فصلنامه کومش
سال نهم شماره 4 (پیاپی 28، تابستان 1387)

Continuing medical education (CME) is a necessary way to keep graduated physicians knowledge and practice up-to-date, thus, play an important role in improving health care. Several years after implementing these programs in the country of Iran, it is necessary evaluate the efficacy of these programs. The aim of this study was to evaluate knowledge of participants in CME program before and after of CME programs.

All general practitioners (GPs) who were participated in CME programs of the Mazandaran University of Medical Sciences (Sari, Iran) in the spring of 2006 entered in the study. A self directed and multi choice questionnaire was designed to seek demographic characteristics and knowledge of them about titles by programs. Its reliability was evaluated by internal consistency and validity by attending. The questionnaires were distributed before and after of each program. Data was analyses by SPSS and paired T- test.

From 300 participates, 235 persons were completed the questioner (q) (response rate=78%). The mean points of ENT q before and after program was 9.15±1.95 and 9.75±1.61, respectively (total point 20). In addition, these mean points were 9.85 ±2.29 and 10.22 ±1.79 (total 18) for general surgery, 11.79±2.65 and 14.12±3.38 (total 23) for psychiatry, 6.48±2.55 and 8.52±3.3 (total 19) for ophthalmology, 5.83±2.39 and 9.07±2.53 (total 17) for urology, and 7.79±2.11 and 10.68±2.54 (total 24)for dermatology.

The mean scores of knowledge of GPs were low and CME programs could not improve it, therefore, it is necessary to re-evaluate the contents and methods of CME programs for improving knowledge of general practitioners.

We investigated the role of sex hormones on changes in brain edema intracranial pressure (ICP), cerebral perfusion pressure (CCP) after trauma brain injury (TBI) in ovarectomized female (OVX) rats.

In this study female rats are divided into five groups. Control group (Intact) sham group and other groups include: vehicle, estrogen group (1mg/kg) and progesterone group (8 mg/kg) which on all groups TBI was induced by Marmarou method. 30 minutes after TBI, drugs were injected i.p. ICP was measured in spinal cord using a standard procedure. CPP was calculated by the mean arterial pressure (MAP) - ICP. Neurologic scores were measured by motor, eye and respiratory reflex

The results showed after TBI, water content was significantly lower in estrogen and progesterone groups (P<0.001) compared with vehicle group. Analysis showed a stable ICP up to 24 hours. The ICP in estrogen and progesterone groups was significantly decreased at 4 and 24 hours as compared to vehicle group (P<0.001in both cases). The CPP at 24 hours after TBI, significantly increased in estrogen and progesterone groups compared with vehicle (P<0.001). Also after TBI, neurologic scores was significantly higher in estrogen and progesterone groups as compared with vehicle (at 1hours P<0.05, and at 24hours P<0.001 for estrogen), (at 1hours P<0.01 for progesterone).

Our findings indicated an improvement of ICP, CPP and neurologic scores produced by pharmacologic doses of estrogen and progesterone after TBI in OVX rat. These effects may be contribute to neuroprotective effects of these hormones

The rising rate of doing behavioral violence to people working in health-care centers is a major problem for nurse’s population. This study was run with the aim of ascertaining how much nurses working in hospitals all over the country (Iran) are under verbal violence and finding out its relation with some individual and environmental factors. This study is a descriptive cross-sectional one which was run with 1317 nurses as the participants in hospitals all over the country of Iran during 2007. Data collection was done through self-report questionnaire. 87.4% of nurses experienced verbal violence at least once in their working surroundings during the last six months. Most of the verbal violence (64.4%) was done by patient's relatives, (44.2%) between 7:30 am to 14:30 pm in the patient's room (48.3%). Results show that only 35.9% of verbal violence was reported by nurses. Investigating the frequency of verbal violence, the results of correlation analysis (x²) showed that there is a significant relationship between verbal violence and variables such as age (P=0.009), sex (P=0.001), job experience (P=0.007), work hours (P=0.001) and job rank (P=0.048). Since lots of violence happens and the risk factors were investigated, more attention must be paid to this issue and the necessary steps must be taken in this regard. The findings of this study can be helpful to reduce, prevent and control the violence to nurses.

Massage therapy for newborns and infants is used as an important care in varied customs, specially in Indian. But clinical and experimental studies have done only in recent years. Because of few study about that over the world and no research in Iran, this study, with the objects of assess the effects of massage therapy to weight gain and sleep behavior in infants have done.

This is a clinical trial study that involved 2 months aged infants who referring to Arak city (Iran) clinics. At first, the infants topometrics sizes (weight, length, head, chest, abdomen, arm and femoral circumference) and sleep behaviors (length of sleep in 24h, and length of night sleep) assessed and then infants divided randomly in 2 groups, with and without massage. In massage group, mothers trained for doing 10 minutes rotational and continually monotonous massage used in all of the infants̓ body, twice each day (morning and night before sleep) for 4 weeks. After 4 weeks, the topometrics size and sleep behaviors were assessed again.

At first of the study, sex frequency and mean of weight, length and other topometric sizes in two groups did not have statistically significant differences. After 4 weeks in massage group mean of weight gain was 965.24 ± 310.12 gram and in group without massage it was 686.14 ± 220.92 gram. This was considered to be statistically significant (P<0.0001) Mean of chest circumference increased in massage group was 2.63 ± 0.82 and in without massage group it was 1.75 ± 0.92 centimeter that was considered to be significant (P<0.05). Length, and head circumference, increased in massage group were more than without massage group, but it was not considered to be statistically significant. Mean increase of night sleep length in massage group was 94.8 ± 28.9 minutes and in control group was 26.4 ± 12.7 minutes. Mean increase in 24h sleep in massage group was 61.2 ± 22.5 minutes and in control group it was 10.24 ± 8.3 minutes. Both of them were considered to be statistically significant.

Results from this study have shown that massage therapy could improve the sleep behaviors, weight gain and also length in infants. These positive effects on growth of infants may result from augmented of growth hormone release due to an increment in duration of the infants̓ night sleep.

Proper nutrition is one of the essential factors to well being for children and adolescents. Meanwhile, breakfast has a major role to supply their requirement nutrients and energy. There are some experimental evidences that suggest that omitting breakfast negatively affects cognitive functioning. This survey was performed to study of breakfast habits and its relationships with some factors in Semnan (Iran) pupils during 2006. In this descriptive analytical study, 1193 pupils in different educational grades were selected by the multistage cluster sampling. Data were collected by using a questionnaire and analyzed with Kruskal Wallis, Mann - Whitney and Spearman Coefficient Correlation tests using SPSS software. The mean and standard deviation of age was 12.4±3.3 years old. 50.7% of them were boys and 49.3% were girls. 53.4% of the pupils stated that they always eat breakfast and the rest of them, do not eat irregularly. 4.4% of the pupils said they never eat breakfast. In this study, there was significant relationship between breakfast habits and age (P<.01), educational grade (P<.0001), sex (P<.0001), the time of getting up in the morning (P<.0001), sleeping time at night (P<.0001), the education of pupil’s mother (P<.04), the education of pupil’s father (P<.05), the birth rank (P<.05) and the intervention of pupils in the breakfast planning (P<.0001). According to pupils’ breakfast for three continuous days, the relative consumption of bread (2.26), tea (2.20) and cheese (1.66) was higher than other foods, such as milk, walnut, honey, egg, fruit and fruit juice. These finding showed that pupils need to learn more about both irregular intake of breakfast and various intake of nutritious foods and this issue must be considered by different authorities.

Postpartum endometritis is 1-8% and cesarean section is one of its risk factor. The present study was performed to compare the effect of manual removal and spontaneous delivery of placenta on post-cesarean endometritis and duration of cesarean operation.

In this prospective (control–case) study, 280 pregnant women undergoing elective cesarean delivery in Shahid Sadoughi (Yezed, Iran) teaching hospital were randomly assigned to two groups: manual placental delivery (140 women) and spontaneous placental delivery (140 women). Antibiotic prophylaxis was administered in both groups. The operation time concluded from skin incision to skin repair. Endometritis was diagnosed in patients who developed clinical signs of fever (>38°C) 24 h after delivery, supra-pubic tenderness and vaginal discharge. Data analysis was carried out using t-test and chi square test by SPSS15.0.

The total rate of endometritis was 12.1% (34 women); 12 women in the spontaneous placental delivery group (8.6%) and 22 women in the manual placental removal group (16%). This difference was statistically significant between two groups (P=0.006). There was no statistically significant difference in duration of operation between two groups (P=0.1).

Our finding indicate that manual removal of the placenta increased postpartum endometritis in compared with the spontaneous method of placental removal, but had no influence on the duration of cesarean.

Diarrhea is one of pediatric infectious diseases, which is the most frequent cases of child mortality. Diarrhea is a health problem in Iran; nearly 70 thousand children were died from diarrhea. Several bacterial agents can cause diarrhea, one of them is Campylobacter jejuni, which is less considered. The aim of this study is to determine the frequency of Campylobacter jejuni in Semnan diarrheic children.

Stool samples were collected from diarrheic children who refer to Amiralmomenin hospital, Shafa hospital and hygiene centers of Semnan and these children did not receive any antibiotic treatment at the beginning of the study. A swab was inoculated in Stuart medium and transferred to clinical laboratory of Semnan hygiene center. The swab was inoculated on Preston blood free campylobacter agar and incubated at 42oC for 48 hours. In order to bacterial identification, gram stain, catalase, oxidase, lack of H2S production in TSI, susceptibility to Nalidixic acid, resistance to Cephalotin and Hyporate hydrolysis were used. Antibiotic susceptibility test was performed by Kirby-Bauer method.

From 276 stool specimens (38.5% females and 61.5% males), Campylobacter jejuni was isolated from 27 cases (9.8%; 44.4% females and 55.6% males). The most susceptibility was seen for Erytromycin (92.6%), and the most resistance was observed for Cotrimoxazole (44.4%).

In this study, the prevalence of Campylobacter jejuni was more than other studies. Therefore, notification to Campylobacter jejuni in patient treatment and bacterial transmission prevention is necessary in this area.

Postoperative pain is a major problem in day-care pediatric surgery and acetaminophen is a common drug, which is used for pain control in infants. The aim of this study was to compare the effect of oral and rectal acetaminophen and also to evaluate the effect of loading single dose of rectal acetaminophen before surgery in pain relief after circumcision. In a randomized clinical trial, 45 children (3 to 6 years old) were divided into 3 groups before circumcision. The first group was received rectal acetaminophen (40 mg/kg) before and oral acetaminophen (15 mg/kg/qid) after circumcision. The second group was given rectal and the third group received oral acetaminophen (both 15 mg/kg/qid) after circumcision. Pain scores was measured every three hours and the amount of sleep hours in the first 24-hours after circumcision. In the study, pain scores and amount of sleep hours in the first group were significantly lower and higher than other groups. There was no significant difference in pain scores between other groups (second and third) but the amount of sleep hours was higher in second group. Efficacy of oral and rectal acetaminophen (15 mg/kg/qid) was similar in pain relief after circumcision but rectal acetaminophen had more sedative effect. In addition, the high dose of rectal acetaminophen (40 mg/kg) before circumcision significantly led to pain reduction in the first 24-hours after circumcision.

Leptospirosisis a very common zoonosis in the world. Culture is low sensitive with high rate false negative. So, serological assays are best alternative way for its diagnosis. Microscopic agglutination test (MAT) is gold standard but performing it requires a panel of some standard strains and need periodic subculturing of them, and also requires double sera with at least two weeks interval to investigate seroconversion. Furthermore, other serological methods should be investigated. The aim of this study was to evaluate an in-house IgM-ELISA developed by using antigen extracted from endemic isolates. I4 endemic isolates belonged to the serogroups: Icterohaemorrahgia, Pomona, Hardjo, and Gripotyphosa, were inoculated in EMJH to take well grown cultures. Whole antigen was extracted from each culture by Freezing-Thawing method in distilled water. Same amount of extraction of each culture with same OD number in 550nm were mixed together and were used for coating Elisa plates. Antihuman IgM conjugated with alkaline phosphatase were used in this assay. We used a commercial quantitative IgM-ELISA (SERION ELISA classic) for cut off determination. MAT was used for confirmation positive and negative cases. Sera with titer ≥ 1:100 in MAT and positive criteria in commercial quantitative IgM-ELISA were considered as positive cases. 98 positive cases and 54 negative cases were chosen by screening 200 sera of patients suspected to leptospirosis by using MAT and commercial quantitative IgM-ELISA. We also used 30 sera of patients affected by hepatitis B, salmonelosis, and brucellosis as control cases. 88 of 98 positive cases were positive (false negative=10), 1 of 54 negative and all control case were negative (false positive =1) in the test. Sensitivity, specificity, PPV, NPV, and accuracy of the test were evaluated: 99.0%, 89.1%, 90.75, 98.8%, and 94.25, respectively. ELISA for measuring specific IgM to leptospires antigen(s) could be a good alternative to MAT, which is not a routine diagnostic assay to perform in clinical diagnostic laboratories and only is reliable when there is paired sera. Sensitivity and specificity of the assay is dependent to several factors, especially to the type of antigen coated on plates, quality of assay materials, and also to the time of sampling. Sera of days ≥ 6 of the disease has enough antibodies to measure and a common antigen extracted from several common pathogenic leptospires, especially from endemic isolates, could be more helpful to increase accuracy of the assay

Nowadays, tuberculosis (TB) is still one of the most important causes of disability and fatality in human population in spite of continuous advances in different medical sciences. Concerning to unknown epidemiologic status of TB in Iran, especially in Damghan district, and also the presence of a considerable number of afghan refugees in this district, the current study was conducted to evaluate the epidemiological characteristics of TB disease in according to the data collected from Damghan TB Centre during 2003-2007. This survey was performed as a cross-sectional retrospective study. Different information from the medical file of patients who referred to Damghan TB Centre (including demographic and characteristic of disease) were collected and recorded in separated forms for further analysis. A total of 89 patients were under treatment in the centre during 2003-2007. 26.96% of the patients were under 30 years old and 30.33 % were more than 70 years old. Forty-four patients (49.43%) were women and 45 patients (50.57%) were men. 77.5% of the patients were Iranian and 22.5 % of them were afghan refugees. 59.5% of the patients were lived in urban area and the rest in rural area. 88.76% of the patients had pulmonary tuberculosis and 11.24% had non-pulmonary tuberculosis. All of the patients with non-pulmonary tuberculosis were recognized by pathological methods and pulmonary tuberculosis was diagnosed in 78.48 % of the patients using sputum smear direct examination or culture. Duration between manifestation of TB symptoms and diagnosis was about 5 months. The findings of our study showed that the most patients with TB had more than 70 years old and 50% the afghan patients with pulmonary tuberculosis were positive for smear. Also the average period of TB diagnosis in patients was 5 months. Therefore, it recommends a more attention for finding patients with TB among the people over 70 years old and also afghan refugees. It seems to be necessary some seminars or workshops for general physicians and medical doctors in order make more attention for TB diagnosis in patients, and also we suggest a general health education for public

Inversion sprain is a result of abnormal forces of plantar flexion and inversion applied to the lateral side of the ankle. This injury recurs in 10% of non-athletes and 80% of athletes. It is believed that Changes in conduction of deep peroneal nerve following inversion sprain and instability occurred following it, to be a cause of recurrence of inversion sprain. Evaluation of the motor branches of deep peroneal nerve in inversion sprain in non-athletes persons is the base of this study. Mechanical instability is assessed through anterior drawer test and talar tilt test and electrical assessment is done first and four weeks after injury in 11 patients in each mechanical instability group of the ankle. All patients had the first incidence of unilateral inversion sprain and normal side was considered as control in the same patient. Electrical assessment of deep peroneal nerve included following: (1) Deep peroneal nerve motor conduction studies in three levels of knee, leg and ankle, (2) Electrical evaluation of tibialis anterior muscle both at rest and minimal contraction. Studies revealed significant changes in temporal dispersion in three levels of knee, below the head of fibula and ankle and motor latency in knee and ankle levels both at the first and second evaluation and motor nerve conduction velocity in leg at the first session in two extremities but no significant difference between mechanical instability was noticed. Also there was a significant difference in recruitment interval of tibialis anterior muscle in comparison of normal and involved extremity and mechanical instability at both sessions. Findings of this study indicated that in lateral ankle sprain deep peroneal nerve incurs is happened and its prognosis is dependent on severity of nerve involvement and grade of instability.

Hemophilia is the most common disorder of deficiencies in thrombotic factors. In most patients, severities of symptoms are in proportion of the seriousness of deficiency in the thrombotic factors. But in some patients with severe hemophilia, having less than 1% in factor level; the clinical symptoms are lower and slighter than the other hemophilic patients. Even in some cases, thrombotic events in the severe hemophilic patients have been accrued. The underlying causes of these findings are unknown. The aims of this study were to determine the role of some factors and also the type of genetic mutation of these factors in the rate and severity of bleeding and also the symptoms of the severe hemophilic patients. Sixty hemophilia A patients (FVIII<1%) with having records in Hemophilic Patients Center were divided on the basis of the received factor rate items per year, bleeding score, orthopedic score and radiologic score, in three groups with mild, moderate and sever clinical presentations (each group with 20 patients). And then the mutation tests in the gene of Leiden V factor, PG20210A, MTHFR, level of thrombotic factors (II, V, VII, VIII, IX, X, XI, XII, XIII, and Fibrinogen), Protein C, S, Antithrombine III, Phospholipid Ab and Hemosisteine and number of platelets were performed. Data using the χ2, Fischer, ANOVA and Tukey test and SPSS-14 were analyzed. Of the studied factors, the differences among 3 groups from view point of daily activity (P<0.002), antithrombine III (P<0.013), number of platelets (P<0.007), protein C (P<0.013) and level of factor XII (P<0.01) was significant. No significant differences were found in three groups in other tested factors In this study, there were significant differences only in the daily activity, antithrombine III, number of platelets, protein C and level of factor XII. Thus, further studies are required to determine the role of other factors that may contribute to differences in the clinical presentations of the severe hemophilic patients.