Archives of Iranian Medicine
Volume:7 Issue: 3, Jul 2004

Background – Hepatitis B and its sequelae are among the most important public health hazards in Iran and other developing countries. Although effective vaccines are available, the high cost of the vaccines has remained an obstacle to their use. The present study was designed in order to evaluate modification of vaccination schemes as a cost-reduction strategy. Methods – The study was a randomized clinical trial in which 182 healthy adults occupied in health care services with no previous exposure to hepatitis B virus volunteered to be enrolled. The subjects were vaccinated with a recombinant HB vaccine using four different vaccination schemes. The rates of seroconversion as well as the levels of anti-HBs titers in the four schemes were compared. Results – Although the seroconversion rate and nonresponsiveness were the same in all of the 4 groups (97.6%, 97.8%, 96%, and 97.2%; p > 0.5), the concentration of anti-HBs was significantly lower in the groups vaccinated intradermally compared to the groups vaccinated intramuscularly (means: 675 vs 3,200 IU/L, p < 0.01). Conclusion – Replacing the second and third injections in the regular scheme of recombinant HB vaccine with two intradermal injections of 2 µg (one-tenth of the regular dose) results in the same seroconversion rates and the same level of anti-HBs as the regular scheme.

Background – Carotid duplex ultrasound (CDU) is routinely used for detection of extracranial internal carotid artery (EICA) stenosis in stroke patients. Power M-mode transcranial Doppler (PMD-TCD) is a new technology designed for studying intracranial vessels. This prospective study was performed for validation of CDU versus digital subtraction cerebral angiography (DSA) and PMD-TCD versus CDU in detection of EICA stenosis.Methods – Part I: Validation of CDU versus DSA in 50 stroke patients (100 carotids) admitted to Walter Mackenzie Center, Canada in 2003. All of the CDUs were performed by a sonographer with an HP Sono 5500 device (USA) and a 13-MHz linear probe. The degree of EICA stenosis was measured using DSA according to North American symptomatic carotid endarterectomy trial (NASCET) method by another neuroradiologist blinded to CDU results.Part II: Validation of PMD-TCD versus CDU in another group of 50 patients (100 carotids) with stroke. All PMD-TCD studies were performed with a TCDM100 device (Spencer, USA) and a 2-MHz probe by a sonographer blinded to CDU results. Results – Part I: Compared with DSA, CDU had a sensitivity of 96%, specificity of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 82% in detecting EICA stenosis of 50% and over. CDU versus DSA confirmed EICA stenosis of 70% and over with a sensitivity of 88%, specificity of 95%, PPV of 96%, and NPV of 87%.Part II: Compared with CDU, PMD-TCD had a sensitivity of 45%, specificity of 94%, PPV of 50%, and NPV of 93% for detection of EICA-stenosis of 50% and over. PMD-TCD, when compared with CDU, confirmed EICA-stenosis of 70% and over with a sensitivity of 43%, specificity of 99%, PPV of 75% and NPV of 96%.Conclusion – In our center, CDU is a highly reliable noninvasive diagnostic tool for detection of EICA stenosis. PMD-TCD of carotid has a moderate sensitivity for detection of EICA stenosis and is not recommended as a screening test for this purpose.

Background – Potter’s syndrome is a rare congenital disorder diagnosed at birth and characterized by bilateral renal agenesis, lack of amniotic fluid, pulmonary hypoplasia, limb deformities, and typical facies. It is found in 0.2% to 0.4% of the autopsies performed on stillborn infants or those who die soon after birth. Currently, there is no way to prevent or treat it and patients have a poor prognosis with the respiratory insufficiency being the leading cause of death. To the best of our knowledge, the current report seems to be the first report of Potter’s syndrome in Iran.Methods - In this prospective report, we studied 15 patients with clinical and pathological characteristics of Potter’s syndrome. Results - Male to female ratio was 2:1. Of the studied cases, 53% had history of oligohydramnios and 60% had intrauterine growth problems. All patients had congenital renal anomalies and two-third of them had lung hypoplasia. All of the cases died, with 70% of fatalities having occurred in the first few hours of life. Conclusion - We recommend establishing the Iranian National Potter’s Syndrome Supportive Group (INPSSG) and prenatal multicenter studies in high-risk populations

Background – Injection drug use plays an important role in the transmission of blood-borne viral infections among injection drug users (IDUs). The purpose of this study was to estimate the prevalence of the main four blood-borne infections in incarcerated IDUs in the Central Prison of Mashhad, the northeastern metropolis of Iran, and comparing it with the same rates in the society. It was also aimed of this study was to obtain some important demographic and risk behavior data of incarcerated IDUs.Methods – The study population comprised a convenience sample of 101 incarcerated IDUs in Mashhad. A blood sample was taken from each subject in August 2001 and tested to detect hepatitis C, hepatitis B (HBsAg), human immunodeficiency virus (HIV), and human T-cell lymphotropic virus (HTLV-1) infection markers by enzyme-linked immunosorbent assay (ELISA) in the laboratory of the Blood Transfusion Organization. A confirmative western blot test was performed for the HIV-positive ones. The data regarding their demographic characteristics and injection-related and sexual risky behaviors were obtained through an interviewer-assisted questionnaire. The Mashhad University of Medical Sciences (MUMS) Thesis Committee reviewed all aspects of the research and approved the protocol.Results – The seroprevalence of HCV, HBV (HBsAg), HIV, and HTLV-1 was 60%, 3%, 7%, and 52%, respectively. Forty-nine percent of the subjects shared their syringes or needles and 20% practiced frontloading. HCV and HTLV-1 infections were associated with injection-related risky behaviors, while no association was found between these infections and the variables pointing to sexual risky behaviors.Conclusion – Given the high rates of the above-mentioned infections among IDUs found in this study and considering the concerning trend of drug addiction problem in Iran, there is an urgent need for effective harm reduction programs in Iran particularly among incarcerated IDUs.

Background – Growth failure in under-5-year children is a multidimensional phenomenon. Undernutrition in infancy and early childhood is thought to adversely affect cognitive development. A cross-sectional anthropometric survey was carried out in Karaj, Iran to measure the risk factors of wasting and stunting in under-5-year children.Methods – From February to April 2002, 600 under-5-year children were selected by multistage random sampling. Household’s demographic and socioeconomic measures as well as child health and anthropometric characteristics were analyzed using Chi-square, t-test, ANOVA, and multiple logistic regression. To make a comparison with the results of National Center for Health Statistics (NCHS), we used Epi Info 6 software. Our data collection methods were weighing by scales, observation, and checklist. Results – The male to female ratio was one. The prevalence of underweight, stunting, and wasting was 13.9%, 20.3%, and 4.9%, respectively. Most malnourished children belonged to the mothers who had low literacy and no history of measles vaccination and breast-feeding. Data also indicated that the principal risk factors for underweight were birth weight below 2.5 kg, a shorter-than-3-year interval from mother’s previous birth, and urban life (p < 0.05).The principal risk factors for stunting were being younger than 6 months and birth weight below 2.5 kg (p < 0.05).Conclusion – Our results support the biological and epidemiologic evidence that underweight, stunting, and wasting represent different processes of malnutrition and have different risk factors

Background –The ocular lesions of Behcet’s disease (BD) naturally progress toward severe loss of vision or blindness. Cytotoxic drugs are the main treatment. To the best of our knowledge, no controlled study has ever been performed to show their efficacy. This study was designed to evaluate the short-term efficacy of intravenous pulse cyclophosphamide (PCP). Methods – In a randomized double blind controlled crossover study, 35 consecutive patients meeting both the International and Classification Tree criteria for BD and suffering from active posterior uveitis and/or retinal vasculitis were randomly assigned to either PCP or placebo group. Both groups received prednisolone (0.5 mg/kg/day). PCP was administered as 1 g per square meter of the body surface once monthly to the PCP group and normal saline to the placebo group. After 3 months, the two groups were interchanged. Disease activity index (DAI) and visual acuity (VA) were calculated. The study was done at Behcet’s Unit, Rheumatology Research Center, Tehran University of Medical Sciences after approval of the Ethics Committee and patients’ consentResults – The mean VA improved from 3.7 to 4.9 (t = 3.309, p < 0.002) in the PCP group and from 4.4 to 4.5 (t = 0.317, p = 0.75) in the placebo group. The difference was significant (t = 2.402, p < 0.02). Other parameters improved more remarkably in the PCP group than in the placebo group, but differences were not statistically significant Conclusion – This study shows the efficacy of the combination of PCP and prednisolone over prednisolone alone.

Background – Premacular subhyaloid hemorrhage is one of the etiologies of sudden visual loss. It may be due to vascular or blood abnormalities or Valsalva retinopathy. Spontaneous absorption of blood may take months and result in macular complications and permanent impairment of vision. Posterior hyaloidotomy by Nd-YAG laser is an outpatient procedure which may obviate the need for more complex surgical interventions. This study evaluates the success of this approach in patients with premacular subhyaloid hemorrhage of different etiologies. Methods – In this interventional case-series study, 12 eyes of 12 patients with premacular subhyaloid hemorrhage were enrolled. All patients had a comprehensive ocular examination before the operation and color fundus photographs were obtained. Fluorescein angiography was performed when necessary. Hyaloidotomy was performed using Nd-YAG laser. Main outcome measures were: success rate in hyaloidotomy (based on release of blood into the vitreous cavity and its subsequent absorption) and improvement in visual acuity and possible complications. Results – Twelve eyes of 12 patients (16.7% males and 83.3% females) with premacular subhyaloid hemorrhage were enrolled. The mean age of the patients was 48.5 ± 10.33 years. The predisposing factor was diabetic retinopathy in eight (66.7%), macroaneurysm (due to hypertension) in one (8.3%), and Valsalva retinopathy in three (25%). Hyaloidotomy was successful in all (100%) of the patients and the trapped blood was released into the vitreous cavity and absorbed within 6 to 16 (average = 9) days. The range of preoperative visual acuity was hand motions to counting fingers at 3 meters which improved from 20/50 to 20/20 postoperatively. Compared with those with vascular pathologies, visual improvement was best in the patients with Valsalva retinopathy. No complications were observed during their average follow-up of 24.5 (range: 8 to 72) months. Conclusion – Nd-YAG laser hyaloidotomy in premacular subhyaloid hemorrhage is a simple, inexpensive outpatient procedure which results in rapid visual recovery and is relatively safe. Further controlled clinical trials are recommended.

Background – Ulcerative colitis (UC) and Crohn''s disease (CD) are chronic inflammatory bowel diseases of unknown etiology. Inflammatory bowel disease (IBD) was believed to be infrequent in Iran; however, unofficial reports have confessed the continuing rise in IBD. Here, we present our experience with 448 patients with IBD referred during a 10-year period, 1992 – 2002.Methods – Demographic and clinical features, extraintestinal manifestations, extension of disease, and complications of 401 patients with UC and 47 with CD were assessed retrospectively. The diagnosis was based on Lennard Jones criteria. The exact course of physicians'' visits of 250 patients with IBD was asked through a face-to-face interview. Finally, the lag time between onset of the disease and time of definite diagnosis was determined.Results – The mean (± SD) age at diagnosis was 30.5 ± 11.8 years. Male to female ratio was 0.8:1.0 for UC and 1.3:1.0 for CD. Eighty-three percent of CD and 84.5% of UC patients were nonsmokers. Patients with UC chiefly presented with rectorrhagia (41.9%) or bloody diarrhea (31%), whereas those with CD complained of abdominal pain (47.5%) or diarrhea (27.5%). Of the patients, 14.1% had noted IBD in their family. Among UC patients, proctosigmoid was revealed to be affected in 51.9%. However, left-sided colitis and pancolitis were reported in 30% and 18.1%, respectively. Colorectal cancer was diagnosed in 2 patients (0.4%). The mean lag time between the onset of symptoms and definite diagnosis was 13.9 and 17.7 months for UC and CD patients, respectively. A total of 32.4% of patients with IBD had at least one of the five major extraintestinal manifestations. Conclusion – The demographic and clinical features of IBD are more or less the same as other developing countries. It seems as if gradual adoption of a western lifestyle may be associated with continuing rise in IBD. Higher prevalence of infectious disease and common disorders such as hemorrhoid, and lack of attention to the increased incidence of IBD in Iran are possible reasons for delayed diagnosis of IBD.

Background – Tibial shaft fractures are the most common among long bone fractures. Except for the fractures with minimal displacement, treatment of these fractures is always surgical. Currently, locked medullary nailing is the preferred surgical treatment. However, use of these implants necessitates a set of instruments and specific facilities which are not currently accessible in many centers in Iran. Considering the successful results of Ender nailing in the last 20 years reported in literature and the fact that Ender nailing can be performed with simpler instruments and limited facilities in Iran, we studied the results of treatment by this method.Methods – From March 1999 to June 2001, 71 patients with tibial shaft fractures (53 males and 3 females) were treated by Ender nailing at Sina Hospital, affiliated to Tehran University of Medical Sciences, Tehran, Iran. We applied 2 to 3 Ender nails 4 to 4.5 mm in diameter. These nails were inserted in the medulla after making 2 small incisions near the tibial tuberosity in lateral and medial sides. Using descriptive statistics, we showed the satisfactory results of this set of operations.Results – Twenty-two (39.3%) fractures were closed and 34 (60.9%) were open. Of the 56 patients, 55 (98.2%) achieved union 8 (mean: 4.7) months after the operation. In 46 (82.1%), the fracture united in a maximum of 5 months and in 9 (16.1%), between 5 to 8 months. The most common complication was soft tissue irritation at the proximal tibia due to protruding Ender nails. Seven (12.6%) patients were affected with this problem and the nails were removed in 5 of them.Conclusion – If used correctly, Ender nail can be an effective tool in treatment of tibial shaft fractures especially in centers with lower access to sophisticated and expensive facilities.

Carpenter’s syndrome (acrocephalopolysyndactyly type II Carpenter) is a rare syndrome characterized by acrocephaly, facial dysmorphism, and brachyclinosyndactyly of the hands and polysyndactyly of the feet. To our knowledge, there are about 40 reported cases of Carpenter’s syndrome. The existence of this syndrome in the siblings of consanguineous parents suggests an autosomal recessive inheritance. The case reported here was a three-day-old girl with many abnormalities diagnosed both clinically and at autopsy. It is noteworthy that Carpenter’s syndrome had existed in more than one sibling in this family. Therefore, prenatal diagnosis of this syndrome by sonography during pregnancy is recommended.

Allgrove syndrome is a rare syndrome with conspicuous neurological abnormalities. We describe a 16-year-old male with Allgrove syndrome suffering from upper and lower motor neuron diseases, autonomic dysfunction, muscle weakness, seizure, optic atrophy, ataxia, and peripheral demyelinating polyneuropathy primarily involving distal lower limbs. Since 3 years of age, he had experienced frequent hospital admissions for convulsion, hypoglycemia, dysphagia, intractable vomiting, loss of consciousness, treatment of achalasia, and suspicious seizure. His younger sister had died at the age of 3 with no diagnosis. Early treatments with corticosteroids dramatically improved his signs and symptoms.

Kennedy disease is a rare X-linked, recessively-inherited disorder, which is diagnosed on the basis of clinical and electromyographic (EMG) findings, and more recently by polymerase chain reaction (PCR). The disease has been reported from around the world.Here, we present 8 members of an Iranian family afflicted with the disease. The diagnosis was supported by PCR findings in 3 while in 5 cases the diagnosis was made based on clinical and EMG findings only. The patients, all males, ranged in age from 20 to 85 years with the onset of gynecomastia during early adulthood and other more specific symptoms during the 5th and 6th decades of life with gradual onset and progression. The symptoms and signs included cramps, generalized weakness, dysphagia, dysphonia, tongue atrophy, tremor, generalized muscle atrophy, fasciculation, areflexia, and impotence. Four of them had hyperlipidemia and 3 had increased levels of blood glucose including one with frank diabetes mellitus. PCR, performed in 3 of the patients, showed an increase in cytosine-adenine-guanine (CAG) repeats on the long arm of X chromosome. Two heterozygote female carriers were diagnosed by the same test.It is important to consider Kennedy disease in the differential diagnosis of lower motor neuron disorders considering its rather benign course and the need for genetic consultation for carriers.

Introduction of intracytoplasmic sperm injection (ICSI) offered an effective therapy for males with infertility including those with azoospermia. The novel techniques for sperm retrieval from the epididymis (percutaneous epididymal sperm aspiration [PESA]) and testis (testicular sperm aspiration [TESE]) have been successfully combined with ICSI. This is the first preliminary report on ICSI with ejaculated sperm (80 cycles), PESA/ICSI (40 cycles), and TESE/ICSI (40 cycles) in Iran. The study population comprised 160 consecutive young males with primary infertility admitted to Research and Clinical Center for Infertility in Yazd, Iran. Eighty subjects (mean ± SD of age: 34.0 ± 4.4 years) could produce ejaculates while in the rest who had obstructive azoospermia, the sperm was obtained by PESA or TESE. All wives were treated for ovarian stimulation and oocytes were retrieved 34 to 36 hours after human chorionic gonadotropin (HCG) injections. Sperm parameters of count, motility, and morphology were analyzed and ICSI was performed 2 to 3 hours after the incubation of the processed sperm. The rate of fertilization and embryo development and transfer were subsequently evaluated. The results showed that the fertilization rate for the groups whose sperms had been obtained by ejaculation, PESA, and TESE was 72.1%, 73.6%, and 51.3%, respectively. The mean number of embryo transfers for the aforementioned groups was 3.0, 3.8, and 2.6, respectively. The parameters of sperm count and morphology were similar in the ejaculate and PESA groups. They were, however, lower in TESE samples (p < 0.01). The results confirm that PESA and TESE are very effective for obtaining adequate numbers of sperms to successfully treat male infertility including obstructive azoospermia