Archives of Iranian Medicine
Volume:7 Issue: 1, Jan 2004

Several consensus guidelines have been formulated to aid the medical practitioner for therapy of Helicobacter pylori infection. While triple therapy with a proton pump inhibitor (PPI), in combination with two antibiotics administered for one week, is the established treatment of choice in many parts of the world, this regimen is far from optimal in Iran. The best results of Helicobacter pylori eradication in this country are obtained with two weeks of furazolidone-based quadruple therapy or clarithromycin based quadruple therapy. Given the high cost of clarithromycin, the former regimen is preferable as a first line treatment. Although documentation of cure is certainly needed for high risk patients (e.g., patients with complicated peptic ulcer or gastric mucosa associated lymphoid tissue), but it is reasonable for any patient who undergoes Helicobacter pylori eradication. Urea breath test 3 months after treatment is the recommended post-eradication testing. For failed treatment, two weeks of quadruple therapy containing a PPI, bismuth and two antibiotics should be used. If a clarithromycin-based regimen was used initially, a furazolidone-based regimen can be used afterwards, and vice versa. Culture and antibiotic susceptibility testing is not recommended unless after failure of second line treatment. The low eradication and higher reinfection rate of H. pylori in Iranian patients in comparison with patients in western countries shows that our H. pylori strains are probably more resistant than those in western countries

BACKGROUND—Iran is among the countries with rather high prevalence of Behcet''s disease (BD). We present here our latest data on different aspects of the disease. Materials AND METHODS—The present investigation is a prospective cohort study carried out on the data of patients presented in our BD registry during the past 28 years. The data were collected on a standard protocol comprising 100 items. These items included demographic features (such as sex, age of onset, age of diagnosis, date of the first visit, and ethnic origin), type of the presentation, different clinical manifestations of the disease, and paraclinical findings (including CBC and platelet count, Erythrocyte sedimentation rate, VDRL/RPR test, urinalysis, HLA typing, and Pathergy skin test). A confidence interval (CI) at 95% was calculated for each item. RESULTS—A total number of 5,059 patients were analyzed. The annual incidence rate was 280 patients in the last 5 years. The male/female ratio was 1.19/1 and the mean age at onset was 26 ± 9.8 (CI: 0.3). As the first manifestations, oral aphthosis (OA) was the most frequent (81%, CI: 1.1). The prevalence of variuos manifestations were OA: 97% (CI: 0.5), genital aphthosis: 65% (CI: 1.3), skin: 69% (CI: 1.3), ocular: 56% (CI: 1.4), joint: 34% (CI: 1.3), CNS: 3% (CI: 0.5), vascular: 8.5% (CI: 0.8), GI: 8% (CI: 0.8), and epididymitis: 10% (CI: 1.1). The laboratory findings were as follows: high ESR: 53% (CI: 1.4), urine abnormality: 10% (CI: 0.9), positive pathergy test: 57% (CI: 1.4), HLA B5: 52.5% (CI: 1.4), HLA B51: 34% (CI: 5.1), and HLA B27: 9% (CI: 0.8).CONCLUSION—Recent survey in Iran revealed a remarkable decrease of the incidence rate of BD and a tendency toward milder forms of the disease. Our data show more similarity with those of Turkey and Japan than with the western parts of the world.

BACKGROUND–Loco-regional recurrence and distant metastases are frequently disturbing events in patients with locally advanced breast cancer. This study was carried out to evaluate the role of postmastectomy conventional adjuvant treatment in such patients.MATERIALS AND METHODS–During the last five years, a total of 117 patients with locally advanced breast cancer (T3-T4 and/or more than four involved lymph nodes and/or fixed lymph nodes) were treated with postoperative chemotherapy and radiotherapy. Departmental records of these patients including stage, histology, sex, age, and therapeutic modalities were reviewed to assess the result of treatment. The cases with proven metastasis or T1-T2N0 lesions were excluded. The patients were divided into three groups. Arm I included T3-4N0, Arm II as a large primary tumor (T3-4) with 1 to 4 positive axillary nodes, and patients with more than 4 involved or fixed axillary lymph nodes, were considered as Arm III. We compared the result of adjuvant treatment in these groups.RESULTS–After a 7-year follow-up, loco-regional recurrence was seen in 13 (11.1%) patients and distant metastasis in 67 (57.2%) patients. The median event-free survival was 28 months in all patients. The median event-free survival was 78 months in patients with negative axillary nodes, 28 months in patients with one to four positive nodes, and 20 months in those with more than four positive or fixed axillary nodes. The difference in event-free survival between 3 groups was statistically significant (p = 0.026).CONCULSION–With conventional, local, and systemic treatment, a marked difference in local and distant failure exists between breast cancer patients with a T3-T4 N0 tumor and patients with positive axillary nodes

BACKGROUND—Gypsies are the groups of people who are not dependent on any special location. Because of permanent immigration, poor socioeconomic status and the special life style, gypsies might be exposed to multiple sexual partners, addiction and various kinds of infections, like hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). The aim of this study was to estimate the prevalence of these infections in gypsies of South-West of Iran (Shahr-e-Kord). MATERIALS AND METHODS—This study was done in Sureshjan Pass near Shahr-e-Kord. Out of 250 gypsies, 226 of them were recruited into the study. Laboratory tests for hepatitis B surface antigen (HBs Ag), hepatitis B core antibody (HBcAb), hepatitis C virus antibody (HCVAb), and human immunodeficiency virus antibody (HIVAb) were performed in the study population. All sera with positive results of HBsAg or HBcAb were tested again for these markers together with HBsAb, HBeAg, and HBeAb. Also sera with positive HIV Ab were retested with immunoblot assay.RESULTS—A total of 226 persons (103 males, 123 females) with a mean age of 20.7 years (range: 9 months to 78 years) were recruited. Thirty-five subjects (18, or 15.5 % male) had positive HBsAg. Fifty-four persons (23.9%) had positive HBcAb. Seven (4, or 3.1% male), had positive HCVAb and 4 persons (2, or 1.8% male) were HIV positive.CONCLUSION—Gypsies in Iran should be considered a high risk group for HBV, HCV and HIV infections. Vaccination against HBV should be considered for all noninfected subjects, and health promotional activity should be planned in order to prevent further spread of these blood born infections among them.

BACKGROUND—Short stature is defined as subnormal height relative to other children of the same sex and age, taking family into consideration. This prospective study was designed in order to determine the etiologies of short stature with especial concern on the prevalence of growth hormone deficiency, and to compare the results with world-wide studies.MATERIALS AND METHODS—We studied 426 subjects (272 boys and 154 girls) aged 4-18 years (mean, 10.8 ± 4.8) with short stature. The decision to investigate the growth hormone axis was made with the knowledge that other explanations for growth failure have been excluded by documention of a normal full blood count, ESR, renal function, and measurement of serum thyroxine concentration. In some female subjects, a karyotype was performed to exclude Turner’s syndrome. Bone age was determined in all subjects.RESULTS—Normal variants of growth including constitutional growth delay and familial short stature were identified as the most common causes of growth failure in this study. The results obtained in this study were in agreement with world-wide reports. Growth problems were more common in boys than in girls (1.8: 1). Among the short subjects, 23.4% had classic growth hormone deficiency (GHD). Boys outnumbered girls 2:1 (p < 0.05).CONCLUSION—We conclude that (1) most children with short stature will not have an endocrine disorder, but in endocrine referral centers, the frequency of GHD is higher than in general clinics and (2) GHD appears to be more common in boys.

BACKGROUND—Vestibular hyperreactivity (VH) is a disorder which is debated as a cause of vertigo and imbalance. We studied the prevalence of VH in patients with vertigo and the associated factors. MATERIALS AND METHOD—A total number of 156 consecutive patients complaining of unexplained vertigo and imbalance, without any specific diagnosis, were referred to the audiologic clinic for caloric and rotational test (chair with decaying sinusoidal motion during the Summer and Fall of 1997. Data were compared with those of the 45 healthy patients.RESULTS—VH was detected in 13 (8%) patients. Contrary to some early reports, no significant statistical relationship was found between this disorder and age, sex, thyroid, gynecology, CNS disorder, or motion sickness. CONCLUSION—The prevalence of VH, the yet unknown disorder, in our country was 8%. Since no documented prevalence rate was found in the pertinent literature, and nor was there any mention of VH as one of the causes of vertigo in most evaluations, the prevalence rate obtained in our study seemed significant, although further studies are warranted. Exact criteria and characteristics of VH and whether it is a newly defined topic or a part of other disorders are not yet clear.

BACKGROUND—To salvage or amputate a severely injured limb is one of the most difficult decisions an orthopedic surgeon may face. We evaluated the efficacy of the different limb injury scoring systems in predicting results of limb saving surgery. Patients AND METHODS—Thirty-one patients with 33 severely injured limbs and arterial damage were studied. The discriminated validity of the four injury-severity scores of lower-extremity, sensitivity, specificity, and Yourdon’s J for predicting amputation were calculated.RESULTS—Eight (24.2%) of the limbs were amputated; seven (88%) amputations were lower extremity, and one (12%) was upper extremity. The modified scoring system: nerve injury, ischemia, soft tissue injury, skeletal injury, shock, and age of patients (NISSSA) demonstrated a high specificity (88%) and sensitivity (87%). CONCLUSION—NISSSA had greater predictive value in damaged lower and upper extremities than other scoring systems.

BACKGROUND—Among the many high risk groups, medical students and residents are especially at risk for hepatitis B virus (HBV) exposure. HBV vaccination is a well-recognized preventive strategy but there is still uncertainty about the duration of protection and revaccination need. The aim of this study was to determine the anti-HBs antibody titer using ELISA method in the years after last dose of vaccine injection.Materials AND METHODS—One hundred and fifty healthy medical students and residents who were training at Kerman University of Medical Sciences hospitals from September 2001 until September 2002, received three standard doses of recombinant HBV vaccine. For a time interval of 1, 2 – 5, and 5 – 10 years after last inoculation, the subjects were divided into three groups of 50-persons each.RESULTS—The subjects were 85 men and 65 women with a mean age of 26.8 ± 4 years. Overall, the mean of anti-HBs antibody titer was 1,766.7 ± 227.1 IU/L with minimum end of zero and maximum level of 10,500 IU/L. Based on the time lapsed since last inoculation the mean titer of anti-HBs antibody at the end of 1 year, 2 – 5, and 5 – 10 years were 3,446.8 ± 497.4, 1,603 ± 338.6 and 250 ± 59.3 IU/L, respectively (p < 0.001). Protective level of antibody (> 10 IU/L) at the end of one year was seen in 98% of vaccinees. It declined to 94% in 2 – 5 year interval and to 84% in 5 – 10 years after inoculation. Most of the non-responders with antibody titer < 10 IU/L (8/12) were in the time interval 5 – 10 years. CONCLUSION—For a revaccination schedule among medical students and residents, we suggest anti-HBs antibody detection at 5 – 10 years after primary vaccination. Revaccination should be arranged due to personal need instead of whole target population.

BACKGROUND—Vernal keratoconjunctivitis (VKC) cases are often resistant to conventional treatments. We aimed to assess the effect of supratarsal injection of triamcinolone acetonide in these patients.Patients AND METHODS—Sixteen patients (32 eyes) with severe VKC, and resistant to conventional method of treatments were selected and underwent injection of 0.5 mL triamcinolone acetonide in supratarsal area (in conjuctival side of upper lid) and were followed up for 54 months. The results were analyzed with SPSS program with 95% confidence interval.RESULTS—Relief of symptoms (burning, itching, lacrimation and photophobia, ropy discharge) was dramatically seen in all patients, in first few days. Size of giant papillae, thickening of limbus, vascularization of cornea (pannus) decreased in the first month. Recurrence of disease was seen in 2 (12.5%) patients after one month. No complication was noticed during the follow up. All patients tolerated the treatment well.CONCLUSION—Rapid and dramatic symptomatic and clinical response, and lack of complications suggest that supratarsal injection of triamcinolone acetonide could be a thrapeutic approach for refractory VKC.

BACKGROUND—Hearing impairment is one of the most important causes of speech problems in children. If the diagnosis and treatment of hearing impairment is delayed, it could cause developmental, emotional, and social problems for the child and his family. We aimed to assess the hearing impairment in a group of high risk infants in Tehran.Materials AND METHODS—Auditory brain-stem response (ABR) was performed in 150 high-risk newborn infants who had at least one risk factor for hearing impairment. These patients were followed up after discharge from the hospital for 3 months and were reevaluated for assessment of hearing.RESULTS—The mean age of the patients was 22 ± 14 days. One hundred and eight patients (72%) had normal hearing and 42(28%) had different levels of hearing impairment. Seventeen (11%), 16 (10.7%), 4(2.7%), and 5(3.3%) of the patients had mild, moderate, severe, and profound hearing impairment, respectively. CONCLUSION—All high-risk neonates should have hearing assessment. ABR, is a sensitive procedure for detection of hearing impairment in the newborns and young infants.

BACKGROUND—Spinal muscular atrophies (SMA) are a group of heterogeneous disorders characterized by the degeneration of the lower motor neurons of the ventral horns of the spinal cord. They are inherited by an autosomal recessive pattern, and because of the high rate of consanguinity in the Iranian population the incidence of these diseases is very high in this region. The precise frequency has not been determined. We set up molecular tests for the diagnosis of affected patients, carrier detection, and prenatal diagnosis for high risk pregnancies.MATERIALS AND METHODS—We investigated the presence or absence of the survival motor neuron (SMN) gene in 47 Iranian families, including 60 patients by polymerase chain reaction amplification of exons 7 and 8 in affected individuals and parents of patients for carrier detection. In addition, prenatal testing was performed on 15 pregnant mothers. RESULTS—Mutation detection in the 22 live patients showed that in the 21 cases, both alleles were deleted. In 1 case only one of the mutations was detected, therefore the other must have been a point mutation. In 34 families, both of the parents were carriers, that is, they carried only one copy of the normal SMN gene. In 9 of the couples only one mutation was detected, therefore in the other one, it should have been a point mutation that was not diagnosed. Molecular testing of 15 fetuses by prenatal diagnostic procedures showed that 4 of the fetuses were normal, 3 fetuses were affected and carried both of the mutations, five fetuses were carriers (they carried one of the mutations), and the other 2 were carriers or healthy, but only one case might have been carrier or affected. CONCLUSION—SMA is a very common disease in the Iranian population, due to the high frequency of consanguineous marriages. Preventive measures by genetic counseling, carrier detection, and prenatal diagnosis are helpful in the prevention of recurrences in the future pregnancies

BACKGROUND—Cushing''s disease is the most common cause of endogenous Cushing''s syndrome (up to 60%) and is usually due to pituitary hyperplasia or basophilic adenoma. Materials AND METHODS—Eleven cases of Cushing''s disease that have been admitted to Shariati Hospital since June 1992 up to September 2000, had been reviewed. These included three male, and eight female patients with an age range between (9 – 34) years with a mean of 21 – 5 years.The most common symptoms were headache, weight gain, and menstrual/libdo disturbances. Obesity, moon face, hypertension, depression were the most common signs in our series.These patients were diagnosed on the basis of high serum and urinary free cortisol, abnormal 2-mg dexamethasone and normal 8-mg dexamethazone suppression test.RESULTS—The neuroimaging investigation revealed normal sella turcica in 7 cases, double floor and enlarged sella turcica in 4.Computerized tomography was the most valuable tool which showed the adenoma in 9 cases, MRI with gadolinium injection were helpful in better delineation of the lesion in the last three cases. All patients were treated surgically via transsphenoidal approach.The mean duration of follow-up was 5 yrs (range, 0.5 – 8 yrs). There were regression of the clinical symptoms in 9 cases (82%), and recurrence of these symptoms in one patient six month after the operation (9%). One patient died because of uncontrolled sepsis two months after operation (9%).CONCLUSION—In conclusion the transsphenoidal approach is a safe and effective procedure for treatment of patients with diagnosis of Cushing''s disease of pituitary origin.

We describe a rare case of intradural chondroma. A 28-year-old man presented with headache and left hemiparesis. Axial brain computed tomography showed a large lobulated and calcified mass in the right frontal convexity. He was operated and the tumor was completely removed through a frontotemporal craniotomy. The tumor was totally intradural. Histopathology examination revealed hyaline lobules of mature cartilaginous tissue compatible with a chondroma.

Obstruction of the small and large intestines is a serious and life-threatening condition that requires prompt attention. Sometimes, a swallowed foreign body passes through esophagus, stomach, small intestine and eventually is compacted in colon and/or rectum. In this report, we present a case of a three-year old boy with colon obstruction due to swallowing sand. Finger manipulation proved aiding evacuation and initiation of normal bowl function.