Acta Medica Iranica
Volume:42 Issue: 3, May -June 2004

Large vessel involvement is one of the hallmarks of Behcet’s disease (BD) but its prevalence varies widely due to ethnic variation or environmental factors. The aim of this study is to find the characteristics of vasculo-Behcet (VB) in Iran. In a cohort of 4769 patients with BD, those with vascular involvement were selected. Different manifestations of disease were compared with the remaining group of patients. A confidence interval at 95% (CI) was calculated for each item. Vascular involvement was seen in 409 cases (8.6%; CI, 0.8). Venous involvement was seen in 396 cases, deep vein thrombosis in 294 (6.2%; CI, 0.7), superficial phlebitis in 108 (2.3%; CI, 0.4) and large vein thrombosis in 45 (0.9%; CI, 0.3). Arterial involvement was seen in 28 patients (25 aneurysms and 4 thromboses). Thirteen patients showed both arterial and venous involvement. The mean age of the patients with VB was slightly higher (P<0.03), but the disease duration was significantly longer (P<0.0003). VB was more common in men. As the presenting sign, ocular lesions were less frequent in VB (P<0.0006), while skin lesions were over 2 times more common in these cases (P<0.000001). VB was associated with a higher frequency of genital aphthosis, skin involvement, joint manifestations, epididymitis, CNS lesions and GI involvement. The juvenile form was less common in VB (P<0.03). High ESR was more frequent in VB (P=0.000002), but the frequency of false positive VDRL, pathergy phenomenon, HLA-B5 or HLA-B27 showed no significant difference between the two groups. In Iranian patients with BD, vascular involvement is not common and large vessel involvement is rare. It may be sex-related, and is more common in well-established disease with multiple organ involvement and longer disease duration.

Despite all advances, treatment of esophageal carcinoma is still unsatisfactory. Currently the standard non-surgical treatment of esophageal cancer is concurrent chemotherapy and radiotherapy (chemoradiation), with results comparable to best surgical series. A few years ago, we started a chemoradiation protocol for the cancer of esophagus as a curative treatment, of which we present the preliminary results here. Files of all esophageal carcinoma patients treated in our department since 1996 until mid 2001 were checked, and those treated by chemoradiation were selected and reviewed. Overall survival was measured from the start of radiotherapy to the time of last follow-up or death. Results were compared to historical controls treated by radiotherapy alone in our department, reviewed in a recent study. Twenty-eight patients (17 males and 11 females, mean age 59 years, tumor location in the middle-third of esophagus in 54%, all squamous carcinoma except one adenocarcinoma) were treated by two courses of cisplatin and 5-FU chemotherapy with concurrent radiotherapy. Radiation dose was mostly 50 Gy in 25 fractions. Mean overall survival was 17 months and median survival was not reached yet due to relatively short follow-up. Compared to 283 patients treated by radiotherapy alone with a mean and median survival of 12 and 8 months, chemoradiation was significantly superior (P=0.0004). Concurrent chemoradiation as used in our department offers a definitely better chance of survival compared to radiotherapy alone. To improve the results, we are pursuing the combination of neoadjuvant chemoradiation and surgery in a clinical trial.

Glutathione S-transferases (GSTs) are widespread in Fasciola. hepatica parasite and sheep liver tissue. Study of GSTs inhibition assays in F. hepatica and sheep liver tissue are a priority of chemotherapeutic targets in parasitic liver diseases including human fascioliasis in Iran. In this research, the whole extract of F. hepatica and sheep liver tissues were purified and eluted for sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) pattern and GSTs inhibition assay. GSTs inhibition was detected by hexachlorophene as an inhibitor and 1-chloro-2,4-dinitrobenzene (CDNB) as secondary substrate. The purified GSTs from F. hepatica and liver tissue contained comparable components and showed a molecular weight of 26kDa. The inhibitor concentration of hexachlorophene, for the remaining 50% activity (IC50%) of GST enzymes from F. hepatica and liver were graphically calculated, and the results were 0.25 µM and 1 µM, respectively. GSTs of F. hepatica may be more sensitive than sheep liver tissue to hexachlorophene.

Abstract-Cervicovaginal cytology is still a widely used cancer screening method that is well established in most countries. The present study aims at detecting and classifying squamous intraepithelial abnormalities and effects of certain infectious agents, particularly the cytopathic effects of human papillomavirus (HPV) in a series of cervicovaginal smears, according to the Bethesda system (TBS). The significance of specimen adequacy in revealing squamous intraepithelial abnormalities (SIEA) was also evaluated. Overall, 9066 smears were examined according to TBS. For interpretation of atypical squamous cell of undetermined significance (ASCUS), certain quality control (QC) guidelines were considered. While stressing on koilocytic atypia, the full spectrum of cytologic alterations due to HPV was investigated. Of all smears, 79% were satisfactory for evaluation and 15% were inadequately satisfactory due to absence of the endocervical/transformation zone (EC/TZ) component. The proportion of SIEA was significantly (P< 0.05) higher in smears having such a component. Of 246 cases with SIEA, 173 (1.90%) cases were classified as ASCUS, 46 (0.50%) as low grade squamous intraepithelial lesion (LSIL), and 27 (0.26%) as high grade squamous intraepithelial lesions (HSIL). Of the latter, 19 cases demonstrated HPV effects. ASCUS was the most frequent diagnosis for which QC criteria were fulfilled. On the basis of our study the adequacy of specimen is of paramount significance, with particular emphasis on the presence of EC/TZ component.

Regardless of severity, earlier intervention to correct hearing loss in children improves speech development and conversational abilities. A cross-sectional study was performed on 230 neonates who were at risk of hearing loss in Tehran University of Medical Sciences hospitals between September 2000 and February 2002. Hearing was examined before the 3rd month by auditory brainstem responses (ABR). Eighteen neonates (8%) had sensorineural hearing loss. There was no significant relationship between hearing loss and sex. We found significant statistical relationships between hearing loss and craniofacial anomalies (P value < 0.000001), the neonate’s age during hospitalization (P value < 0.005),hyperbilirubinemia (P value < 0.01), using artificial ventilation (P value < 0.05) and use of ototoxic drugs (P value < 0.05). It seems that it is much better to screen all neonates for early detection of hearing loss. If this goal is not achievable, all neonates with risk factors must be checked. Severe hyperbilirubinemia is a main risk factor of hearing loss.

Intra-operative management of thyroid gland in laryngeal cancer is controversial. To determine the rate of thyroid involvement in patients with laryngeal cancer treated by radical surgical excision, we reviewed the records during 1996-2000 in Imam Khomeini Hospital, Cancer Institute, and Amir Alam Hospital.We studied several factors such as age, gender, and tumor location, presence of thyroid involvement, tumor staging and tumor grading. Thyroid involvement was confirmed by pathologic findings. Two hundred and eighty patients were included in this study. The results showed that only 4.64% of patients (13 cases of 280) treated by laryngectomy had thyroid involvement. Direct invasion was responsible for thyroid involvement in all cases. It was most prevalent in the sixth decade of life and seen in stages 3 and 4 of laryngeal cancer. Thyroid involvement appeared more in men, and in all cases cancer was squamous cell carcinoma. We recommend limited indications for laryngectomy and thyroid lobotomy, including glottic tumor with subglottic invasion, subglottic tumor, intralaryngeal tumor with transcartilage invasion, tumor of sinus piriformis (in stage 4), glottic and supraglottic tumors stage III or IV, which should be individualized. In suspected cases such as those with abnormal thyroid consistency, the decision should be made during laryngectomy.

Despite the fact that most people are worried about having high cholesterol levels, low cholesterol may actually be associated with adverse behavioral effects such as aggression and depression. The aim of this survey was to show whether there was a significant relationship between cholesterol and triglyceride with depression. The level of cholesterol and triglyceride was measured in 80 depressed patients referred or admitted to Sina hospital whose depressive symptoms were assessed by DSM IV criteria. The control group comprised of normal subjects. Cholesterol and triglyceride measurements were done on blood samples of the two groups. There was no significant relationship between age, sex and triglyceride levels with depression (P>0.05), but there was a significant relationship between low cholesterol and depression (P<0.05). It can be concluded that there is significant relationship between low cholesterol and depression whereas it is not the case for triglyceride

Performing cochlear implantation in patients with inner ear malformation has always been a matter of dispute. This study was designed to analyze the operative findings,complications, and postoperative performance of patients with inner ear anomalies who underwent cochlear implantation. Six patients with inner ear malformations underwent implantation in our academic tertiary referral center from 1997 to 2002. The average follow-up period was 27 months. Malformations included one incomplete partition, one common cavity, one narrow internal acoustic canal (IAC) in a patient with Riley-Day syndrome and 3 cases of large vestibular aqueduct. All received multi-channel implants either Nucleus 22 or Clarion device. Facial nerve was anomalous in 2 cases. CSF gusher occurred in 4 patients, which was controlled with packing the cochleostomy site. In all cases, the full length of electrode array was inserted, except one with Mondini''s dysplasia where insertion failed in the first operation and was referred to another center for a successful surgery on the opposite ear. No other surgical complications were encountered. In 4 cases, all the 22 electrodes could be activated. All patients showed improved hearing performance after implantation. Four showed open-set speech recognition. The one with narrow IAC showed improved awareness to environmental sounds. In the other case (common cavity), the perception tests could not be performed because of very young age. Cochlear implantation in patients with inner ear malformations is a successful way of rehabilitation, although complications should be expected and auditory responses may be highly variable and relatively moderate.

Elevated amounts of free radicals due to ionizing radiation have damaging effects on the body. H2-receptor antagonists have potential oxygen radical scavenging properties. We tried to determine the effects of two H2-receptor antagonists (cimetidine and ranitidine) on lipid peroxidation (LPO) and lipid profile (LP) in plasma and liver of γ-irradiated (1Gy/day for 3 days) BALB/c mice. The control group of mice were fed with normal food and drinks but the experiment group of mice were fed control diet and drinking water, containing cimetidine or ranitidine (1mg/lit). After 3 days of supplementation, the animals were subjected to sublethal γ-radiation, which caused a significant increase in cholesterol level in experimental group (100% increase in comparison with the control group), but the amount of phospholipids did not change. The ratio of cholesterol to phospholipid showed a slight increase. Also γ-irradiation caused a significant increase in lipid fluorescence (11-48%), conjugated dienes (33-81%) in liver and increase in malondialdehyde (19-300%) in serum of mice who had received 1.09-3.1 Gy for 1-3 days. Cimetidine or ranitidine supplementation was able to restore the changes of LPO and LP in mice (1 Gy-radiated for 3 days). It is therefore concluded that the mice treated with cimetidine or ranitidine were able to tolerate biomembrane damages provoked by sublethal γ-radiation. This supports the hypothesis that cimetidine or ranitidine may afford an efficient protection against ionizing radiation or diseases that are characterized by in vivo free radical-mediated oxidative stress mechanisms.

Duane’s retraction syndrome (DRS) type I is often associated with esotropia (ET) and face turn in those with fusion. This study was designed to delineate the quantitative relationship between the angles of eye deviation with that of face turn. Ten patients with DRS type I with ET and face turn toward the deviated eye, who had central fixation, were chosen. Esodeviation was measured by alternate prism-cover test, and the angle of face turn was measured by an orthopedic protractor in degree and then converted to prism diopter. The subtraction of eye deviation from face turn showed 2.4 prism diopters of face turn underestimation in comparison with esodevition, which is so small that deviations of eye and face may be considered virtually equal.

Moslem pregnant women are inclined to fast during the month of Ramadan. Ketonuria and hypoglycemia are harmful in pregnancy. The aim of this study was to find out whether clinical symptoms and/ or calorie deficiency of fasting pregnant women before Eftar (ending of the daily fast) can accurately predict ketonuria and hypoglycemia. In a descriptive study, 185 volunteer fasting pregnant women in Ramadan of 1999 were tested just before Eftar taking into account their clinical symptoms, intake of the previous 24 hours and testing their ketonuria and serum glucose. The positive predictive values of clinical symptoms before breaking the fast for ketonuria and hypoglycemia were 32% and 56%, respectively. The negative predictive values of clinical symptoms for ketonuria and hypoglycemia were 70% and 33%. The positive predictive values of over 500 Kcal deficiency in ketonuria and hypoglycemia were 33% and 57%. Severe calorie deficiency (more than 2000 Kcal) positively predicts ketonuria in 70% of cases and sufficient calorie intake (less than 500 Kcal deficiency) negatively predicts ketonuria in 93% of women. Clinical symptoms and calorie intake were not appropriate criteria for predicting ketonuria and hypoglycemia except in asymptomatic or severely calorie deficient cases or those with sufficient calorie intake whose ketonuria was predicted accurately.

Different contraceptive methods are used by breastfeeding mothers. To investigate the effects of progestogen - only contraceptives on human milk components, a non-randomized, follow-up study was carried out in Iran (Varamin) on 140 breastfeeding women, 51 of whom used progestogenonly contraception including progestogen-only pills (POP) or depo-medroxyprogesterone acetate (DMPA), and 89 used non-hormonal contraception methods, starting at 6 weeks after delivery. Human milk components were compared between the groups after 26 weeks. There were no statistically significant differences between groups, in terms of protein, sodium, calcium, phosphorus and potassium concentration of milk, but triglycerides in the hormonal group and magnesium in the non-hormonal group were higher than the other group (P< 0.05). It seems that progestogen-only methods (POP and DMPA) do not have an adverse effect on human milk composition, and are safe contraceptives during lactation.

In order to create an effective arteriovenous fistula (AVF) in patients with sustained chronic renal failure (CRF), surgeons need to become familiar with various anatomical variations of venous structures in the operating field. Because of variety and different types of cubital venous anatomies, there is more than a 90% possibility of creating suitable AVFs in the cubital fossa, but in the wrist and forearm, due to old injections and thrombophlebitis, there is less chance to do so. Since cephalic vein is the main venous conduit for constructing an AVF in the antecubital region, this study focuses on the various anatomical variations of cephalic vein and its communicating branches. We studied the cubital cephalic anatomy of 103 patients with CRF during construction of an AVF from July 1999 to June 2001. Five types of cephalic vein anatomy were seen: type A (44.66%), type B (30.1%), type C (18.44%), type D (3.88%) and type E (2.29%) in 39 right and 64 left arms. Seventy-six anastomoses were performed to brachial trunk, 25 to the radial and 2 to the ulnar artery. Eleven cases with progressive swelling after AVF were uneventfully cured by hand elevation. No infection, false aneurysm, venous hypertension or steal syndrome was detected. In order to obtain the best results and select appropriate operative technique for reliable vascular access in CRF, it is necessary to understand the anatomical variety of cephalic vein.

Resistance of Streptococcus pneumoniae against penicillin is considered to be of great importance. While low-resistant strains could be treated by penicillin, treatment of highly resistant strains is very difficult and needs broad-spectrum antibiotics. This study was performed in Imam Khomeini Medical Center, Tehran, Iran, from 1999 to 2001 to evaluate pneumococcal resistance against penicillin and some other antibiotics. Specimens were collected from different hospitals. Samples were cultured and resistance of S. pneumoniae against selected antibiotics was determined. The main aim of this study was to measure minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC), using serial dilution method. Disc diffusion method was also performed to be compared with the main procedures (MIC and MBC), on 66 strains obtained from 100 clinical specimens. Five different antibiotics (penicillin, cefazolin, ampicillin, amoxicillin and vancomycin) were employed in this study. In the case of penicillin, 47 sensitive strains and 19 highly resistant strains were obtained. No intermediate or low-resistant strain was found. The frequency of resistant strains against other antibiotics was found to be 10.6%, 7.5%, 18.1% and 0%, respectively. All strains were sensitive to vancomycin except for a low resistant one. Care should be taken to choose a suitable drug when being faced with a resistant strain. Vancomycin can be used with confidence to cure infections induced by penicilin-resistant S. pneumoniae.

Granular cell tumors are rare neoplasms of uncertain histogenesis but with a typical histologic appearance composed of cells with characteristic granular cytoplasm. These tumors occur most often in adults as an asymptomatic solitary papule or nodule. Multiple granular cell tumors are rare, especially in children and teenagers. We represent a case of multiple granular cell tumors in a 19-year-old girl presented with multiple cutaneous and mucosal nodular lesions. The diagnosis was documented by histopathology and immunohistochemistry.

Bloody nipple discharge in infancy has rarely been reported in medical literature. We report a 7 month-old female infant with a one month history of bilateral nipple discharge. Endocrinologic and hematological workups were within normal limits. Breast ultrasonography showed two non-echogenic cystic areas in each breast. The problem resolved after a period of observation. This is a benign condition and resolves spontaneously, but if persistent, should be properly investigated. Biopsy or excision is not indicated. We recommend breast ultrasonography for the follow-up of this condition.