مجله دانشگاه علوم پزشکی مازندران
پیاپی 58 (خرداد و تیر 1386)

Background and

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Its pathophysiology is described by canalolithiasis theory. A safe and simple treatment has been proposed in recent years (canalith repositioning maneuver). This study has been performed to compare the effectiveness of physical maneuver and medical therapy in the treatment of BPPV.

The study was a clinical trial. Patients with BPPV (Being diagnosed based on positive Dix – Hallpike test and history) were randomized into 2 groups on first visit. They were matched for sex, age and cause of BPPV. 23 patients received Epley maneuver and 22 patients received Betahistine. Patients were evaluated at first week and first month after the beginning of the treatment.

After one week, 58.3 % of patients in drug group and 94.1 % of patients in maneuver group had negative Hallpike test. After 1 week, all patients were asked about the resolution of symptoms. After 1 week, 39.77% of patients in drug group and 81.52 % of patients in maneuver group improved. This difference between the 2 groups was statistically significant (2 = -4/338 p< 0/001). After 1 month, 56. 83 % of patients in drug group and 86.98 % of patients in maneuver group improved (z =- 3/ 305 p<0/01). The difference of subjective improvement was statistically significant between 1 week and 1 month follow up in drug group (z = -2/85 p<0.01), this difference however was not statistically significant in maneuver group (z= -1.5 NS).

In short term the Epley maneuver is much more effective than medical therapy to control symptoms of BPPV and is the best treatment for this disease.

Background and Topical metronidazole (10 percent) has been previously demonstrated to decrease post operative pain after hemorrhoidectomy. The aim of this study was to evaluate the effect of topical metronidazole (10 percent) on postoperative and after defecation pains of hemorrhoidectomy. A double-blind randomized trial was conducted to compare post- hemorrhoidectomy pain using topical metronidazole (10 percent) to. placebo carrier applied to surgical site. Forty-seven patients were randomly selected to receive metronidazole (n=25) or placebo (n=22). Pain was assessed using a visual analog scale (VAS) preoperatively as well as on postoperative hours 6 and 12, and on days 1, 2, 7, and 14. The use of narcotic, additional analgesics and complications were recorded. (Pain scores were calculated and compared with baseline values and control group (t-test, SPSS ver.10). Patients in the topical metronidazole group had significantly less postoperative pain than those in the placebo group by the day 14 (P≤0.04). There was no significant difference in narcotic analgesic requirements between groups, except for hour 12 (P<0.05). In the metronidazole group, after defecation, pain was ranked significantly lower on day 2 (P=0.016) and patients required fewer additional analgesics postoperatively on days 2 and 7 (P≤0.04). These finding indicate that topical 10 percent metronidazole significantly reduce post- hemorrhoidectomy discomfort and postoperative defecation pain is reduced compared with that of the placebo control group.

Background and Evaluation of suspected biliary obstruction is performed by common old methods such as Ultrasound, CT, and invasive cholangiography. These techniques have limitations due to the poor visualization of intraductal stones (US, CT) and the need for an invasive procedure (ERCP, PTC). Magnetic resonance cholangiography (MRC) is noninvasive imaging modality that provides good visualization of the hepatobiliary system. The aim of the present study was to determine the utility of Magnetic resonance cholangiography, Ultrasonography and Liver function test in preoperative assessment of patients with symptomatic cholecystolithiasis and suspected biliary obstruction. Patients selected for elective open cholecystectomy with risk factors of common bile duct stones as suspected biliary obstruction underwent MRC, US, and Liver function test preoperatively. All patients underwent open cholecystectomy and intraoperative cholangiography in Imam Khomeini Hospital, Academic Medical Center of Medicine School, Mazandaran University of Medical Sciences, Sari, Iran from January 2003 to February 2006. 30 patients (11 male, 19 female) with the mean age 53.93±13.32 years in a range of 38-75 years underwent all preoperative and operative assessments. 81.81% Sensitivity, 87.5% specificity and 83.33% efficacy in MRC 18.18% Sensitivity, 87.5% specificity and 36.66% efficacy in US, and 54.54% Sensitivity, 37.50% specificity and 50% efficacy in Liver function test were the results obtained for biliary stones. MRC has excellent diagnostic accuracy in the detection of biliary disease. Due to its non-invasive nature, MRI may have advantages over invasive cholangiography when diagnosis is the major goal of the procedure.

Background and The breast cancer is the most common malignancy in women. Bcl-2 expression has been determined in more than half of the cases of breast cancer. The purpose of this study was to determine the expression of bcl-2 gene in primary breast cancer and its correlation with grade, stage and axillary lymph node involvement. The study was a cross-sectional one that was performed on 75 patients with breast cancer admitted to Mostafa Khomeini hospital (2000-2005). After preparing the samples, a tissue section from each sample was obtained. One of the tumoral sections and one of the lymph node sections were stained using H & E. We determined the type of the tumor, the number of lymph nodes, the stage and the grade of the tumor. We studied Bcl-2 with polyclonal antibody by IHC. Our study showed that 69.3% of patients had hymph node involvment. In addition, 41.3% of samples were positive for Bcl-2, 58.7% of samples were in stage II and many patients (42.7%) were in grade III. In this study, we didn’t find any relationship between bcl-2 and stage and lymph node involvment. We also found a significant association between bcl-2 and grade (P<0.006). Also, high bcl-2 expression was more frequent in high-grade tumor. According to the results obtained from earlier studies and our study, it seems that bcl2 is a prognostic factor in breast cancer. But further investigations with more specimens and long-time follow-up are required to clarify the exact role of Bcl-2 in the prognosis of breast cancer.

Background and Neuromuscular relaxants are one group of the important drugs in providing good condition for tracheal intubation and operation. Rapid intubation is needed in most situations. Also, most of non- depolarizing relaxants almost have long onset time. We compared the priming with pancrunium and atracurium in providing good and rapid relaxation for tracheal intubation. In this prospective study, 65 patients with ASA class I, II were randomized into two groups. Group A received pancrunium and group B received atracurium. Primimg dose was injected as 20% of total dose of relaxant. Twitching response was measured with peripheral nerve stimulator. Intubation was done when % 80 of the twitching response disappeared. The time of total disappearance of twitching response was also recorded. The mean time for the injection of the first dose of relaxant until the time of intubation was 94.47 seconds in group A and 142.9 seconds in group B, which were significantly different (P<0/01). If intubation until the time of twitch response is detained, the time gap of group A will again be less than group B (P<0/01). In priming technique, the time of tracheal intubation with pancrunium is significantly less than atracurium. So, considering the patient's condition and the need for rapid relaxation, pancrunium could be is a better relaxant than atracurium.

Background and

Former studies showed that the Matricaria chamomilla hedroalcholic extract affects pain and anxiety of male and female mice sex-dependently. In this research we examined the effect of Matricaria chamomilla (chamomile) hydroalcholic extract on locomotor activity behavior in presence and absence of sex glands in adult male and female NMRI mice.

Animals were divided into groups of seven including intact, sham, gonadectomized and receiving hydroalcholic extract of chamomile (30 and 50 mg/kg i.p). Motor activity monitor system was used to evaluate locomotor activity parameters (number of line crossing movments, stereotype movments and number of rearing movments) in open field test on all groups.

1) Hydroalcholic extract of chamomile (50 mg/kg dos) decreased motor activity parameters in presence and absence of sex glands in male mice. 2) Hydroalcholic extract of chamomile (50 mg/kg dose) increased motor activity parameters in presence and absence of sex glands in female mice.3) Gonadectomy did not have any effect on locomotor activity parameters on male mice.4) Gonadectomy decreased motor activity parameters on female mice.

It seems that chamomile extract influences motor activity parameters via some sex related factors like neurochemical systems in male and female mice. This effect may in part depend on sex hormones receptors in female mice.

Background and Due to the high annual birth rate of thalassemia major in our country, its prevention by prenatal diagnosis is of important priority. Gene mutation remains unknown in 10-20% of thalassemia trait people in Iran. In these cases, linkage analysis using polymorphic sites which are located near or within the gene is necessary to follow the mutant or the normal chromosome. SspI polymorphic site which is studied for the first time in Iran is located in the second intron of beta globin gene. The aim of this study was to determine the polymorphism frequency of this site in Mazandaran province. Peripheral blood of 211 thalassemia trait patients living in Mazandaran province was collected. After DNA extraction and amplification of the beta globin gene region containing the SspI polymorphic site, the effect of SspI restriction enzyme was evaluated on agarose gel. In 422 analyzed chromosomes, 20.6% were negative for SspI polymorphic site. Negative sites were almost equally associated with normal and mutant alleles (11.9% and 14.3% respectively). SspI site analysis can be applied to follow the normal or mutant alleles of beta globin gene.

Background and Low serum ferritin levels correlate with low iron stores, whereas high levels are associated with an acute-phase reaction. Our objective was to determine whether elevated levels of ferritin in the genital tract can be a potential marker to identify patients at risk for spontaneous preterm delivery. We performed a nested case-control study involving 28 women who had spontaneous preterm delivery. 28 term control subjects mathched for parity, age, education, previous history of PTL and vaginal bleeding selected from 275 women enrolled in the preterm prediction study of the prenatal care unit at Imam hospital. Cervical ferritin was measured using radoimmunoassay. Cervical ferritin levels were significantly higher in women who subsequently had spontaneous early preterm delivery (mean SD: 54.5 5 ng/ml VS 36.39 1.59 in control, P=0.001). Elevated cervical ferritin levels in 22=24 weeks of gestation in asymptomatic women are associated with subsequent spontaneous preterm birth. Cervical ferritin, alone or in combination with other potential markers, maybe a useful tool to help identify high risk women who would potentially benefit from such prospective intervention. Until the identification of such clinical interventions in a clinical trial, the use of cervical ferritin for the prediction of preterm delivery remains experimental.

Background and Helicobacter pylori(HP) has an important role in the pathogenesis of gastritis, peptic ulcer and gastric cancer. The eradication of HP results in the prevention of the recurrence of peptic ulcer and its complications. In developed countries, the recurrence of infection is unusual and rare after the successful eradication of HP infection, however it is likely in developing countries and the rate is variable in different parts of the world. The aim of this study was to evaluate the recurrence rate of HP infection, at least 2 years after the successful eradication of HP infection. Those patients with documented duodenal ulcer (according to endoscopy) and HP infection (according to rapid urease test) were included in this study. The patients were treated with different HP eradication regimens and the eradication was proved, using the 14C Urea Breathing Test (UBT). The patients were re-evaluated with 14C UBT at least 2 years after the first negative UBT result (mean duration: 36 months, ranging from 24 to 30 months). Eighty patients (51 males and 29 females) were included in the study. Mean age was 40.53 + 10.99 years (ranging from 20 to 79 years). HP infection recurrence was documented in 11 patients (13.75%). Although HP eradication was performed successfully, the recurrence rate was significant. This can influence the therapeutic and the following up strategies of the patients.

Background and

Several studies have shown differences in HTN prevalence between urban and rural populations. The aim of this study was to compare the prevalence of HTN and the status of HTN awareness, treatment and control between Iranian urban and rural populations aged over 20 years.

As a part of a nation-wide survey in 2004 on risk factors of non-communicable diseases, a cross-sectional study was performed on 75.132 adults aged over 20 years. In all participants, blood pressure was measured for twice in a standard method, followed by a collection of data on patients’ awareness, treatment and control of HTN. The data were compared between urban and rural populations.

The crude prevalences of HTN were 30.5% (CI 95%: 30.496- 30.50), 29.2% (CI 95%: 29.19-29.21), and age-adjusted prevalences were 26.09% (CI 95%: 26.086-26.094) and 26.03% (CI 95%: 26.015-26.025) for urban and rural populations, respectively. Rural residents were significantly less aware of HTN, its treatment and control than urban people.

Considering the similarity of age-adjusted HTN prevalence between Iranian rural and urban communities, there is the same burden on our health system. With respect to the lower degree of HTN awareness and control in rural residents, and the integral role of rural health system in diminishing the mentioned difference, further developments are recommended for system.

Background and Ambulatory medicine is one of the most important parts of medical education. Due to its profound relation with professional future of physicians, ambulatory medicine is especially under attention and many studies have been performed to survey its quality and to design some ways to promote it. There is obvious deficiency in our evidence about ambulatory medicine. The aim of this study was to survey the quality of teaching of the ambulatory medicine from the viewpoint of the faculty members and students of medical faculty of Mazandaran. This was a descriptive and cross-sectional study. The study's population consisted of students, residents and clinical faculty members who were included by simple sampling. Data collection was performed by a questionnaire with 22 questions about demographic and educational variables as well as respondents’ opinions about environmental conditions, independent activities, instructors’ supervision, and social training in the ambulatory clinics. The validity of the questionnaire was controlled by content validity with expertise consultation, and its reliability was controlled by test-retest(r=0.85). Data were analyzed using spss13 software. Response rate was 79%, the mean age of 36 faculties was 43.6+- 8.7 years and 32% of them were female. The mean age of 146 students was 25+-3.6 years and 61% were female. The attitude of the majority of the students (88.3%) towards the quality of ambulatory teaching was negative, but majority of faculties (66.7%) had positive attitudes. There was no significant difference among teaching departments. Attitude of junior trainees was even worse. Attitude of faculty members and students was similar towards inappropriate physical environment of ambulatory clinics, but it was significantly different from independent activities of trainees in clinics (p=0.000) relational drugs prescription (p=0.000) management (p=0.004), and supervision of faculty members (p=0.000). The overall attitudes towards the current condition of ambulatory teaching (especially trainees) were negative because of the impossibility of independent activities for trainees, low supervision of faculties, absence of teaching for rational drug prescription, differential diagnosis and management.

Background and MR vaccination is prohibited among pregnant women, therefore pregnancy is recommended three months after vaccination. On the other hand, pregnant women acquiring these diseases face unwanted complications. We tried to determine the frequency of congenital disorders in the newborns of the vaccinated pregnant women under 25 years in Mazandaran province. This historical cohort study was done by consent method on 1031 cases throughout Mazandaran province. 406 cases out of the population were vaccinated without prior information about their pregnancy. The data were collected by questionnaires through referring to their healthcare files and telephone contacts just to make sure about their vaccination conditions. The data obtained from these cases along with the data from 493 pregnant women who were not vaccinated during the years 2002-2003 were statistically analyzed. Pregnancy complications were observed in 58 (6.5%) subjects 24 (41.38%) in the control group and 34 (58.62%) in the case group. The rate of complications in the subjects under the study was as follows: premature delivery in 27 (46.57%) subjects 8 (29.62%) in the control group and 19 (70.38%) in the case group weight under 2500 gram at birth in 19 (32.75%) subjects 12 (63.16%) in the control group and 7 (36.84%) in the case group still birth in 6 (10.34%) subjects 1 (16.67%) in the control group and 5 (83.33%) in the case group abortion in 6 subjects (10.34%) 2 (23.33%) in the control group and 4 in (66.67%) in the case group. Only one person in the control group had intra uterine growth retardation. No significant pregnancy complication difference was observed between the case and the control groups in this study (P>0.05) Results of this study and the related researches indicate that though MR vaccination during pregnancy is safe, the randomly performed vaccination of pregnant women, should be advised and the followed up for the probable unwanted complications.

Background and There are more than five million neonatal death around the world of which %19 was because of Asphyxia at birth time. In our country, there has been educational program in order to decrease the mortality caused by Asphyxia and to practice a scientific method for resuscitation. This study was conducted to determine the rate of knowledge, attitude and practice for every learner of neonatal resuscitation in the governmental hospitals of Mazandaran province in 2005(1384). current study was a descriptive cross sectional done on All Trainees who had professional direct contact with birth Asphyxia. We selected exactly 137 people who had attended Neonatal Resuscitation Workshop for three days. The subjects under the study were %62/8 midwife and %89/8 women. Data show that % 44.5 had good knowledge and % 11.7 had very good knowledge on neonatal Resuscitation. The highest acknowledge was %93/4 and %89/1 on chest compression and breath stimulation way respectively. Data also suggested that totally % 96.34 of the subjects had good and very good attitudes towards neonatal resuscitation. The results show that only % 38.4 of the subjects under the study had a good level practice and their attitudes in terms of age were significantly different (P<0.01). Also, their practice on job showed a significant difference (P<0.017). In the study, there was a converse relation between age and professional experience which was r = 0.25 and r = 0.26, respectively. Results obtained suggest that the amount of knowledge and practice for the subjects under the study was average, but their attitudes towards neonatal resuscitation was good. There fore, according to the positive attitude of the subjects,there must be a trend to promote knowledge and practice.

Background and The range of medical services is so large that rendering services under the support of medical insurance is not possible for the insurance companies. Many of the patients need the supplemental insurance, specially when this type of insurance completes the general medical insurance. Client's consent with the health service center is undeniable nowadays. This study was performed to determine the rate of working staff's consent at Mazandaran University of Medical Sciences of the supplemental insurance company in Sari. In a descriptive study, 120 out patients and hospitalized patients who had benefitted from the supplemental insurance for once company underwent the study. Data collected by questionnaire were confirmed on account of P validity to be used in the pilot study. Also, data were analyzed in descriptive method with SPSS software. The obtained results were as follows 63 (%52.5) were male, 79 subjects aged 30-49 years (65.8%), 63 had higher education (52.5%), 90 were married (75%). 54 (%45) subjects were hospitalized with cardiovascular disease and digestive problems. Also 72 subjects (%60) had the history of 3 days hospitalization. Sonography was the method of treatment (43%) that was used for %43 of them. Regarding the purpose of the study, many of the subjects under the study, (51.7%), were satisfied with the supplemental insurance company in terms of behavior, 64 subjects (%53.3) with insurance compancy's cooperation and finally 59 subjects (%49.2) were pleased with the organization's commitment to its responsibility. The X2 test showed that there is significant relationship among the age, education number of hospitalization, the reason of hospitalization, diagnostic procedures, and the rate of satisfactions p<0.001. This finding indicates knowledge, relation with the medical care centers, type and quality of rendered services. Therefore, it is suggested that a logical planning be conducted by the authorities of the insurance company to achieve the utmost degree of satisfaction.

Background and The medical importance of cockroaches is much greater than what has generally been realized. They are known to carry pathogenic viruses and bacteria such as escherichia coli, Staphylococcus aureus and salmonella species including S.typhi and S.typhimurium. As a result, their eradication is very important. One of the best and effective ways of controlling cockoaches is thought to be the chemical method, which is performed by insecticides. It should be stated that the chemical treatment must be combined with enviromental sanitation, otherwise, the results will not be satisfactory. This study was carried out by using four different insecticides like: Permethrin 0.92% Deltamethrin 0.98% and Supermithrin 0.92% to evaluate their susceptibility and resistance. In this study, the cockroaches were collected from Imam Khomeini and Boo Ali Hospitals in Sari and were tested by different cocentrations of above -mentioned insecticides. Susecptibility of cockroaches was performed according to the standards of World Health Organization (W.H.O). In this study, all the strains of cockroaches were exposed to the concentration of the above-mentioned insecticides through surface contact method. Imam Khomeini strain showed the LT50 of 20/24, 19/30, 19/64 minutes and Boo Ali hospitals 19/87, 17/6, 18/66 minutes. For susceptible strain, 8/89, 8/8, 8/64 minutes were obtained to Permethrin, Deltamethrin and Sumithrin respectively. On the other hand, LT90 for Imam Khomeini strain were 42/91, 41/21, 37/38 minutes and Boo Ali hospitals 42/59, 40/88, 34/05 minutes. For susceptible strain, 17/58, 18/43, 17/28 minutes were obtained to Permethrin, Deltamethrin and Supermithrin respectively. In surface contact, the resistance ratio (RR) to pyrethroids insecticides (Permethrin, Deltamethrin and Supermithrin) of BoAli hospitals strain was 2/23, 2 and 2/15 respectively, while this ratio for Imam Khomeini strain was 2/2, 2/19 and 2/27. Direct use of permethrin, Deltamethrin and supermithrin has developed the resistance of German cockroaches significantly.

The familial spastic paraplegia (FSP) is a heterogeneous group of motor neuron disorders characterized by slow progressive weakness and spasticity of lower limbs. The disorder can appear at any age, but it usually occurs in childhood or early adult life. The genetic pattern of this disease is mainly autosomal dominant trait, but occasionally as an autosomal recessive trait, and very rarely as an X-linked recessive disease. The prevalence of this disease ranges from 2.0 to 4.3 per 100000. In this study, there were 5 patients in a family and 3 in another family who had weakness and spasticity of lower limbs in the first decade of their life. In physical examination, there were normal sensation, ankles spasticity, extensor plantar reflexes, deep tendon reflexes 4.2, tip toe walking, contracture of knees and ankles. Genetic pattern of disease was these patients is autosomal dominant trait.

Background and Oculogyric crisis which is a dystonic reaction commonly caused by typical antipsychotics treatment of acute dystonias, rarely occurs with atypical antipsychotics like clozapine. The aim of this report was to describe a rare case of clozapine-induced oculogyric crisis successfully treated with biperiden. Case: The patient was a 42-year-old woman with a 19-year history of schizophrenia treated with high-potency typical antipsychotics, risperidone and lithium augmentation with appropriate doses and duration. Because of poor response to prior medications, she was prescribed clozapine started with 25 mg/d and gradually titrated up to 150 mg/d. She has experienced two episodes of oculogyric crisis treated successfully with biperiden. Although low affinity of clozapine for blocking D2 dopaminergic receptors and its anticholinergic activity may explain the significantly lower incidence of dystonic reactions, they may happen in some patients and could be suppressed with biperiden. Clinicians should consider dystonic reaction as a possible clozapine adverse effect and on the basis of this report, clozapine-induced oculogyric crisis may be treated successfully with biperiden.

Fish tank or swimming granuloma caused by Mycobacterium marinum is an opportunist pathogen commonly found in aquatic environments. We present a 16 year-old boy with frequent exposure to aquarium water who had several nodules (sprotrichoid forms) on his right hand. Pervious studies showed that fish tank granuloma is a rare skin infection (0.27 per 100,000 population in one year). However, taking proper history and considering the patient’s signs and symptoms could be helpful in diagnosis and treatment.

Reduction mammaplasty is increasingly used for the treatment of discomfort associated with macromastia. Breast cancer is a tumor with the highest prevalence and incidence in women. As it can be expected, reduction mammaplasty specimens occasionally reveal breast cancer. So, before reduction mammaplasty, patients should be assessed for breast cancer risk and evaluated by physical examination and mammography. We report here the discovery of breast cancer in specimens from a patient who underwent elective breast reduction. Preoperative mammography showed no evidence of malignancy. But, final pathologic evaluation of reduction specimens revealed foci of “invasive ductal carcinoma” on the left side, therefore the patient underwent modified radical mastectomy. In conclusion, thorough preoperative clinical examination and mammography may reduce the rate of incidentally discovered cancer during reduction mammaplasty procedures. Pathologic examination of RM specimens is imperative, and sending all of them for pathologist is mandatory. These recommendations emphasize breast reduction as an opportunity for detection of occult potential fatal disease in higher risk groups.