Acta Medica Iranica
Volume:42 Issue: 4, July - Aug 2004

Although the diagnostic category of atypical squamous cells of undetermined significance (ASCUS) has been known since 1988, its use and appropriate clinical follow up and management still remains controversial. This study was carried out to evaluate the diagnostic value of ASCUS, using cytohistologic correlation. A retrospective review of archival materials in our cytology laboratory files was performed for cervicovaginal smears diagnosed as ASCUS from March 1999 to February 2002. In 8551 cervicovaginal smears examined, ASCUS was reported in 236 (2.76%) cases, with histologic follow up in 98 (41.2%). During the follow up period of patients with ASCUS, 51 patients (52%) had benign/reactive lesions, 43 patients (43.9%) were diagnosed as having a squamous intraepithelial lesion (SIL), 2 (2.1%) specimen were insufficient and finally two cases (2%) proved to be invasive cervical carcinoma on histology. Of cases diagnosed as SIL, 22 (22.4%) were interpreted as flat condyloma, 9(9.1%) cervical intraepithelial neoplasia (CIN) 1, 2 (2.1%) CIN 1-2, 3 (3.1%) high grade SIL, 6 (6.1%)basal cell abnormality of undetermined significance, and 1 (1%) had features of CIN 1 in presence of severe inflammation. Patients whose smears fall into the category of ASCUS may exhibit a spectrum of findings, ranging from benign/reactive lesions to frequent SIL and rarely to invasive carcinoma. Therefore, patients with a diagnosis of ASCUS justify careful follow-up and investigation.

Oligoclonal bands (OCB) can be detected in a significant percentage (90%) of patients with multiple sclerosis (MS), however, a much lower percentage has been reported in some studies, mainly from oriental countries. On the other hand, OCB have been detected in other neurological disorders (OND), even in diseases without any definite evidence for inflammation in CSF such as myasthenia gravis. This study was undertaken to evaluate the sensitivity and specificity of OCB detection in cerebrospinal fluid (CSF) in diagnosis of MS and to compare the clinical history of patients with and without OCB. CSF and serum of 80 patients, 40 with the diagnosis of MS and 40 with OND, were collected and analyzed for presence of OCB, using SDS-PAGE method. OCB were found in CSF in 28 (70%) of MS patients and in 8 (20%) of OND group. There was a significant statistical correlation between detection of OCB in CSF and MS diagnosis (P<0.0001). In MS group, the duration of the disease was longer in OCB positive patients (P= 0.045) and OCB detection was less common in patients with spastic paraparesis as a dominant clinical sign (P=0.006). In respect to other parameters, including age, sex and CSF cell count and protein, no significant difference was found. According to this study, there is a positive correlation between OCB and MS diagnosis as well as the duration of MS, and a negative correlation between OCB and spastic paraparesis as the dominant sign of MS.

The rational use of insecticides largely depends on a broad knowledge of the susceptibility and irritability levels of malaria vectors to currently used insecticides especially pyrethroids. In this study the susceptibility and irritability levels of Anopheles stephensi and An.culicifacies to DDT 4%,malathion 5%, propoxur 0.1%, deltamethrin 0.025%, lambdacyhalothrin 0.1%, cyfluthrin 0.1% and permethrin 0.25% were determined. Susceptibility and irritability tests on adult mosquitoes were carried out according to WHO methods. The results showed that An.stephensi was resistant to DDT 4% and mortality rates to this insecticide in Gavdary and Abtar areas were 64.2%±3.9 and 61.8%±4.36, respectively. An.stephensi was assumed susceptible to other insecticides. An.culicifacies was found susceptible to all the tested insecticides. The irritability tests carried out with pyrethroids exhibited that permethrin 0.25% had the highest irritancy effect against both species. Lambdacyhalothrin 0.1% and deltamethrin 0.025% had the least irritancy effect against An.stephensi and An.culicifacies, respectively. Average numbers of take offs/females/minute of An.stephensi to permethrin, deltamethrin, cyfluthrin and lambdacyhalothrin were 6.64±1.04, 3.11±0.67, 2.73±0.61 and 2.57±0.67, respectively. These figures for An.culicifacies were 2.24±0.37, 1.44±0.38, 1.59±0.35 and 1.46±0.5, respectively. Irritancy effect of pyrethroids should come in consideration while they are used for control of malaria vectors.

Rheumatic mitral valve stenosis is the most common form of organic heart disease encountered during pregnancy and continues to cause maternal and fetal mortality. Medically refractory congestive heart failure due to mitral stenosis is a clinical challenge and its optimal management remains controversial. On the other hand due to hazard of x-ray to mother and fetus, there are some limitations for perceutaneous balloon mitral valvotomy (PBMV) with fluoroscopy. Therefore, we performed PBMV with the guide of transesophageal echocardiography (TEE) with Inoue method in 18 pregnant women with NYHA class 3 or 4 due to mitral stenosis during pregnancy. The average procedure time was 29.9 (20-40) min and the average fluoroscopy time was 51.7 (28-101) seconds. The average NYHA class decreased from 3.11 to 1.33. There was no maternal or fetal complication or mortality and no premature delivery occurred. Overall risk to fetus was lower than previous reports of surgical commisurotomy performed during pregnancy. PBMV can be performed safely during pregnancy with the guide of TEE and is effective in reliving symptoms of severe congestive heart failure. It offers an effective alternative for the pregnant patients with severe mitral stenosis when congestive heart failure is not controlled by conventional medical treatment.

Local anesthetic solutions are frequently mixed to take advantage of the useful properties of each drug but the medical literature is surprisingly deficient in well controlled studies about the onset and duration of action of these mixtures for epidural anesthesia. A total of 32 patients scheduled for elective operation were enrolled in this prospective randomized controlled study; in group I, 16 patients received 15 ml solution containing bupivacaine 0.5% and lidocaine 2% as a single injection epidural anesthesia after 3 ml test dose containing 15 mcg epinephrine; in group II, 16 patients received 15 ml bupivacaine 0.5% with the same technique. The times from injection of the test dose to the onset of sensory anesthesia at inguinal ligament and umbilicus and the time of termination of anesthesia at the maximum sensory level and two levels regression of anesthesia level were checked with pinprick test. The results were compared with two sample t test. Times to onset of sensory block in L1 and T10 levels (mean±SD) were 14.87±3.1 min and 21±3.37 min in group I and 17.12±2.18 min and 24.9±2.54 min in group II, respectively (P< 0.025 and P< 0.001, respectively). Times to termination of sensory anesthesia at the maximum level of anesthesia and two dermatomes regression were 75.12±8.26 min and 87.8±7.01 min in group I and 116.37±22.4 min and 134.87±21.64 min in group II, respectively (P= 0 and P=0,respectively). Mixing lidocaine 2% with bupivacaine 0.5% in a 1:1 ratio compared to 0.5% bupivacaine solution results in significantly more rapid initiation and termination of sensory block.

Lamotrigine has been used widely in the treatment of partial and secondary generalized seizures. In this study use of lamotrigine as monotherapy for the newly diagnosed primary generalized tonic–clonic seizure has been investigated and compared with carbamazepine. After dose escalation (3 weeks for carbamazepine and 6 weeks for lamotrigin), patients were followed every 4 weeks for the first 16 weeks and then every 8 weeks for the next 32 weeks. Total number of patients was 91, randomly divided in two groups, 46 patients in lamotrigine group and 45 patients in carbamazepine group. The efficacy of the two drugs against primary generalized tonic clonic seizure was almost the same. The proportion of patients with seizure episodes in the last 40 weeks of treatment in both groups was similar (24.2% versus 24.6%). Overall, fewer patients in lamotrigine group than in the carbamazepine group withdrew because of adverse events (6.5% vs. 24.5%, P = 0.0216). The commonest side effect leading to withdrawal with lamotrigine was rash and with carbamazepine was drowsiness. More lamotrigine than carbamazepine recipients completed the study (88.9% vs. 73.3%, P = 0.0961). Lamotrigine and carbamazepine showed similar efficacy against primary eneralized tonic clonic seizure in newly diagnosed epilepsy. Lamotrigine, however, was better tolerated.

Lipoprotein(a), an LDL variant, has been claimed to have a role in atherogenesis and therefore coronary artery disease (CAD). However, its production and atherogenecity seems to vary among ethnic groups. In order to study the possible correlation between levels of Lp(a) and CAD in Iranian patients who suffered myocardial infarction (MI), a case-control study was carried out on 120 MI patients and 120 matched healthy subjects. Levels of Lp(a) were significantly higher in the MI patients than the control group (P < 0.0001), which demonstrates a possible correlation between levels of Lp(a) and CAD. Estimation of Lp (a) may be helpful in evaluating the risk of CAD, particularly in those patients with borderline levels of triglycerides and cholesterol.

Type I diabetes mellitus (DM) is frequently associated with autoimmune thyroid disease (ATD). Association of ATD and type I DM has been described with varying frequencies but there is still debate about the situation in the Iranian population. We investigated the prevalence of anti thyroid peroxidase (anti-TPO) antibodies and ATD in children and adolescents with type I DM. A total of 145 patients with type I DM were participated in this study. They were screened for anti-TPO antibodies and TSH levels. Signs and symptoms of hypothyroidism and hyperthyroidism and the presence of goiter were sought. A group of 50 healthy unrelated girls and boys aged 11-16 years served as controls. Anti-TPO antibodies were found in 34 (23.4%) diabetic patients and 1 subject (2%) in the control group (P<0.001). Frequency of anti TPO antibodies was significantly higher in girls than boys (P<0.05). We failed to show any significant correlation between thyroid autoimmunity and duration of DM. We found that younger patients at diagnosis are more likely to be anti-TPO negative (P<0.001). Out of 145 diabetic patients, 32 (22%) had visible goiter. Subclinical hypothyroidism, hypothyroidism and thyrotoxicosis occurred in 1, 9 and 1 patients, respectively. Visible goiter was found in 2 subjects (4%) of the control group, but all of them were euthyroid. In conclusion, the evaluation of thyroid autoimmunity in type I diabetic patients may improve the diagnosis of thyroid disease in early stages. Yearly examination of anti-TPO antibodies allows identifying diabetic patients with thyroid autoimmunity.

Common variable immunodeficiency (CVID) is a heterogeneous heritable disease characterized by arrest in B cell differentiation. An association between CVID and two HLA haplotypes, haplotype I (HLA-A1, HLA-B8, HLA-DR3) and haplotype II (HLA-A29, HLA-B44, HLADR7)has been previously documented. In the present study, we have attempted to find an association between susceptibility to CVID and HLA class I and II antigens in Iranian population. Seventeen Iranian patients with CVID (mean age 17, range 3-28 years; 12 male and 5 female), including two couples of brothers and 100 healthy controls were studied. All subjects were typed for HLA class 1, and 12 patients and all controls were typed for HLA class II, using microdroplet lymphocytotoxicity technique. Out of 12 CVID patients typed for HLA-DR and DQ specificities, five patients presented DR-1, which showed an increased frequency in patient (41.6% vs. 12% in controls), and 3 presented DQ-2, which also showed an increased frequency (25% vs. 4% in controls), both of which reached statistical significance (P = 0.018 and P = 0.026, respectively). HLA-DR10 was present in 2 patients (16.6%), which was markedly more frequent compared to controls, but this difference was not significant statistically. Our results suggest that HLA-DR1 and DQ-2 may contribute to susceptibility to CVID. We did not find any significant association between HLA-A1, B8 and DR3 that has been previously reported to be associated with CVID.

Otosclerosis is the most frequent cause of conductive hearing loss in patients with intact tympanic membrane. It can be treated by surgery with various techniques. Because of limited manipulation and comparably similar results, stapedotomy at present is preferred over other surgical techniques by most surgeons. Here we present the operative results of 114 otosclerotic patients who underwent stapedotomy between 1997-2002 in Rahnemoom hospital, Yazd and Amiralam hospital, Tehran. The aim of this study is to evaluate the efficacy and safety of stapedotomy in otosclerosis surgery. The average air-bone gaps of patients improved significantly from 41.82 db to 14.23 db after operation. Other hearing parameters of patients (including air conduction, bone conduction and speech discrimination score) also improved significantly. Permanent vertigo did not occur after operation and preoperative tinnitus resolved in 56 of 78 patients. Stapedotomy is a safe and effective modality for improving conductive hearing loss in otosclerotic patients.

According to statistical data from WHO, respiratory tract infections are among the most important health problems all over the world. Differentiating viral from other causes of respiratory infections is difficult, but a good knowledge of viral etiologic factors can guide the physicians in the diagnosis and treatment of the disease. We carried out this descriptive, case-series study to evaluate the relative frequency of parainfluenza virus (PIV) infections in upper and lower respiratory tract infections. A total of 263 three children with respiratory infection were studied from autumn 1998 to autumn 2000. We prepared samples from their nasopharynx with sterile swabs for viral culture and study of cytopathic effects of PIV. Thirty six cases had positive culture for PIV (14%). There was a significant statistical correlation between the prevalence of PIV infection and age of patients. The highest prevalence was in the of 1-5 years old age group. There was also a correlation with season, and majority of cases were seen in autumn and spring (P< 0.0001). There was no significant correlation between PIV infection and sex. PIV infection had significant correlation with croup and bronchiolitis (P<0.0001). PIV plays an important role in causing lower respiratory tract infections.

Urinary stones are prevalent and Corynebacterium urealyticum, a urease-positive bacteria, is a frequent urinary tract pathogen. However, the association of this organism with urinary stones is not sufficiently studied in Iran. This study was carried out to determine the prevalence of C. urealyticum in patients with urinary stones referred to the urology sections of Tehran University of Medical Sciences. This study was performed using case-control method. A total of 150 urine samples from patients with urinary stones and the same number from the control group without urinary stones or infection were collected. The two sets of samples were cultured and biochemically identified. The pH of urine samples also measured with pH paper. C. urealyticum was detected in 11.34% of cases which was significantly higher than that in control group (P < 0.01). The frequency of alkaline urine was four times more in the patients than those in control group which was statistically significant (P< 0.01). According to the results, C. urealyticum, which is known to cause alkaline urine, might enhance formation of stones. Further studies using cohort or experimental methods are recommended.

Soon after successful results of balloon valvuloplasty in treatment of congenital pulmonary stenosis, use of this technique for relief of congenital aortic stenosis (AS) was attempted in different parts of the world. With the purpose of assessment the value of valvuloplasty in comparison with surgical valvotomy in relief of congenital AS, we retrospectively studied 115 patients with valvar AS, 48 of whom underwent balloon valvuloplasty (mean age 9.63 years), and 67 subjected to surgical aortic valvotomy (mean age 10.32 years), in a six year period from 1991 to 1997 at Rajaie heart hospital. Comparison of balloon valvuloplasty with surgical valvotomy revealed that reduction in the mean pressure gradient in balloon valvuloplasty group was greater than those subjected to surgical valvotomy (73.54 vs. 45.03 mmHg, P < 0.0001). Decreased incidence of aortic insufficiency and mortality in balloon valvuloplasty in comparison with surgical valvotomy are other notable points in this study. Although it is difficult to compare the results of the two procedures and determine their different indications, our successful experience with balloon valvuloplasty for congenital AS and the safety of this procedure encourage us to use this technique for the patients with congenital AS more than ever. These results must be supported by future studies.

Generalized pustular psoriasis with hypoparathyroidism has been reported previously often as a post thyroidectomy syndrome with hypoalbuminemia and hypocalcemia. But reports on association of pustular psoriasis with idiopathic hypoparathyroidism are very rare, and almost all of them occurred in patients with known psoriasis vulgaris. We report one of the youngest cases of this association in a 17 year old girl without previous history of psoriasis which her eruption disappeared completely after the correction of hypocalcemia and remained free of eruptions until 6 months afterward. This case adds further evidence to the importance of calcium in the pathogenesis of at least some forms of psoriasis.

Subcutaneous emphysema is a rare complication of postoperative nausea and vomiting and can lead to airway compromise. We describe a case of delayed, severe subcutaneous emphysema after postoperative vomiting which fortunately did not lead to airway compromise and eliminated with conservative management. Rough and difficult laryngoscopy and intubation, presence of clots and bloody discharge after extubation, beginning of subcutaneous emphysema in the neck spreading caudally to the chest and fibroptic bronchoscopic findings all confirmed tracheal trauma as the cause. In this case the late onset of the subcutaneous emphysema, good response to conservative treatment and spontaneous resolution is considerable.

Massive hemoptysis is one of the most important respiratory emergencies and pulmonary infiltrating diseases are among the rare causes of hemoptysis. Bronchial artery embolization (BAE) is a safe and effective treatment in these patients. Our case was a 45 years old woman with a 7 year history of Hodgkin''s lymphoma who presented with massive hemoptysis of 20 days duration. CT scan revealed prebronchial infiltrating pattern. Diagnostic angiography showed hypervascularity in both hilar and perihilar areas and simultaneous opacification of both bronchial arteries from a right common trunk. BAE was successfully performed with 300 µ diameter polyvinyl alcohol. In follow up, hemoptysis did not recurred and patient was in good general health.