مجله علوم پزشکی رازی
سال دهم شماره 4 (پیاپی 37، زمستان 1382)

The object of the present study was to determine the effect of 2 doses of intrathecal morphine on extubation time and on postoperative analgestic requirements after coronary artery bypass graft surgery. This prospective, randomized, double blind placebo-control study was carried out on 60 adult patients(ASA II, ASA III) without emergency surgery, valvular heart disease, contraindication for spinal anesthesia or addiction. Patients (40-70 years old) were randomly divided to three groups to receive placebo, 3μg/Kg or 73μg/Kg interathecal morphine preoperatively. Intraoperative midozolame and fentanyl injection were limited to 153μg/Kg and 303μg/Kg intravenously. Patients were extubated in the intensive care unit by a blinded observer using predefined extubation criteria. Time to extubation and postoperative requirements for intravenous morphine was recorded by a blind observer. Patient in three groups did not have any significant difference in terms of age, weight or height. Extubation times were 465±207 minutes for placebo group and 414±245 minutes and 335±177 minutes for 3 μg/Kg & 7μg/Kg intrathecal morphine group(P=0.19). Postoperative morphine requirements in 3μg/Kg, 7μg/Kg and placebo groups were 18.8±7.8, 13.3±6.4 and 28.3±6.5(mg)(P=0.001). ABG analysis in three groups in ICU indicated that average Paco2 were 40.1±4.1, 43.6±6.5 and 47.9±4.8(mmhg) in placebo, 3μg/Kg and 7μg/Kg in intrathecal morphine groups respectively(P=0.001)(mean±SD). Despite decreased post operative morphine requirements, intrathecal morphine administration did not have a clinially relevant effect on extubation time after CABG surgery. This study suggests that 3μg/Kg intrathecal morphine is a suitable dose for providing significant postoperative analgesia without delaying tracheal extubation time and has minimum respiratory depression.

Ballantyne syndrome is a syndrome with severe hydropic placenta and fetus followed by maternal hydrops. Several different causes may lead to this syndrome. In fact, Ballantyne syndrome may result from any factor causing severe hydrops fetalis. The diagnosis can be supported by sudden and rapid weight gain, severe edema, oliguria with albuminuria, blood pressure less than 140 mmHg and hemodilution. In this study, a case with Ballantyne syndrome and hyperstimulated ovaries is reported on which ceasarian section was performed but the newborn infant died after some hours.

Aplastic anemia is a clinical syndrome in which there is peripheral blood pancytopenia due to reduced or absent production of blood cells without evidence of another marrow disorder. The disorder may be acquired or inherited like Fanconi’s anemia. In this study, survial and prognostic factors in acquired aplastic anemia is determined. This analytic cross-sectional study was done on 224 child patients who referred to blood disease clinic of Hazrat Ali-Asghar Hospital from 1977 to 2000. Data of patients was collected retrospectively in census methods. Survival state, demographic variables, signs & symptoms, laboratory test and kind of treatment were all recorded. Data was analyzed by Kaplan-Meier survival curves and life tables. In order to determine the factors influencing survival log rank test and cox-regression analysis in SPSS software, log rank test and cox-regression analysis in SPSS software were used. 5 and 10-year survival of acquired aplastic anemia were 55%, 41.6% respectively. In bivariate analysis, absolute neutrophil count less than 100/μlit (P=0.00) and ESR more than 60 mm/h (P=0.04) were negatively associated with survival and improved survival was associated with pallor at time of diagnosis(P=0.04). In multivariate analysis just association between absolute neutrophil count (EXP(B)=5.18) and pallor (EXP(B)=0.41) with survival were proved. In this study, survival of patients with acquired aplastic anemia in comparison with other countries was in the lowest range of survivals.

Premenstrural syndrome(PMS) which includes psychological and physical symptoms regularly occurs during the second half of the menstrual cycle and it is estimated to affect up to 95% of women to some degree. Five percent of these women will be affected so severely that this causes disruption in their daily activities and social interactions. The main cause of this syndrome is unknown and a lot of women suffer from PMS therefore, the treatment is very important. Recently, it has been found that calcium supplementation is useful for curing symptoms of PMS. The object of the present study was to find the effect of calcium on reducing the symptoms of premenstrual syndrome. First, medical and paramedical female students were screened for 20 symptoms of cyclically premenstrual symptoms through administering a questionnaire. Later, 100 women were selected for this trial. Symptoms were prospectively documented over 3 menstrual cycles with a daily rating scale that had 20 symptoms of PMS. Participants received 1000 mg of effervescent calcium per day in 5 days, when the symptoms were maximum in the previous cycles. Daily documentation of symptoms were monitored. After 3 months data analysis was done. Among 20 symptoms of PMS, 12 symptoms including psychological symptoms such as fatigue, sleep disorders, irritability, depression, appetite changing, and physical symptoms such as body dismorphia, breast tenderness, acnea, headache, arthralgia, low back pain, weight increase had significant reduction or they completely disappeared with calcium supplementation. Using 1000 mg calcium supplementation per day in the second half of menstrual cycle for 5 days in women affected with premenstrual syndrome results in overall 62% reduction of psychologial symptoms and 61% reduction of physical symptoms. Thus, more study in this field can be recommended to find out daily consumption of 1000 mg calcium supplementation by women who suffer from premenstrual syndrome will significantly reduce overall symptoms and prevent disruption of daily activities and social interaction.

The aim of this clinical trial was to compare the effects of two techniques forward & backward running on the static balance. In a pilot study the reliability of static balance test was confirmed. A convenient sample of 30 healthy young men was selected and randomly assigned into two groups of 15. The testing period for both groups lasted about 6 weeks with 3 sessions per week each session took 15 minutes. The used test for static balance was Modified Phomberg test and measurements were taken at the beginning and every two weeks hence forward. Therefore, there was between and within group analysis using independent t-test and dependent t-test. After the end of the sixth week, significant increase in static balance was observed in both groups, but these two techniques had similar effects, i.e., the observed difference between groups was not statistically significant. Additionally, the advancement in backward running group was faster.

Natural killer(NK) cells are defined as effector cells that have the capacity of spontaneous cytotoxicity toward various target cells and are not major histocompatibility complex(MHC) restricted. NK cells are the first line of immune system defence and serve in surveillance of certain tumor and virus-infected cells. The aim of this study was to determine CD16++CD56+ marker(NK cells) in healthy Iranian population. Peripheral blood samples of 500 male and female subjects, from different age group(18-60 years), were obtained. Flowcytometry technique with dual color monoclonal antibodies (CD16++CD56+) against NK cells was used to analyse the samples. Statistical analysis was done through SPSS software. The mean of CD16+CD56+ was found to be 15.93±7.02 for male and 13.30±5.89 for female population(P<0.05). The mean ranges of NK cells in different age group in the combined population were significantly less in the subjects aged 31-40 years as compared with subjects aged 50-60 years(P<0.001). Study and determination of NK cells in the peripheral blood indicates that sex, age and race should be a consideration in the evaluation of the immune system. Therefore, the results of the present study can be used in Iran laboratories and research centers to evaluate infectious diseases, tumors and other diseases.

Nitric oxide (NO) is an unstable small molecule which acts as lipophilic free radicals. It is synthesized in different mammalian cells and thought to be involved in many physiological and pathological conditions. There are many evidences that show NO acts as a neurotransmitter in Non-Adrenergic, Non-Cholinergic (NANC) nerves, innervating smooth muscles of digestive system and also has direct influence on smooth muscle cells. Infantile hypertrophic pyloric stenosis(IHPS) is one of the most common pathological conditions among the neonates. It is thought that any failure in NO synthesis could be one of the reasons of IHPS. Pregnant Sprague-Dawley rats were used in this study. Different doses of the L-NAME (20-80mg/kg) as an NO inhibitor in normal saline was injected intraperitoneal (IP) during the last week of pregnancy period per day. The embryos were removed on the day of expected delivery. The stomach and duodenum were dissected, fixed by Bouin solution and tissue processing was done. By using rotatory microtome, 5μ serial cross sections were obtained and stained with Trichrom-Mason and Pop-Nicola. Statistical analysis of macroscopic and light microscopic findings showed that 80mg/kg of L-NAME causes significant changes in embryos of trial group including: IUGR, hind-limb disruption, embryo absorption, pyloric hypertrophy and hyperplasia. On the basis of these results it is believed that 80mg/kg of L-NAME can be one of the reasons of pyloric stenosis in infants.

Although we have access to various drugs and diagnostic equipment today, tuberculosis is still regarded as the most fatal disease of single microbial factor. A large number of children across the world have been made orphans due to this disease. World Health Organization(WHO) called a global emergency for tuberculosis in 1993. Because of MDR(Multi Drug Resistance) there is a risk that tuberculosis turns to a disease difficult to treat. Among the causes of global defeat in the treatment of tuberculosis and formation of MDR, are delay in treatment and physicians’ faults. Nevertheless, the disease can still be controlled by implementation of DOTS(Directly Observed Short Course). The necessity for organizing such course is the cooperation of all private sectors. One of the plans of this course, based on which national schemes are designed, is educating the medical staff at all levels specially the physicians. This study is aimed at evaluating one of the educational methods on the knowledge and attitudes of general practitioners. This study is based on a before-after study method in which 340 GPS of private sector have been simply sampled randomly. The knowledge and attitudes of the physicians were tested by a questionnaire. A self study method was also used as an educational method, using the book entitled “National Guide for Combating Tuberculosis”. The study proved that the physicians primarily had a favorable attitude to the national plan but their knowledge was very low(1.8%). Education proved to have a positive effect on knowledge and attitudes of the physicians in a way that the mean scores given to physicians’ knowledge and attitudes before and after education showed a significant difference. The change in knowledge and attitudes of physicians of public sector did not show any significant relation with demographic and work experience variant in public sector. Based on the results of the present study it can be concluded that self-learning has a positive effect on attitudes and specially knowledge of the physicians.

Responses to painful stimulus are associated with broad range of physiological changes in human body. One of these significant responses is an increase in plasma norepinephrine level that may cause different systemic effects like coronary spasm, hypercoagulation, demand/supply ratio imbalance in myocardium, etc. Many clinical trials have tried to eliminate or decrease these changes by using different drugs and increasing depth of anesthesia. In this clinical trial study, the effects of two drugs of propofol and thiopental on norepinephrine level during laryngoscopy were studied. 60 ASA I patients, candidated for elective surgery under general anesthesia in the range of 15 to 45 years old, were randomly allocated to two groups. BIS monitoring was performed to measure depth of anesthesia. For all of the patients midazolam was administered as a premedication to reach BIS 70, then blood sampling was done. Thiopental was injected to one group and propofol to the other to reach BIS 40. Atracurium (0.5mg/kg) and fentanyl (3mcg/kg) was administered to both groups and intubation was done. Second blood sampling was done 3 minutes later. Norepinephrine level was measured in two stages: one as basal level and the other after laryngoscopy via ELISA method. Data showed that plasma norepinephrine level was 0.236±0.125 (mean±SD) after laryngoscopy in propofol group and 0.216±0.118mcg/dl (P=0.534). in thiopental groups. There was no significant statistical difference between two groups (P>0.05) therefore, it can be concluded that clinical decision for selection of drugs is only based on patient condition, drug side effects and cost–benefit ratio but not the type of drug itself.

Optimal treatment of 3 and 4-part fractures of the proximal humerus is still controversial and is accompanied with many complications. These fractures can be treated with variety of osteosynthetic methods especially in younger ages, but some complications such as limited range of motions, mal:::union:::s and avascular necrosis are common. Hemiarthroplasty can be used in old patients with low activity or in severely comminuted fractures, but this is an expensive method and has major limitations in undeveloped or developing countries. In this article the results of TOSF technique are presented. 28 patients with 3 or 4-part fractures or fracture dislocations of the proximal humerus were treated with TOSF technique from 1996 to 2002. 3 cases were excluded from the study and the 25 remaining ones were assessed. The mean age was 43.2 years(20-68 years) and the duration of follow-up was 39 months(3 months to 6 years). Preoperative diagnosis was based on plain radiographs and CT-Scans. Fixation was made with non-absorbable or late absorbable sutures(no.5-USP) and a range of motion exercises began immediately after the surgery according to patients’ tolerance. The obtained data from the latest clinical and radiographical examination was then analysed. In one patient the greater tuberosity was non:::union:::ed. Also, no neurovascular injury during operation, no infection and no avascular necrosis was found. Mal:::union::: rate was 32%. The average range of motion was 157˚ in flexion, 21˚ in extension, 31˚ in external rotation, 132˚ in abduction and in internal rotation it was up to L2-L3. Satisfaction from surgery according to Neer’s rating system was 64% excellent, 20% satisfactory, 12% unsatisfactory and 4% failure. Returning to previous job was 72%. Thus, TOSF technique for treatment of these fractures has acceptable results with minimal complications, and it can be used in all age group with severely comminuted fractures or osteoporosis. Also, this treatment is a reasonable substitute for hemiarthroplasty in undeveloped or developing countries.

It has been suggested that prolonged exposure to ionizing radiation may induce immune alteration which may facilitate the development of cancer. However, over the past decades some scientists have reported that low-dose of ionizing radiation is not only a harmless agent but often is benefical. The aim of this study was to evaluate the effects of occupational exposure to low levels of ionizing radiation on immune system. The studied population consisted of 48 healthy radiographers exposed to annual dose of x-rays below the maximum permissible occupational limit(MPOL 50 mSv/year) and 18 healthy unexposed individuals similar in age, gender and job grade. Total number of WBC, lymphocytes, lymphocyte subsets(CD19, CD3, CD4, CD8, CD16-56) HLA-DR, CD4/CD8 ratio, platelet and concentration of IgG, IgM, IgA, C3, C4 were measured. The investigation was carried out by flow cytometry for lymphocyte subsets and immunoturbidimetry for immunoglubolin and complements. Although the number of CD8 and CD4/CD8 ratio decreased and increased respectively with increase in age, no influence of the radiation on the immunological parameters in peripheral blood was found. This study showed that ionizing radiation received by radiographers (at least in very low-dose range) does not affect the immune system.

Knee osteoarthritis causes joint laxity, muscle weakness and atrophy. These factors compromise neuromuscular protective mechanisms of the muscle, cause excessive joint loading and increase pain and disability. This condition also causes balance impairment which in this patients may be due to proprioceptive impairment and quadriceps weakness. The object of the present study was to compare the effect of muscle strengthening and neuromuscular training methods on therapeutic parameters improvement in patients with primary knee osteoarthritis. In this study 30 subjects with primary knee osteoarthritis(mean age 59.8, range 50-65) were divided non randomly into two groups and received training in two special therapeutic methods. An electrogoniometer was used for evaluation of propriception and biodex stability system was used for assessment of the balance. Pain and activity of daily living(ADL) levels of the subjects were assessed by using an extensive questionnaire. Based on the obtained results, both therapeutic methods appeared to be beneficial in therapeutic parameters improvement in patients with primary knee osteoarthritis(P<0.05) but the neuromuscular control method appeared to be more benifical(P<0.05).

In the present study a new technique used in the treatment of scapulothoracic arthrodesis has been described. This technique was used in 6 patients(two patients bilaterally) for winging of scapula due to facioscapulohumeral dystrophy from 1988 to 1999. In this technique combination of plate and wire was used. The reasons for doing this surgery were: scapular winging, pain in shoulder, limitation in active shoulder motion, and impaired daily living activities. The objectives were to improve motion, strength and performance of activities of daily living as well as pain relief. After surgery, active motion improved in all patients for flexion from 64 to 104 degrees and for abduction from 67.5 to 112.5. The only complication was a hemothorax in a patient which was treated easily. The average length of follow-up was 32.5 months (from 14 to 55 months) and results did not change with the passage of time.

Mccune Albright syndrome is a polyosteotic fibrous dysplasia which manifests itself with disturbance of endocrine function and pigmented patch in skin at birth. The prevalence of polyosteotic is between two and three per million. The upper end of femur is the frequent site of involvement in polyosteotic form with multi endocrinopathy and limb deformity and multiple fractures. The present study is the case report of a 19-year-old girl who referred for left lower limb shortening and deformity of thigh following conservative management. In follow-up, and at the age of 19 due to recurrence of deformity and lower limb shortening(10 cm) the patient underwent derotational subtrochantric valgus osteotomy and bone graft, fixation with plate and concomitant distal femural supracondylar close wedge osteotomy. After operation limb deformity and discrepancy were corrected.

Prevention of infection by hepatitis B virus in patients undergoing hemodialysis is very important but has its own problems such as reduction of hepatitis B vaccination efficacy and the falling of HbsAb to unprotective levels after unknown time. These factors bring up a need for assessing the antibody levels at specified times (e.g. every 6 months) and revaccinating the patients when it seems necessary. The present study was conducted to determine the factors that influence the efficacy of hepatitis B vaccination in patients undergoing hemodialysis. This case-control study was carried out on 121 patients undergoing hemodialysis in the hemodialysis ward of Shahid Hasheminejad Hospital in Tehran. 64 patients(with antibody levels under 10mlU/ml) were in case and 52 ones (with antibody levels equal or more than 10mlU/ml) were in the control group. The checklist consisted of demographic and laboratory information, duration of hemodialysis, history of having diabetes and history of smoking which were all extracted from the patients’ hospital records and/or asked from them. Analysis of the data was done via SPSS 10 and EPI Info 6 software using indices of frequency, mean, standard deviation and standard error. Different statistical tests such as Chi2, Levene, Kolmogorov-Smirnov, t, and Pearson and Spearman coefficients were also employed. Multiple linear regression was used for assessing the predicting factors. Of 121 patients, 56 were female and 65 were male. Rh-positive blood group had more frequency in cases than in controls (P=0.010, odds ratio=2.63) and the number of the smokers was significantly more in the control group than in the case (P=0.031, odds ratio=0.27). Moreover, increases in weight (P=0.015, r=-0.225) and age (P=0.006, r=-0.253) decreased the HbsAb levels significantly. The patients’ age and Rh blood group were the identifiers of antibody levels in the regression model. This study has found out that increasing age, malnutrition and Rh-positive blood group are factors in decreasing the efficacy of hepatitis B vaccination in patients undergoing hemodialysis and it has also marked the need for paying further attention to the patients having these risk factors.

3 beta-Hydroxy-Delta-5-steroid dehydrogenase is an important key anzyme of steroid hormone biosynthesis, which is involved in catalyzing the conversion of pregnenolone to progesterone in the biosynthesis of steroid sex hormones. This complex enzyme is the second enzyme in the steroid hormone biosynthesis pathway and it is identified as an autoantigenic target. In this study, a simple method is presented for the quantitative assay of 3β-Hydroxy steroid dehydrogenase activity in testis of rat. An excess of pregnenolone was incubated with several concentrations of whole testis homogenate. The reaction mixture containing the pregnenolone, NAD, isonitrotetrazolium in 0.15 M Tris-HCL buffer(PH=8) and the enzyme extract from testis of rat was incubated for 1.5 at 37˚c. Absorbance at 495 nm was read in a spectrophotometer. The results showed that 3-β-hydroxy steroid dehydrogenase activity was linear with time and protein concentration. The present method can easily be performed and is sensitive enough to assay 3-β-hydroxy steroid dehydrogenase activity in rat testis.

Glutamic Acid Decarboxylase(GAD) catalyses the conversion of glutamic acid to Gama amino Butyric Acid(GABA) which is one of the major inhibitory neurotransmitters in central nervous system. GAD has two isoforms with molecular weights of 65 Kda(GAD 65) and 67 Kda (GAD 67). GAD 65 gene is located on chromosome 10 and expressed in β-cells of pancrease. The presence of high concentrations of Anti-GAD Antibodies(GADA) in serum of patients with IDDM is evident. Evaluation of GADA levels in individuals with NIDDM and their first degree relatives can also be used as a predictor of late insuline dependency. High concentrations of glucose induce the production of GAD 65 in β-cells which is associated with an increase in GAD 65 gene expression. It has been shown that patients with NIDDM may produce higher levels of GADA and after short period of time developing IDDM. In the present study anti-GAD levels were determined and compared in 50 type II Iranian diabetic patients, in 32 of their first degree relatives and in 56 healthy subjects. The evaluation of GADA levels were carried out by the use of ELISA method. The mean level of anti-GAD in the healthy subjects was 6.64±7.01ng/ml, in the patients was 10.76±13.59ng/ml and in their first degree relatives was 19.71±32.1ng/ml. In regard to the cut off, 18% of patients had seropositive anti-GAD and 21.9% of their first degree relatives had seropositive anti-GAD but all of the healthy subjects had seronegative anti-GAD. The frequencies of anti-GAD positivity in patients and their first degree relatives compared with that of healthy subjects were significantly higher(P<0.001 and P=0.001 respectively). It can be concluded that the determination of anti-GAD in healthy subjects and their first degree relatives of type II diabetic patients can be used to predict the development of diabetes and insuline dependency.

The patient of the present study is a 15-year-old female who referred to clinic with pain and severe swelling in her neck. She had severe quadriparesis. Due to severe destruction of C1, C2 and C3 vertebrae and cervical spine instability, she underwent surgery in two stages. In the first stage, the surgery was done with posterior approach to achieve decompression, post stabilization & fusion and taking material for biopsy. In the second stage, the surgery was done through anterior approach to achieve tumor resection, stabilization and fusion. Fortunately, complete neurological recovery occurred after surgery. The patient is presently able to walk without any assistance and the spine has rigid fusion.

Cardiovascular disease(CVD) is still a health and a social problem in our country. Major risk factors have been identified for CVD in different studies. Other surveys have mentioned some dietary and non-dietary factors related to these risk factors. The aim of this study was to determine the predictors of CVD risk factors in distinct 13 of Tehran. Dietary intake assessment was undertaken with 2-day 24-hour recall in 486 cases older than 20 who participated in Tehran Lipid and Glucose study after excluding the under-and over-reporters. The data about anthropometric, smoking, education level, blood pressure and the level of blood lipids was later obtained. To determine the predictors of CVD, stepwise linear regression was used. Based on the obtained results, BMI and WHR increased with age in women(P<0.01 and P<0.05 respectively). Distribution of people in different age groups was not equal in terms of smoking and education level. Results showed a strong and positive relation between BMI and carbohydrate intake with serum triglyceride(P<0.05, β=0.7, P<0.05, β=2.4) respectively. Furthermore, there was a strong and positive relation between LDL and weight(P<0.05, β=1.1), LDL and age(P<0.05, β=1.6) and LDL and cholestrol(P<0.01, β=0.7). Thus, it can be concluded that there is relation between some dietary and non-dietary factors with CVD risk factors. Considering these relations is important in prevention and reduction of CVD.

Hepatitis C virus(HCV) is responsible for the majority of cases of viral hepatitis in transfusion dependent thalassemic patients. Although recent screening policies have markedly decreased the incidence of HCV infection, this problem is still one of the most important causes of mortality and morbidity in thalassemic patients. This retrospective study was designed to investigate the frequency of HCV infection in Iranian thalassemic patients.The hospital records of 507 multitransfused thalassemic patients who referred to receive their care in Ali-Asghar Children Hospital in Tehran from 21st March 1999 to 20 th March 2000 were reviewed. Twenty four-percent(122 patients) were anti-HCV positive. All but one had received their first transfusion before 1996 when the screening of products for HCV became mandatory. Liver biopsy was performed in a subgroup of 38 patients. In all of them true HCV infection was confirmed by polymerase chain reaction test. There was a positive correlation between ALT means and the liver histopathology through stage(P=0.04) and grade I to III(P=0.015). Similarly, AST mean level was correlated with progression from grade I to III(P=0.010). No correlation was found between AST and ALT means and progression to stage IV or grade IV liver disease. There was a reverse correlation between serum albumin level through stage 1 to 4 (P=0.029). The serum albumin level did not have any correlation with grading. HCV infection is common in multi-transfused thalassemic patients. Increased transaminase levels and/or depressed serum albumin levels predict significant histhological changes in liver biopsy.