Medical Journal Of the Islamic Republic of Iran
Volume:20 Issue: 1, Spring 2006

Bachground: The main objective of this study was to define the clinical changes of facial deformity in patients older than 5 years with congenital torti-collis treated by proximal and distal sternocleidomastoid tenotomy. We retrospectively evaluated fifteen patients who had had an open tenotomy of the sternal and clavicular and mastoid origins of the sterno-cleidomastoid muscle for muscular torticollis. The average length of follow-up was 4.5 years.The patients were divided into three groups according to their time of opera-tion. Group I consisted of patients who were operated on between the age of 5 and 10 years. Group II, patients who were operated on between the age of 10 and 15 years, and Group III patients were operated on when they were 16 years old or older. Most patients were operated on between the age of 10 and 15 years. According to our method of evaluation two patients in group I had excellent resolution of facial asymmetry and in group II two patients had excel-lent and six patients had good results at the final follow-up. And in group III only one patient had good results and four patients had fair results. We conclude that the patients age at operation, the duration of the disease and the severity of the facial deformity before operation had the major effect on cosmetic results.

Spaghetti wrist is a sharp volar wrist laceration in which at least 10 structures, including tendons, at least one major nerve and usually one major vessel are divided. These injuries are usually accompanied with severe permanent complications. The aim of this study was to evaluate the spaghetti wrist injury in Iran and find ways to decrease complications and obtain better re-sults. This study was done during a 5- year period between March 1999 and March 2003 in the Department of Plastic and Reconstructive Surgery of 15th Khordad Hospital, Shahid Beheshti University Medical School, Tehran, in the subset of 30 patients available for follow-up examination. This study reviewed 124 patients with "spaghetti wrist" lacerations. All injuries were sharp lacerations. A total of 115 men and 9 women, average age 24.5 years (range 8 to 62 years) sustained spaghetti wrist injures. The most commonly injured hand was the right hand (74.9 percent). The most frequently injured tendons were third and fourth FDS (98.3 percent). The ulnar nerve was more commonly injured than the median nerve. The ulnar artery was more commonly injured than the radial artery.In the subset of 30 patients available for follow-up examination, range of motion was excellent in 14 patients and good in 8 patients. Intrinsic muscle re-covery was good in 9 patients and fair to poor in 21 patients. Sensory return was disappointing: 17 patients recovered only protective sensation and 13 pa-tients demonstrated return of two-point discrimination that ranged from 7 to 13 mm in 10 patients and from 2 to 6 mm in 3 patients. Generally recovery of function in "spaghetti wrist" after repair is not satisfactory. In order to obtain better results accurate repair of injured structures, early movement, appropriate physiotherapy and patient co-operation are required.

To assess the diagnostic value of hys-terosalpingography (HSG) in the evaluation of the uterine cavity in recurrent aborters in comparison to hysteroscopy as the gold standard of diagnosis. 58 reproductive age women, all with habitual abortion (3 con-secutive abortions), were examined by both HSG and hysteroscopy. The overall sensitivity and specificity of HSG was 18.75% and 82.2%, respectively. The false positive and false negative results of HSG were 17.8% and 81.25%, respectively, and the positive predictive value for HSG is, therefore, 37.5%. Regarding very low sensitivity, specificity and high false-negative rates of HSG, it is concluded that it has low value in detection of uter-ine cavity abnormalities in habitual abortion and hysteroscopy should be used as the gold standard method for diagnosis in these patients.

High resolution CT scan has made early diagnosis of intra-ventricular hemorrhage (IVH) easier. Posttraumatic intraventricular hemor-rhage has been reported to a greater extent because of the CT scan. 904 patients were admitted in the NSICU from March 2001 to March 2002 with severe closed head injury, of those only 31 patients with in-traventricular hemorrhage (GCS less than 8) are reported herein and the mechanism involved is discussed. Nine cases had intracerebral hemorrhage (contusional group), four cases in the frontal lobe, three cases in the temporal lobe and two cases in the parietal lobe. Nine cases (basal ganglia hemorrhage group) had hemorrhage in basal ganglia, six in the caudate nucleus and three in the thalamus, all spread-ing into the ventricles. In thirteen cases the original site of hemorrhage could not be determined. In this group six cases had accompanying peri-brain stem hemorrhage (peri-brain stem hemorrhage group) and different brain stem injury signs. Four cases had IVH less than 5 mL with or without minor intracranial le-sions (minor intracranial lesion group). Accompanying major intracranial hem-orrhage was found in sixteen cases, six cases had epidural hematoma, four cases had subdural hematoma, and seven had a combination of ASDH, EDH and contusional prarenchymal hemorrhages, all requiring primary surgical evacuation, and seven cases had different degrees of minor abnormalities (i.e. minor epidural hemorrhage, minor subdural hemorrhage, sub-arachnoid hemor-rhage, minor cortical contusions or subdural effusions which did not need sur-gical intervention). Two cases had acute hydrocephalus and needed ventricular external drainage. Acceleration-deceleration impact along the long axis of the skull might be the possible mechanism in shearing injury to perforating vessels of the basal ganglia for early appearance of hemorrhage in the caudate nucleus and thalamus. Hemorrhage in basal ganglia and brain parenchyma eventually find their way to the ventricles.

Postoperative pain is an important surgical problem. Recent studies in pain pathophysiology have led to the hypothesis that with periopera-tive administration of analgesics (pre-emptive analgesia) it may be possible to prevent or reduce postoperative pain. This study was planned to investigate the efficacy of pre-emptive analgesia on postoperative pain after major gyneco-logic abdominal surgeries. In this prospective, double-blinded, randomized, and placebo-controlled trial, 60 ASA physical status I and II patients undergoing major abdomi-nal gynecologic surgeries were randomized to receive 45 mL of bupivacaine 0.375% or 45mL of normal saline; 30 mL and 15 mL of the treatment solution was administered into the peritoneal cavity and incision, respectively, before wound clo-sure. The pain score of the patients was evaluated by the visual analogue scale (VAS) on awakening, and at 6, 12, and 24h after surgery. Time to first analgesia re-quest and total analgesic requirements in the first 24h were recorded. Pain scores were significantly higher in the placebo group than in the bupivacaine group on awakening (5.981.01 v.s 1.051.05; p<0.001), and at 6h after surgery (5.370.85 vs. 2.511.02; p<0.001). First request to analgesia was significantly longer in the bupivacaine patients than in the placebo group (5.873.04 h vs. 1.350.36; p<0.001). Meperidine consumption over 24h was 96.00 17.53 mg in the placebo group compared with 23.28 14.89 mg in the bupivacaine patients (p<0.001). A combination of intraperitoneal and incisional bupivacaine in-filtration at the end of abdominal gynecologic surgeries reduces postoperative pain on awakening and for 6 hours after surgery, and provides significant opioid-sparing analgesia for 24 h after gynecologic abdominal surgeries.

In this study our purpose was to determine whether 8 and/or 12 hour urine total protein values correlate with the 24 hour value to confirm the diagnosis of pre-eclampsia. The study population included 70 inpatients with hypertensive disorders of pregnancy. Patient''s urine was collected over 24 hours with the first 8 hours, next 4 hours, and remaining 12 hours in separate containers. The urine volume and total protein and creatinine levels were measured in the 8, 12, and 24 hour samples. The 8 and 12-hour results were compared to the 24-hour results by use of simple regression analysis. Of the 70 patients 31 patients had no proteinuria, 32 patients had mild proteinuria and 7 patients had severe pro-teinuria. The results of our study reveal that the protein values for the first 8 and 12 hours of a 24 hour sample do correlate with the entire 24 hour sample for patients with mild and severe disease (p

Experience with vesicoureteral reflux (VUR) differs in differ-ent centers and there are plenty of controversies. The aim of this study was to evaluate the outcome of primary VUR complications and the rate of recurrence of UTI. The medical charts of all infants and children with primary VUR who were followed up by two nephrologists were reviewed. During 19 years (1985-2004), 330 patients (271 females, 59 males) with 496 refluxing ureters were followed up as primary VUR. The patients age at diagnosis was 4 days to 16 years (mean: 4.1 years) and the mean duration of follow-up was 4.5 years. Urinary tract infec-tion (UTI) was the presenting symptom in 95% and fever was recorded in 35% of cases. Frequencies of different grades of VUR at initial investigation were 10%, 35%, 30%, 13% and 12% for grades I to V, respectively. Recurrence of UTI in VUR of grades I to V were 22.2%, 18.1%, 20%, 23.4% and 17.9%, re-spectively. Follow-up voiding cystourethrogram revealed resolution of VUR in 55%, improvement in 27.5%, no change in 12%, and deterioration in 5.5%. Complications such as chronic renal failure and hypertension were observed in 13 and 13 patients, respectively. Renal scarring was present in 52% of boys and 29% of girls. The present study indicates that symptomatic primary VUR is more common and has better prognosis in girls. Recurrence of UTI is not re-lated to the grade of VUR.

Nowadays there is an attempt to perform lateral internal sphincterotomy (LIS) operation on an ambulatory basis under local anesthesia. This study aimed to compare postoperative outcome in local anesthesia with spinal anesthesia. A randomized, double blinded, controlled trial was performed on 62 patients divided into group A (Local Anesthesia) and Group B (Spinal An-esthesia) with n=31 equally. To achieve adequate anesthesia a cocktail, 6cc of Lidocaine 2% and Marcaine 0.5% with the addition of some bicarbonate was injected into subcutaneous tissue and 20 cc of this was injected into the inter-sphincteric space before LIS. Postoperative pain was assessed by a 10 cm VAS. Needle pain scores in group A and B were: 2.291.40 vs. 16.10.88 but pain scores, 6 hours after LIS, before leaving hospital and at the first week after the operation were significantly lower in group A than B (1.901.07 vs. 3.771.25, 0.900.47 vs. 1.650.75, 0.710.46 vs.1.060.51 re-spectively). Need of opioid and codeine in the first 24 hours after the operation in group A was significantly less than the other group. Also nausea and vomit-ing in group A was significantly lower than group B. The study showed that LIS under local anesthesia is a less painful technique in office surgery.

Acute appendicitis is the most common cause of acute surgical abdomen. Inspite of the introduction of ultrasonography, computed tomography scanning and laparo-scopy in the years 1987-1997 the difficulty in accurate diagnosis of acute appendicitis has remained the same. Our way of reaching a decision for operating in a patient suspected of hav-ing acute appendicitis (which will follow) has superiority to other introduced so far approaches. 3046 patients suspected of having acute appendicitis were evaluated during the years 2003-2005 at Shohada Medical Center. We have adopted a 3 point system, giving 1 point each to history, physical examination and laboratory tests if they meet the criteria:1. Typical history gets 1 point if: an abdominal pain shift from epigastrium or periumbilical area to RLQ accompanying anorexia, nausea and vomiting depending on age.2. Typical physical RLQ tenderness associated with rebound tenderness,3. Laboratory tests: leukocytosis between 10,500 to 18,000/mm3 along with normal urinaly-sis or leukocyturia without presence of bacteria. In pregnancy where leukocyteosis exists shift to the left is considered positive.Each of the criteria gets zero or 1 point if it meets that mentioned above and those who get two or three points will be operated on, otherwise the patient will be observed for 12 hours until his symptoms improve or progress to have two or three point criteria when he or she will be operated on. The results of histopathological examination of appendix have been used for the accuracy of this method. Among 3046 patients, 1241 (41%) were operated on rightaway with diagnosis of acute appendicitis since they had 2 or 3 points on arrival. From these 1213 (97/1%) had acute appendicitis. 1805 (59%) patients who didn''t get at least 2 points were observed for 12 hours, during this period 115 (6.4%) patients, who got at least two points were operated on, and 92 (80.5%) patients had non-perforated appendicitis; and the others were dis-charged since their symptoms improved. None of the patients, who were observed, devel-oped perforation of appendix or peritonitis. Sensitivity and specificity of this method was 100% and 97.1% with positive and negative predictive values of 93.3% and 95.5%. So this method is a safe way of approaching patients suspected of having acute appendicitis. The 2 out of 3 points criteria for approaching the patients suspected of hav-ing acute appendicitis provide a nonexpensive, noninvasive, simple, rapid and accurate method for diagnosis of acute appendicitis.

Carcinoma of the cervix is a common neoplasm and accounts for a consid-erable number of cervical diseases that lead to death in developing countries. In these countries early detection and improved methods of treatment have re-sulted in comparatively better control of the cancer and long survival; however, invasive and metastatic disease still occurs. The authors present the case report of a 44-year-old woman with clear cell carcinoma of the uterine cervix with metastasis to the abdominal wall.