, 63, 72, and 3 Leishmania isolates reacted with anti-L. tropica, anti-L. major and anti-infantum respectively. Of the three isolates that reacted with anti-L.infantum; two were isolated from patients with cutaneous leishmaniasis and one was the organism isolated from rat in a region with a high prevalence of visceral leislunaniasis. In this respect, mixed reactions with the monoclonal antibodies was also observed as six isolates reacted with anti-L.tropica and anti-L.major, five reacted with anti-L. tropica and L. infantum and one with anti-L. major and anti-L.infantum. The monoclonal antibiodies used did not react with none of the isolates.

Since medical practice is one of the stressful occupations as a result of high work-load, sleepless conditions and hyposomnia, management of severely ill patients and occasionally death of them, this study was performed to determine the rate of stress in a group of specialists and residents of different fields in Shaheed Beheshti University of Medical Sciences. The descriptive and cross-sectional strategy of this study was performed on 202 of specialists and residents using a self-assessment stress questionnaire standardized for our country. For selection of cases, an easy sampling method and access to them in the studied hospitals. The results showed that level of stress in physicians is high and 73.4% of them tolerate stresses from mild to severe degrees. This level was 75.5% in residents and 65% in specialists. In this regard, there was no significant difference for the different fields or between the specialists and residents. Meanwhile, level of stress (from mild to severe) in residents of surgery and anesthesia tend to become significant (P=0.059) compared to other fields. In a similar way, the level of stress in female physicians tends to become significant (P=0.057) compared to male ones. There was no significant relationship for stress, age, working hours, and the marital status. It is concluded that the sources of stress differ between the specialists and residents, that is, traffic and occupational stress is the top stressors for specialists and for residents, the expected exams, passing the courses, and economical issues are more important.

Considering the significance of continuous medical education and its role in the quality of the presented health and treatment services, and the holding of more than 3000 of such programs, this study was carried out to determine the effect of continuous medical educational program regarding renal stones during the years 1997-1998. In this study, the educational trial strategy was carried out on 100 physicians having their offices in Tehran. In this respect, the effect of training was evaluated on the knowledge, perspective, and way of management of physicians before and after stone ejection, renal colic pain, and its diagnosis. For this purpose, the trained medical students as false patients ( one week before and two months after the program) referred to the offices. The level of knowledge was measured using a 29-item and four-choice questionnaire. For perspective, a 10-item questionnaire was used according to Likert score. The influence of programs was assessed by McNemars, Sign, and Chi-square tests. Out of I 00 studied patients, the data was complete only for 80 ones. In this respect, 19 (24%) were female and 61 (76%) were male at an age range of 43.2 ± 12.5 years and a period of 14.5 ± 11.9 years has passed from their graduation. It was shown that the training program was successful in improvement of knowledge and perspective, even for the total period of the study (P<0.001). In addition, only the way of management showed a significant and successful improvement. In this regard, the serum administration had been reduced significantly (P<0.01) in patients with colic pain. It is concluded that the contents of training programs in proportion to the requirements can upgrade the knowledge and perspective and in this way can affect the efficiency of physicians and other methods should be applied for alteration of behavior.

Considering the increasing trend for ectopic pregnancies in the world and different reports on its complications and the fate of the following pregnancies, this study was performed to determine the relationship between these factors in referrals of the hospitals of Shaheed Beheshti University of Medical Sciences from 1991 to 1996. The cohort strategy of this research study was carried out on 260 women. The case group (n = 130) consisted of cases with a pathologic diagnosis of tubular pregnancy and had undergone radical surgical procedures and then still willing to become pregnant. The control group (n = 130) comprised of cases with normal pregnancy and had a personal and history as case group. The required data were gathered from their medical records. In addition, the condition of next pregnancies, the fertility in this regard, having the term or early labor, having again ectopic pregnancy, and spontaneous or neglected abortion were considered and the results were analyzed using statistical tests. Out of 260 cases, 70% and 3.8% of cases in case and control groups respectively and had infertility after 14.2 ± 10.8 months and the difference was significant (P<0.0001). In control group, the elapsed time with the next pregnancy was shorter and 99.4% of women had become pregnant again in the first year. The rate of next term pregnancy for case and control groups was 50% and 65.4% and the difference was significant (P<0.02). There was also no significant difference between case and control groups regarding premature labor and next abortions, but there existed a higher chance of ectopic pregnancy in case group compared to control group (P<0.001). In summary, it can be concluded that ectopic pregnancy is a great threat for the next pregnancies and their fate and for this reason, newer diagnostic and treatment methods is suggested for such patients.

Low and high intake of fat consumption regardless of its kind can jeopardize personal and public health. Despite the importance of quality and quantity of fat in the diet and its relationship with some chronic disorders such as coronary heart disease, some types of cancers, obesity and diabetes, the consumption pattern of fats and their . constituent fatty acids have not yet been assessed in our country. The purpose of this study was to determine the pattern of edible fat consumption in IO provinces of our country. To this aim, the type and amount of fatty acids in Iranian dishes were calculated using the available food composition tables and the existing data. Then data from the household food consumption survey in the provinces were employed to calculated total saturated, mono unsaturated and polyunsaturated fatty acids as cholesterol, essential and ro-3 fatty acids in each province in total and in relation to urban and rural distribution. The studied provinces were Tehran, Hormozgan, Bushehr, Mazandaran, Kennan , Yazd, Kohguiluyeh and Boyer-Alunad, Hamedan, Charmahal Balclitiari and West Azarbayjan. It was shown that percentage of energy derived from fats was within the recommended range (WHO) of 15-30 % and it was always higher in urban regions than rural ones. In addition, consumption of saturated fatty acids was high in 7 out of the 10 provinces and consumption percentage of unsaturated, especially polyunsaturated fatty acids was below the recommended levels in all of the provinces . Also, The PUFS/SF A ratio was very low (0.14-0.22). Intake oflinoleic acid was satisfactory in all provinces except rural areas of Kerman and Kohguiluyeh and Boyer-Ahmad provinces. For the latter provinces, intake of linolenic acid was below the recommended level. Furthermore, consumption of eicosapentaenoic acid and docosahexaenoic fatty acids were considerably lower than recommended level except for the province of Hormozgan.

The present study was performed to determine the relationship vaginal bleeding in first half of pregnancy and fate of pregnancy in referrals of teaching hospitals of Tehran University of Medical Sciences during the years 1993-1994. The case-control strategy of this study was carried out on 432 patients. In this respect, 216 ( case group) out of them had vaginal bleeding during the first half of pregnancy and the remainder had no history of bleeding (control group). Both groups were nearly alike regarding knowledge, occupation, the surveillance of pregnancy period, number of conceptions and labors, interval between pregnancies, bearing a dead baby, and premature labor. For collection of data, an interview was set. The variables were premature labor, birth-time low weight, and perinatal mortality. The results showed that there is a significant relationship between vaginal bleeding in first half of pregnancy and premature labor (P<0.05) and birth-time low weight (P<0.02), but there is not such a relationship for perinatal mortality.

Although many years have passed from the recognition of otitis media with effusion (OME), there is much controversy on its etiology, pathogenesis, and treatment strategies. This condition occurs more frequently in infants and children. Moreover, it is more common in Eskimo and Native American than White American and Blacks. In addition, socioeconomic and cultural factors can affect its prevalence. In this regard, racial differences for length, width, and angle of eustachean tube and skull base dimensions should also be considered. In this study, lateral cephalography was used. In this research, 30 patients with bilateral OME referred to otolaryngology clinic of Loghman Hakim hospital as case and 30 children at an age range of 4-9 years as control were chosen. Then, for evaluation of mastoid system, middle ear, and eustachean tube, the reference points were determined as follows: posterior nasal spine (PNS), pterygoid (PTT), Mastoid apex (MA), middle ear point (MEP), posterior mastoidal point (PMP), and tuberculum articulare (TA). Thereafter, the variables MEP PMP, MEP-MA, MEP-PT, MEP-TA, TA-PT, TA-PNS, PT-PNS in mm, and MEP-PT PNS in degree were measured. The data was obtained for control and case groups and the average values were determined. For statistical analysis, studentchr('39')s t-test was used. The averaged age for control and case groups was 73 ± 16 and 78 ± 18.6 months respectively and there was no significant difference between them. The results showed that there was only a significant difference between the two groups regarding MEP-PMP, MEP-PT, MEP-TA, TA-PNS, and PT-PNS (P<0.001). Therefore, it can be concluded that in patients, there exist a shortened tensor veli palatini in both horizontal and vertical portions and a less mastoid pneumatization. These results showed that there is an anatomical (craniofacial) difference between affected patients and normal persons and it should be considered as an important ethiopathogenetic factor.

The preventive medicine is the most rapid way for health establishment in the society and can be carried out through upgrading the knowledge level of the citizens including mothers. Therefore, the aim of this study was to investigate the knowledge and performance of pregnant women referred to the obstetrics clinics of Kerman regarding the execution of intra-conception cares on 700 pregnant women. The descriptive and cross-sectional strategy of this study was performed on 700 pregnant women selected through random and cluster sampling with regard to population density. They had an average age of25.7 ± 3.8 years, a period of 19.7 ± 3.8 passed from their marriage, the knowledge level as 8.1 ± 4.8, number of pregnm1cies as 2.5± 1.8, and pregnancy period as 39 ± 1.4 weeks. In 91.4% of them, the pregnancy-induced hypertension was controlled, whereas 67% of them had received tetanus vaccine. Meanwhile, 95.5% of them affirmed complete blood test as necessary during pregnancy, but only 13 .6% had information for this fact that diabetics could not have consecutive pregnancies as normal persons. In addition, a significant difference was observed between the level of knowledge and performance. Furthermore, a significant difference was observed between the knowledge and age, occupation, number of conceptions, performance, and the age at the time of marriage. Considering results, it can be concluded that knowledge and performance is not sufficient during the pregnancy and it is necessary for health professionals to train more skills in this respect.

The iodinated radiopaques are widely used in radiologicals procedures for their higher quality and for better pathological diagnosis. Since they are numerous and can lead to cellular toxicity and/or genotoxicity, this study was carried out to investigate the efficacy of two routine compounds, that is, urographin 76% and telbrix 38. For this purpose, the metaphasic chromosomes of 30 patients undergoing brain computerized tumography by urographin 76% (n = 15) and telbrix 38% (n = 15) at two stages (before and 30 min after the injection of contrast medium) were prepared. Then, the cytogenetic effect of the procedure on lymphocytes was analyzed. In addition, the same protocol was used for 15 patients undergoing simple brain computerized tomography. The results showed that both contrast mediums are able to induce chromosomal damages (P<0.05). In this regard, urographin had more ability in damage induction than telbrix 38, although this difference was not significant. Meanwhile, the radiological procedure itself did not had any effect if induction of damage. The chromosomal damages may be as a result of some structural changes.

Considering the high incidence and mortality rate of esophageal cancer in some areas of the country, and its diagnosis at a time of advanced growth, this study was carried out to determine the predisposing factors and the most effective and applicable surgical procedure. In this descriptive study, 158 patients (95 males and 63 females) with esophageal cancer were studied. They referred to Shohada Tajrish hospital during the years 1991- 1999. The highest incidence rate was for patients at an age range of 40-60 years. The main cause of refer was dysphagia and then weight loss and etc. In 66 out of the patients, the tumor was in the middle third of esophagus and in 92 cases, it was in the lower third region. For treatment, 48, 40, and 42 of patients were operated by the methods Ivor-Lewis, Mckeown, and Oringer respectively. In 28 of cases, there existed unremovable tumor and for them, gastrostomy was performed. In the remaining 13 patients, other operations such as Akyama and colon interposition were carried out. Out of 130 operated patients, 18 cases of post-operative decease existed, that is 11 cases for Ivor-Lewis method (16.6%), 5 cases for Mckeown method (28.5%), and 2 cases for Oringer method (8.3%). For the incidence of complications, the most prevalent and premature consequence was pleural effusion ( 16% ), and the most common and late developing consequence was anastomosis constricture (17.8%). In addition, there existed 8 cases (7.15%) of anastomosis leak (5 cases for Ivor-Lewis, 2 cases for Mckeown, and 1 case for Oringer). Other complications in order of incidence were pneumonia (10.7%), in situ infection (8.9%), ampim (7.1%), cardiac complications (3.5%), and ARDS (1.7%). It is concluded that Ivor-Lewis method is followed by the highest incidence of complications. Meanwhile, most of the patients left the hospital 10 days after operation and the least time of hospitalization was for Oringer method.

The increasing trend in the occurrence of antibiotic resistance for Pseudomonas aeruginosa (a hostile bacterium growing on skin wounds especially those as a result of burn and leading to infectious conditions) has been accompanied with numerous complications and can even lead to septicemia and mortality. The spread of skin infections, especially those as a result of resistant variants of Pseudomonas aeromonas is associated with a longer hospitalization time, higher treatment costs, and its greater spread within the office and society. In this study, samples were taken from 271 patients with usual skin infection or infections as a result of burn that were hospitalized in Golestan and Taleghani hospitals of Ahwaz. After cultivation, the isolated colonies were evaluated. Among them, the gram-negative bacilli that were oxidase-positive and unable to ferment carbohydrates were further studied. Finally, the pattern of drug resistance was obtained for Pseudomonas aeromonas through disk diffusion using Kirby-bauer method. Out of 271 studied patients, 95 (35%) had skin infection as a result of Pseudomonas aeruginosa (55 cases (77.4%)) were in the Taleghani hospital (burn accident division) and the remainder (40 cases (20%)) were in the different surgical divisions of Golestan hospital. Out of the patients, 55.8% (53) of Pseudomonas-positive cases were female and 44.2% ( 42) were male. The evaluation of antibiotic resistance pattern for isolates showed that a resistance of 100% existed for carbenicillin, cephradine, cephalexin, ceftizoxime, and cefazolin and resiatance was greater than 90% for kanamycin. The results showed that although 83% and 1000 of isolates were still sensitive to klistin and polymyxin respecttively, but because of various problems including side-effects and their deficiency in drug-stores, amikacin with a sensitivity of 51 % can still be administered as one of the most efficacious treatments for Pseudomonas infections.

Primary hyperparathyroidism is not nowadays considered a rare disease and according to some reports, its incidence is 1/1000. This disorder can be accompanied with severe complications including renal failure and bone illnesses and this can highly elevate the treatment costs and causes social problems and troubles within families. The descriptive strategy of this study was carried out on 30 patients with primary hyperparathyroidism and it was attempted to demonstrate its clinical symptoms, paraclinical signs, and radiological findings and to compare it with the related data of other western countries and in this way to propose recommendations for rapid diagnosis and appropriate management of the patients. The results showed that the most common clinical findings were bone pains, renal stone, weight loss and generalized weakness. In addition, nearly half of them were confined to bed. The average time elapsed to make a definite diagnosis was 5.8 ± 5 years. Radiologic findings showed reduced mineralization, subperiosteal bone resorption, salt and pepper appearance for cranial bones and bone fracture in 93, 86, 76, 60 and 47% of cases. Furthermore, the level of serum calcium, phosphorus, alkaline phosphatase and the patientchr('39')s PTH divided by upper limit of normal PTH were 11.2 ± 1.3 mg%, 2.2 ± 0.5 mg%, 1346 ± 1335 IU/1 and 4.2 ± 2.8 respectively. Pathologic findings verified solitary adenoma in 25% of cases, double adenoma in I case, four gland hyperplasia in 2 of the cases and two cases of parathyroid cancer. It is concluded that manifestations of patients with primary hyperparathyroidism are different from those residing in western countries. Since routine measurment of serum calcium is not available and the patients are diagnosed when the disease has progressed far advanced, then it is better to keep it in mind that differential diagnosis of patients with bone pain and renal stone should be made to establish the diagnosis earlier and prevent the ensuing complications.

Brucellosis is an acute and chronic disease of cattle and can be transmitted to human beings. This disease is associated with numerous clinical manifestations and the rate of incidence of its skin complications is 5% in the affected patients. One of its rare skin complications is brucella abscess. In this study a 9-years old girl is presented with skin abscess of the posterior part of right ankle and by performing laboratory tests the Brucella melitensis was diagnosed.