Acta Medica Iranica
Volume:43 Issue: 4, July - Aug 2005

Behçet’s disease (BD) which is classified among vasculitides is a systemic disease with various manifestations. Its clinical course is characterized by attacks and remissions. Till now, two nationwide surveys of BD from Iran and Japan and 4 major case series from Turkey, Korea, Morocco and England have been reported. Clinical picture of BD is dominated by mucous membrane manifestations, including oral aphthosis - seen in 96.8% of patients in Iran, 98.2% in Japan, 100% in Turkey, 97.5% in Korea, 100% in Morocco and 100% in England- and genital aphthosis which is seen less frequently- 65.3% in Iran, 73.2% in Japan, 88.2% in Turkey, 56.7% in Korea, 83.5% in Morocco and 89% in England. Skin aphthosis is not frequent but it is the most characteristic lesion of BD. Ocular manifestations include anterior uveitis, posterior uveitis and retinal vasculitis. Joint manifestations include arthralgia, monoarthritis, oligo/poly arthritis, and ankylosing spondylitis. Other manifestations include neurological, gastrointestinal and cardiopulmonary manifestations, vascular involvement, orchitis and epididymitis. Erythrocyte sedimentation rate is usually elevated. Urinary abnormalities are infrequent and transient. Positive pathergy test has been reported in 57.4% of patients in Iran, 44% in Japan, 57% in Turkey, 40% in Korea, 68% in Morocco and 32% in England. Lesions usually heal without sequela, except for lesions of eyes, brain and vascular system. The major cause of morbidity is the ocular lesion, which could lead to severe loss of vision or blindness.

It is sometimes difficult to recognize a jaw lesion as osteosarcoma, ossifying fibroma or ‎fibrous dysplasia in routine hematoxylin and ‎eosin staining and a more accurate technique is needed to differentiate these ‎lesions. ‎Many studies have shown the potential usefulness of silver-stained nucleolar organizer region (AgNOR) parameters for the diagnosis of various neoplasms. This study was carried out on 42 archival biopsy specimens of jaw lesions including 14 fibrous dysplasias, 14 ossifying fibromas and 14 ‎osteosarcomas (10 well differentiated and 4 poorly differentiated). Number of AgNORs was evaluated on formalin-fixed, paraffin embedded sections. The mean AgNOR counts showed significant differences between these lesions. The mean counts of AgNORs were < 1 ‎for fibrous dysplasia, 1 to 2.5 for ossifying fibroma and well differentiated osteosarcoma, and > 6 for poorly ‎differentiated osteosarcoma. By considering a cutoff point of 1.81-2.5 for well differentiated osteosarcoma and 1-1.8 ‎for ossifying fibroma, well differentiated osteosarcoma can be differentiated from ossifying fibroma with a sensitivity of ‎90% and a specificity of 64.3%. The area under the ROC curve was 0.84. ‎The results in this study indicate that AgNOR staining is a useful technique for differential diagnosis of osteosarcoma, ossifying fibroma and fibrous dysplasia of jaws when it is difficult to recognize these lesions in routine hematoxylin and ‎eosin staining.

Many studies with different results have been conducted regarding varicocelectomy in patients with subclinical varicocele and its effect on semen parameters. This clinical trial was aimed at assessing the effect of varicocelectomy on the spermiogram of patients with subclinical varicocele. A total of 142 patients with varicocele (79 clinical and 63 subclinical) took part in the study. Two spermiograms were taken from the patients, one before and the other 3 to 6 months after varicocelectomy. ‎Although the spermiogram results of the patients with subclinical varicocele did not show a significant change after operation, the spermiogram of the patients with clinical varicocele improved significantly (P < 0.05). In patients with subclinical varicocele, bilateral and right varicoceles were more prevalent compared to group with clinical varicocele (P < 0.05). In addition, incidence of secondary infertility in the patients with subclinical varicoceles was higher in comparison with the other group (P < 0.05). ‎Considering ineffectiveness of operation in patients with subclinical varicoceles and considerable clinical differences between these patients and patients with clinical varicocele, we recommend avoiding surgery in these patients unless no other causes of semen abnormality, such as hormonal abnormality, internal urogenital abnormality or immunological disorders can be found.

Tobacco smoke contains numerous compounds, many ‎of which are oxidants and capable of producing free radical and enhancing ‎the oxidative stress. The aim of this study was to investigate the effect of cigarette smoking on the erythrocyte antioxidative enzyme activities and the plasma ‎concentration of their cofactors. ‎Sixty eight healthy men were enrolled, 32 of whom had never smoked and 36 had smoked at least 10 cigarettes per day for ‎at least one year. Hemolysate superoxide dismutase (Cu-Zn SOD), glutathione peroxidase (GSH-Px) and ‎catalase (CAT) activities were measured using spectrophotometer. Plasma copper, zinc and selenium concentrations were determined ‎using atomic absorption spectrophotometer. Plasma iron concentration was determined by colorimetric ‎method. We found that erythrocyte Cu-Zn SOD activity was significantly higher in tobacco smokers ‎compared with non-smokers (1294 ± 206.7 U/gHb in smokers vs. 1121.6 ± 237.8 U/gHb in non-‎smokers, P < 0.01). While plasma selenium concentration was significantly lower in tobacco ‎smokers (62.7±14.8 μg/L in smokers vs. 92.1 ± 17.5 μg/L in non-smokers, P < 0.01), there were no significant ‎differences in erythrocyte GSH-Px and CAT activities and plasma copper, zinc and iron concentrations between the two groups. ‎It seems that cigarette smoking can alter antioxidative enzymes activity and plasma concentration of some trace elements.

Role of labor induction has increased in the last decade due to the ‎early detection of fetal jeopardy. Although very useful, oxytocin alone is not always successful for induction of ‎labor. In a randomized clinical ‎trial we compared vaginal dinoprostone plus oxytocin with oxytocin alone for ‎induction of labor in 91 ‎pregnant women at 40 weeks or greater gestation with Bishop scores ≤ 4. Forty six patients ‎assigned to the dinoprostone group received 3 mg intravaginal dinoprostone. Six ‎hours later the Bishop score was evaluated and if the patient had not at least 3 contractions in ‎10 minutes lasting for more than 40 seconds, intravenous oxytocin was started at a dose of 6 mu/min and ‎increased by 6 mu/min at 40 minute intervals until adequate uterine activity. Forty five patients ‎assigned to the oxytocin group underwent oxytocin induction from the start of labor induction. ‎Although the Bishop score change after 6 hours of receiving vaginal dinoprostone from 2.54 ‎to 4.97 was statistically significant, the oxytocin only group had a much better response with a change from ‎2.60 to 6.28. Median time between induction to the start of active labor was significantly ‎shorter in the oxytocin alone group (P = 0.04). Median time between ‎induction to delivery and the rate of cesarean did not differ significantly in two groups (P > ‎0.05). It was concluded that single dose of ‎dinoprostone is effective for initiating labor in patients with an unfavorable cervix and ‎appears safe but it is not as effective as oxytocin.

Presence of maternal diabetes mellitus (DM) during pregnancy has important consequences for both mother and child. To determine maternal and fetal/neonatal complications of gestational DM and compare them with pre-gestational DM, a prospective study was performed in 100 diabetic women delivered in our hospital from January 2001 to April 2002. Pregnancy outcome in 27 women with gestational DM and 73 women with pre-gestational DM and their offspring were studied and analyzed. The mean age of women was 28 years, women with gestational DM being slightly older than women with pre-gestational DM. Mothers with gestational DM were at increased risk of presenting with pre-eclampsia and preterm labor compared to pre-gestational DM. Frequency of Cesarean section was higher in mothers with pre-gestational DM. Frequencies of abortion and hypoglycemic episodes were similar in gestational DM and pre-gestational DM. Infants born to mothers with pre-gestational DM were at increased risk of suffering from respiratory distress syndrome and congenital malformations but rates of unexplained intrauterine fetal death and large for gestational age were higher in infant of mothers with gestational DM. Gestational and pre-gestational DM are associated with increased risk of maternal and neonatal morbidity. Pregnant women with gestational and pre-gestational DM and their offsprings should be monitored and managed carefully.

Poor inhaler technique is a common problem both in asthmatic patients and healthcare providers, which contributes to poor asthma control. This study was performed to evaluate the adequacy of metered-dose inhaler (MDI) technique in a sample of physicians and nurses practicing in hospitals of Hamadan University of Medical Sciences. A total of 173 healthcare providers voluntary participated in this study. After the participants answered a questionnaire aimed at identifying their involvement in MDI prescribing and counseling, a trained observer assessed their MDI technique using a checklist of nine steps. Of the 173 participants, 35 (20.2%) were physicians and 138 (79.8%) were nurses. Only 12 participants (6.93%) performed all steps correctly. Physicians performed essential steps significantly better than nurses (85.7% vs. 63.8%, P < 0.05). The majority of healthcare providers responsible for instructing patients on the correct MDI technique were unable to perform this technique correctly, indicating the need for regular formal training programs on inhaler techniques.

After using 3 different generations of antibodies including human and non-human hyperimmune sera, monoclonal antibodies and chimeric antibodies, more recently a newer approach has been developed in which the antibody genes are cloned directly from a patient peripheral B-lymphocytes and expressed in a host like E. coli. In this study the Candida albicans serotype A (NCTC 3153) mannan was purified using a modified Fehling method and used for selection of human recombinant antibody from a C. albicans phage antibody library. After four rounds of affinity selecting (panning), 2 predominant clones were chosen by DNA fingerprinting and ELISA. A 248 amino acid DNA fragment coding for anti-C. albicans mannan scFv was sequenced and cloned in a pBAD-TOPO cloning vector to produce a soluble and phage free antibody. The analysis of antibody sequences by V base Index (DNAPLOT) confirmed the human antibody origin with the VH4 family in V segment of heavy variable chain and VL3 (Lambda 3) in J segment of the light variable chain. This antibody fragment was purified using immobilized metal affinity chromatography and inmmunoblotted as a 31kDa recombinant protein.

Prolonged cough occurs in a large proportion of the 2 million pilgrims who participate in the annual Hajj in Saudi Arabia. There is no unique cause for pilgrims’ respiratory involvement, but several studies suggest a high incidence of influenza as a cause of the disease. To determine influenza vaccine efficacy against respiratory disease in pilgrims, we conducted two similar cohort studies on 51100 Iranian pilgrims who had participated in the annual Hajj in the years 2003 and 2004. We calculated vaccine efficacy in these two years with the use of “1- odd’s ratio” formula and compared the results. The vaccine efficacy for prevention of influenza like illness in the year 2003 was 51% but the vaccine was not efficient in the year 2004. It was concluded that etiologic agents other than influenza virus should be considered as the cause of respiratory disease in Hajj. Bacterial infections superimposed on chronic respiratory diseases, and allergic or toxic conditions are suggested caourses for more investigation.

Patients with chronic low back pain hold various perceptions, experiences and beliefs about their pain which are based on prior learning and social influence. This study was employed to earn perceptions and beliefs of patients regarding low back pain to apply in health education planning. Eight focus group discussions including 6-10 people taking part in each of them was performed. Subjects included volunteers who recruited from Rheumatology Research Center of Tehran University of Medical Science and met the criteria of being women, 18 years of age or older, having chronic low back pain diagnosed by physician and not having experience of surgical operation in last two years. Participants were interviewed regarding two themes: experiences of subjects about non-healthy behaviors resulted in low back pain and the causes of non-healthy behaviors. The results showed that the most common non healthy behavior was hard manual work with improper posture. About 50% of participants stated they had performed hard manual work because they did not have any knowledge about the effects and consequences of it. The rest of participants mentioned other factors such as lack of belief, positive attitude, skills and social support. This study proposes that in addition to knowledge, factors such as attitude, perceptions and beliefs of patients should be considered in health education planning.

Celiac disease (CD) has been reported in association with genetic disorders ‎such as Down’s syndrome and Turner’s syndrome (TS). This study was undertaken to assess the prevalence of CD among a group of patients with TS. Forty eight girls with TS and a control group composed of 48 healthy girls were screened for CD by IgA antiendomysial antibody (IgA-EMA). Total IgA of serum was measured in all of the patients and controls and EMA was measured in subjects who had normal range of IgA. Endoscopy and biopsy of duodenum was performed for EMA positive patients and pathologic evaluation was done according to Marsh’s classification. Total IgA of serum in all of the subjects was in normal range. Two subjects, both with TS, were EMA positive, resulting in a prevalence of 4.1% for CD in TS. Duodenal biopsy was performed in these patients and histologic changes of samples were classified as grade II in one and grade III b in another one. Results of this study are compatible with previous observations placing girls with TS at higher risk for CD relative to general population and justifying screening of CD in patients with TS.

Tracheobronchial injuries are uncommon and their successful diagnosis and treatment often requires high level of suspicious. Surgical repair should be individualized for each type of injury. This article reviews diagnosis and management of traumatic injuries to the trachea and major bronchi. From March 1991 to March 2003, twenty-seven patients with major airway trauma were managed in Nemazee Hospital, Shiraz, Iran. Afterwards these patients were prospectively studied, for a period of 10 years. The mechanism of injury was blunt trauma in 13 patients, stab wound in 6, gunshot in 2 and iatrogenic in 6. Two patients had associated esophageal injury. Twenty-one patients were male and 6 were female. Eight patients had major bronchial injury, 13 had cervical tracheal injury and 6 had mediastinal tracheal injury. Six patients had re-implantation of main bronchus (5 right and 1 left), and two patients had repair of bronchus with concomitant bi-lobectomy in one of them. In cases of tracheal injury, 12 patients had primary repair of trachea with distal tracheostomy in two. However, 7 patients were managed conservatively with later sleeve resection of trachea and laryngotracheal anastomosis in three patients. Three patients died. Tracheobronchial injury is extremely challenging due to its early threat to life. A high level of suspicious and the liberal use of bronchoscope are critical in the diagnosis of tracheobronchial injuries. Avoidance of iatrogenic complications, primary repair and liberal use of autogenous tissue for wrapping or buttressing increases success rate.

Post cardiac surgery ophthalmic complications are uncommon, and sudden visual loss is one of the most important ophthalmic problems in these patients. We report a 54-year-old woman that suffered transient sudden bilateral visual loss seven days after orthotopic heart transplantation. In ophthalmologic examination positive findings were bilateral normal size pupils without direct and indirect pupillary light reflex and bilateral severe diffuse vasospasm of retinal arteries. Other ophthalmologic findings were normal. Problem lasts for 12 hours and resolved spontaneously. Funduscopic examination identified bilateral normal retina at this time and fluorescein angiography revealed normal retinal vasculature. This presentation suggests retinal vasospasm as an unusual benign cause of bilateral sudden visual loss after orthotopic heart transplantation.

Warfarin induced skin necrosis is a rare complication associated with the use of oral ‎anticoagulants. Most patients develop this complication at the initiation of therapy. The complication is ‎usually associated with an underlying thrombophilia. Here we describe a case of a 75 year old ‎patient who developed skin necrosis in her both breasts during warfarin treatment for a ‎deep vein thrombosis. Thrombophilia screening demonstrated the presence of protein S and ‎antithrombin III deficiency. The necrotic lesion was excised and defects eventually ‎covered with skin flaps.

As fetal compensation against hypoxemia progresses, the afterload on the heart and peripheral vascular resistance increases. Eventually, the right heart fails, which is transmitted to the fetal venous system, causing decreased flow during late diastole or atrial contraction and increased resistance in the ductus venosus and inferior vena cava. The ductus has forward flow during atrial contraction, the disappearance of which is always pathologic. This is a report of a case of retrograde ductus venosus atrio-wave in a fetus referred with decreased movement for fetal assessment.