مجله علوم پزشکی رازی
سال یازدهم شماره 3 (پیاپی 42، پاییز 1383)

The objective of the present study was to determine the clinical features, underlying factors and treatment outcomes of infants with immune thrombocytopenic purpura(ITP). Due to lack of study on this age group a retrospective analysis of 62 infants with ITP was carried out from 1998 to 2002. Age, sex, clinical features, treatment outcomes and the rate of chronic ITP were evaluated. Among 62 infants with ITP, 39 male and 23 female subjects had an average age of 10.8 months. All patients had purpura and 12 of them had active mucosal bleeding, most commonly epistaxis. 44 patients had ITP after viral upper respiratory infection, one after chicken pox, 8 following vaccination and in 9 cases the cause of ITP was unknown. 55 patients received IVIgG, 39 only IVIgG, 16 IVIgG+prednisolone, 4 received nothing and 3 patients received multiple medicines. 46(74%) patients responded to a single course of treatment, 6 gave partial response and 6 patients no response. Among the patients 51(82.25%) had acute ITP and 11(17.75%) chronic ITP. Infants with ITP responded favorably to treatment and were less likely to develop chronic ITP. On the whole vaccination may play an important role in the etiology of ITP in infants.

Routine classification of pituitary adenomas is not appropriate for diagnosis of adenoma type and in some cases there is inconcordance between clinical presentation and histological type of adenoma. The aim of this study was to determine the type of adenoma secretion based on immunohistochemical staining. 102 paraffin blocked specimens of pituitary adenoma were stained with hormone markers of TSH, PRL, FSH, LH, GH and ACTH by immunoperoxidase method. Clinical presentations of patients were collected from hospital records and then were compared with histological type of adenoma. Age range of the patients was 10-67 years(mean=39.25) with female to male ratio of 10 to 7. 26.5% of pituitary adenomas were nonfunctional, 14.7% GH secreting, 0.8% PRL secreting, 4.9% ACTH producing, 2% TSH secreting and 48.1% plurihormonal. The relationship between acidophilic adenoma and GH and PRL secretion was significant. Also, there was a significant association between basophilic adenoma and ACTH secretion and chromophobe adenoma and GH and PRL secretion(P<0.05). No significant association was seen between other adenomas and secretions. On the whole, because of no significant association between most of hormonal secretions and morphologic type of pituitary adenomas in hematoxilin eosin staining, immunohistochemical staining seems to be necessary for definite diagnosis and appropriate treatment of pituitary adenomas.

The role of Nitric oxide in myometrial function is known and Nitric oxide donors are used for prevention of preterm delivery during recent years. This research was conducted as RCT during 14 months in Shahid Akbar Abadi Hospital. 150 pregnant women with live and singletone pregnancies in the 34-37th week of gestation and with preterm uterine contractions were randomly divided into two groups: case(isosorbide dinitrate) and control(no medication) group. Age, gestational age, parity, cervical dilatation and effacement were the same in both groups. Based on the obtained results it was found out that isosorbide dinitrate(ISD) was effective for prevention of preterm delivery at least for 48 hours(P<0.0001). ISD had no adverse effect on 1 and 5 minute Apgar score. The mean time from initiation of ISD to suppression of uterine contractions was 3.291±1 hours. Side effects of ISD were hypotension(7.4%), headache(4.9%) and tachycardia(2.5%). On the basis of these findings, it can be concluded that ISD is a good choice for prevention of preterm delivery because of its low cost and side effects as well as its easy usage.

The aim of this study was to identify risk factors of intrauterine fetal death. A retrospective analysis was conducted on 1288 stillbirth as case and 3888 live birth as control subjects, from first of March 1997 to the end of February 2001. Intrauterine fetal death was defined by an estimated gestational age more than 20 weeks, or fetal weight more than 500gm. The goal of the present was to find out the risk factors for intrauterine fetal death. All women who had stillbirths, as described herein, were identified through the medical records and the records were census selection for each case. Three records were simple randomly extracted for control group. Data were obtained from medical records and the collection took three months. Uncompleted records were excluded. Adjusted odds ratios and 95% confidence interval for each qualitative variable related to intrauterine fetal death were significant. Logistic regression analysis showed that among variables which were different between two groups the following variables were associated with intrauterine fetal death. The variables were: parity (p=0.024), abortion (p=0.012), low birth weight (p=0.0001), dystocia (p=0.041), glucosuria (p=0.002), proteinuria (p=0.016), congenital abnormalities(p=0.0001), fetal distress (p=0.003), hydraminious (p=0.003), true cord node (p=0.002), cord prolaps (p=0.002) and abnormal cord coiling around the neck (p=0.016). Intensive antenatal care and increased monitoring for women with history of stillbirth and other problems are the most important steps for decreasing intrauterine fetal death. Early diagnosis and prompt deliveries for women with forthcoming problems might be helpful in reducing the number of intrauterine fetal death. Prenatal care givers should also be made aware of such problems for taking actions in emergency cases.

Firefighters and fire victims are exposed to different particles of fire smoke and high temperature of the fire. In order to evaluate pulmonary complaints and function test, 120 firefighters were randomly chosen from different stations and were studied by questionnaire and spirometry. They were then compared with medical college personnels who were not significantly different from them in terms of age, high risk exposure and smoking. SPSS software, T-test, chi-squared test and ANOVA were used for data analysis. There was a significant difference in pulmonary complaints such as cough, sputum, wheezing and dyspnea between firefighters and the control group but FEV-1 and FEV-1/FVC were higher in firefighters. However, no significant difference in FVC and the size of beta angle was detected. Although fire fighters had more symptoms, their pulmonary function test in FEV-1 and FEV-1/FVC was better than that of the control group.

An inadvertently retrobulbar and lid injection was performed by the mixure of lidocaine and formalin(instead of bupivacaine) for a 75-year-old lady who was under cataract surgery. Subsequently, the patient developed lid contracture, exposure keratopathy, central retinal and ophthalmic arteries occlusion, and occular ischemic syndrome. To the best of our knowledge, this is the first report of inadvertent simultaneous retrobulbar and lid injection of formalin. This report consists of a brief review of formalin toxicity and clinical findings of retrobulbar and lid toxicity of that.

Listeria monocytogenes, a gram-positive bacillus growing in 4˚c, is a ubiquitous pathogen with food-borne transmission, mostly. Listeriosis is an uncommon disease in a healthy immunocompetent individual, whereas two thirds of listeriosis cases have occurred in immunocompromised persons in whom it causes high mortality rate. The rest of listeriasis cases (1/3) have been seen in pregnant women in whom it causes high fatality rate due to abortion, full-term stillbirth or neonatal infections. Although listeriosis is increasingly recognized as a cause of life-threatening disease, there are certain countries (particularly Asian countries) that have reported only a few cases or have failed to report even a single case. Because of the absence of a perfect study or even a few reported cases of listeriosis in Iran, it was decided to report two cases of perinatal and nonperinatal infections with listeria monocytogenes. The first patient was a 63-year-old woman with diabetes mellitus. She was a known case of idiopathic myelofibrosis from 10 years ago who was hospitalized because of fever and chill. At first she was diagnosed with myocardial infarction, due to elevation of cardiac enzymes(CPK, CPK-MB, Troponin T) and ST segment depression in EKG, but finally, on the 4th day of admission, the patient became lethargic and had respiratory distress, pulmonary edema, loss of conciousness and blood pressure depression. On the 5th day, she expired because of respiratory and cardiac arrest. The blood cultures of her were positive for listeria monocytogenes for two times. The second patient was a 30-year-old woman at the 20th week of gestation. She was a known case of systemic lupus erythematosus(SLE), under treatment of corticosteroid, who was admitted for fever. After two days, doctors terminated the pregnancy for her because of fetal heart rate decrease. Then, the fever was reduced and finally the patient was discharged from hospital with good condition. Listeria monocytogenes was isolated three times from patient’s blood cultures.

Urological complications after kidney transplantation(Tx) have been reported by many transplant centers. Most of surgical teams have planned for ureteral stent to prevent these urological complications especially urinary tract obstruction. In this report we present a 40-year-old woman who received a kidney allograft from a living unrelated donor(LURD) in May 1999. Because of disused small bladder, indication for ureteral stent was proved. Renal Tx was done without any intra-operative complications, such as hypertension or abnormal bleeding, but urinary output decreased from 8500 ml/24 hrs on the first post-operative day to 300 ml/24 hrs and patient remained oligotenuric for two months. After 3 months the patient referred with maintenance hemodialysis(HD) and then ureteral stent was decided to be removed under local anesthesia which surprisingly led to brisk dialysis. Renal function test declined and patient was discharged with good functioning graft and remained normal after 3-year follow-up. We conclude that ureteral obstruction due to ureteral stent malposition must be considered as a differential diagnosis of renal allograft dysfunction.

reast cancer is the most frequent cancer among women. Approximately one third of all cancers in women is breast cancer which has a high mortality rate and is second only to lung cancer in cancer related deaths in women. Unfortunately, during the past 50 years, the prevalence of breast cancer has been raised probably due to life style changes. Recently, the prevalence of this cancer in different areas of world ranges between 8 to 23 in every one hundred women. The prevalence in Iran has not been established yet, but some unpublished data from three academic centers related to Mashhad University have indicated that the prevalence of breast cancer raised in women during reproductive age is different and has not been clearly identified. In addition, the risk factors in different countries are not the same and our country has its specific risk factors that should be identified. The main aim of this research was the assessment of certain breast cancer riskfactors during reproductive age. This research was a descriptive-analytic and multi-variant study with two groups of case and control. The total number of participants in this research was 350 persons; 170 of them were in case and 180 in control group. Interview forms were used for the assessment of the problem. Results indicated that variables such as age, race(heredity), geographiclocationof residence, occupation and its duration, history of marriage, the age at first pregnancy, mensturac regularity, nulliparity, history of preterm labor, history of infertility, medical and surgical history, cigarette smoke exposure and x-ray exposure are some significant risk factors associated with breast cancer among premenopausal women living in Mashhad.

This study was conducted to investigate the role of cell immunity in adults suffering from chronic sinusitis who referred to Rasoul-e-Akram Hospital for endoscopic sinus surgery. CD3, CD4, CD8 & CD4/CD8 ratio in sinus mucosa of serum IgE level were all measured in the patients. The three studied groups were: chronic sinusitis with high serum IgE(28 cases), chronic sinusitis with normal range serum IgE(45 cases) and a control group with no sinusitis and normal serum IgE(10 cases). It was found out that chronic sinusitis occurred more often in persons with high serum IgE than normal range serum IgE(P=0.012). Females with serum IgE more than 100IU/ml, had a higher risk for chronic sinusitis compared to males(P=0.05, OR=2.8). CD3, CD4, CD8 counts and CD4/C 8 ratio had no correlation with age and serum IgE. CD4 to CD8 ratio in different anatomical regions of mucosa showed that CD4/CD8 in nasal cavity was greater than ethmoid sinus(2.6vs 1.9) and it was greater in ethmoid sinus than in maxillary sinus(1.9vs 0.9). Also, more CD8 lymphocytes were seen in maxillary sinus mucosa than ethmoid sinus mucosa and nasal cavity, but statistically there were no significant differences between these anatomical regions. CD3 cells in nasal cavity and CD4 cells in ethmoid sinus were greater than other regions. Number of CD4 cells were significantlyhigher in patients with nasal polyp than in others(P=0.002). Due to several affecting factors in cellular immunity in sinus mucosa, it is necessary to perform more detailed studies in this regard.

Gallstone is one of the most common diseases in the human society. Risk factors for stone formation are age, race, female sex, underlying disease, obesity and smoking. Some studies have mentioned probable relationship between gallstones and diabetes. Because of the high prevalence of diabetes in our country, it was decided to assess the relationship between gallstone formation and diabetes mellitus. This analytic cross-sectional study was carried out on all of the hospitalized patients in Kashan in 1993 who had undergone a gall bladder ultrasonography. The cases were those patients whose sonography showed the gallstone(63 patients), and those who did not have any stones, were categorized in the control group(501 patients). In all of the patients age, sex, gallstone, diabetes history and the duration of diabetes(if any), were assessed. Data analysis was performed by SPSS 10.05 software, using Chi-squared test, t-test and the correlation coefficients. The mean age in the case group was 61.98(58-65.97) and in the control group 51.59(49.64-53.50) years old(P<0.001). Of 564 patients, 4.9% had diabetes out of whom 22%(14 patients) were in the case and 7%(39 patients) were in the control group. In 63 patients(11.2%), gallstone was diagnosed with sonography. Sex ratio and duration of having diabetes was the same in both case and control groups. There was a significant relationship between diabetes and gallstone(P<0.001, r=0.156). In this study and other similar ones, diabetes was an effective factor in forming gallstones. Matching for sex, duration of diabetes, age, BMI, LDL, HDL and family history all showed this relationship as well. Although there is a difference in the ratio of patients with gallstones and diabetes in various studies, there is an evidence of relationship between diabetes and gallstone in all of them. The probable mechanisms of stone formation in diabetic patients are: diabetic neuropathy, gall bladder motility defect and the increasing volume of gall bladder in diabetic patients.

The objective of the present study was to evaluate the effective factors in irregular prenatal care. A cross-sectional study was performed on 800 healthy pregnant women who had prenatal care in our prenatal clinic and were in last month of their pregnancy. 400 women had regular prenatal care(at least 8 times visits according to health care records) and 400 women did not have regular prenatal visits. Age, occupation, number of pregnancies, race(Iranian or non Iranian), income level, place of residence(city or village), unwanted pregnancy and the level of education were recorded and compared in two groups. The two groups had statistically significant difference in terms of age(P<0.001), number of pregnancies(P<0.001), race(P<0.002), income level(P<0.005), place of residence(P<0.002), unwanted pregnancy(P<0.005) and education level(P<0.001). However, there was no significant difference between two groups in terms of occupation. Older age, more previous pregnancies, unwanted pregnancies, low education, low income and living in villages have essential importance in irregular and late prenatal care and render these groups as high risk in their pregnancies.

Increasing evidence suggests that oxidative stress plays a major role in the pathogenesis of diabetes mellitus and the development of its chronic complications. The aims of this study were to investigate the susceptibility of erythrocyte lipids to oxidation and to evaluate antioxidant status in type 1 diabetic patients. Thirty-five young type 1 diabetic patients and 28 age and sex-matched healthy subjects were enrolled in the study. The susceptibility of erythrocytes to oxidation and the released malondialdehyde(MDA), erythrocyte glutathione level(GSH), erythrocyte glutathione peroxidase activity(GSH-Px) and total plasma antioxidants(FRAP) were measured and then compared in both diabetic patients and normal subjects. Results showed that FRAP and erythrocyte GSH content was significantly lower in diabetic patients than in control subjects. The activity of GSH-Px did not differ significantly from values obtained in healthy subjects. Susceptibility of erythrocyte lipids, MDA level, and MDA maximal release were significantly elevated in diabetic patients. The level of MDA was positively correlated with the age of subjects and also with FBS and HbA1c but negatively correlated with FRAP. The erythrocytes GSH content was positively correlated with duration of diabetes and negatively with FBS and HbA1c. FRAP was also negatively correlated with FBS and HbA1c. There was not any significant correlation between measured parameters and cholesterol, triglyceride and creatinine. Thus, it seems that diabetic patients undergo an important oxidative stress, which is related to glycemic control and they are more susceptible to oxidants probably because of disturbed antioxidant status.

The objective of the present study was to investigate the effect of calcium supplementation on prevention of pregnancy induced hypertension. A randomized clinical trial of calcium supplementation in pregnancy versus no Ca supplementation was performed on 400 primigravida with 20 completed weeks of pregnancy. 200 patients(Ca supplementation) and 200 patients(without Ca supplementation) were similar in age, weight, economic and occupational situation. In Ca supplementation group calcium gluconate was prescribed 2gr daily from 20th completed week of pregnancy. All the patients were followed monthly until 28th week of pregnancy and after that every 2 weeks until 36th week of pregnancy, then weekly until delivery and 24 hours after delivery. The rates of pregnancy induced hypertension(PIH), preterm delivery and cesarean section were evaluated. Two patients from control group and 6 patients from calcium supplementation group who did not have delivery in our hospital were excluded from the study. Of 198 patients in control group 10 cases(5.05%) and of 194 patients in calcium group, 4 patients(2.06%) had PIH which was a statistically significant difference(P<0.01). Preterm delivery and cesarean section did not have statistically significant difference in two groups. To conclude, Ca supplementation can reduce pregnancy induced hypertension and may prevent this dangerous complication of pregnancy.

Poisoning is one of the major causes of morbidity and mortality in most countries. One of the most prevalent causes of poisoning is drug. Children with 1-5 years of age, youth with 12-30 and elderlies beyond 50 years are the most frequent age groups in poisoning. The aim of this study was to evaluate drug poisoning in Boo-Ali and Nimeh-Shaban Hospitals, which are poisoning centers in Sari. Existing data method was used to investigate the problems of drug poisoning in Sari. A total number of 194 acute drug poisoning cases in these hospitals were studied from 19th March 2000 to 20th March 2002. Results indicated that 65% of poisoned persons were adults and 35% were children. BDZ and TCA were the most prevalent drugs that induced poisoning to 25.5%. Non-drug poisoning was 28.4 % of total cases (e.g. opioids, hydrocarbons, chemical materials and so on). Data was compared in terms of sex, age of poisoned patients, type and agent of poisoning. This comparison indicated that the number of drug poisoning in females was generally greater than that of males,which was with the goal of committing suicide. Family quarrels, spiritual tensions, marriage troubles, unemployment, corruption, addiction of parents and lack of knowledge were the main problems causing intentional poisoning. Poisoning in children indicated lack of parental supervision. Public education, necessary prescription, hard or uneasy accessibility to drugs, suitable price and increase in knowledge concerning their side effects and replacement of drugs with high side effects with low ones have important roles in preventing accidental poisoning, specially in children. Changing prescription patterns with a shift from higher toxic tricyclic antidepressants to less toxic selective serotonin reuptake inhibitors is also recommended.

The goal of this research was to investigate whether at appendectomy for uncomplicated appendicitis (neither gangrenous nor perforated), the coverage of anaerobes with metronidazole for prophylaxis of infectious comlications of appendectomy has any additional benefit. Appendicitis is the most frequent cause of acute abdomen that requires surgery. The two complications of appendectomy are wound infection and intra abdominal abcess which are, however, uncommon after uncomplicated appendicitis, (about 5% and 1% respectively) but important from epidemiologic aspect due to high number of performed appendectomies. Prophylaxis with antibiotics against gr+ and gr– and anaerobes is suggested for prevention of these two complications which includes cefazolin plus metronidazole or cefoxitin. However, the current problem is that metronidazole is relatively expensive and is not easily found and cefoxitin and cefotetan are not accessible in Iran. Therefore, none of these regimens is appropriate, accessible and inexpensive for wound infection prophylaxis and they are specially impractical in emergency situations. It is known that colonic anaerobes can almost never induce infection without companionship with aerobes thus, theoretically it is expected that if antibiotics are just given against aerobes, anaerobes need not to be covered (for prophylaxis not for established infection). This randomized clinical trial study was carried out on patients at Rasoul-e-Akram Hospital who were operated on with diagnosis of simple appendicitis in 2003. The patients were divided into two groups: a group who received anti-anaerobe antibiotic (cefazolin plus metronidazole) compared with another group who did not receive anti anaerobe antibiotic (only cefazolin). Overally, 100 patients with pathologically established simple appendicitis were evaluated (each group had 50 patients). At each group one patient had wound infection (overall 2%) and intra abdominal abcess was not seen in any of the patients. Mean age, weight and operation time was not statistically different in two groups. Therefore, considering that no additional advantage was seen with metronidazole in this study, it seems that coverage of anaerobes for prophylaxis of infectious morbidity in simple appendicitis is not necessary. On the other hand, percentage of wound infection with cefazolin was 2% in this study that approximates the reported percentages with other standard antibiotics (1.9% in a study with cefotetan). Thus, it seems that cefazolin alone is an appropriate antibiotic for prophylaxis of infectious morbidity at simple appendicitis. However, since sample size and percentage of observed complications are low, definitive conclusion needs other studies with higher sample sizes.

Diarrheal diseases are the most common health problems in developing countries and have an important role in malnutrition of children. Zinc deficiency is usually present in patients with failure to thrive and diarrhea. The aim of this study was to evaluate the effect of a 14-day course of supplemental zinc administration in children with acute watery diarrhea and failure to thrive. This study was performed on 71 children, aged 12 to 36 months, with acute watery diarrhea and failure to thrive of two outpatient pediatric clinics of Kashan. Patients were enrolled into two groups (zinc group and control group). Duration of diarrhea and the average of diarrheal episodes were recorded. Data were analyzed by the use of Chi-squared test, odds ratio and unpaired t-test. Using t-test, this study showed that the average of diarrheal episodes was significantly lower in the zinc group (4.93 1.21vs. 8.61 1.92 respectively). Diarrhea more than seven days was not significantly lower in the zinc group (odds ratio= 0.617 and 95% CI=0.18-2.08) however, diarrhea more than fourteen days was significantly lower in the zinc group (Chi-square=4.512 and P value=0.034).

Squamous Cell Carcinoma(SCC) is a rare disease. The main cause of SCC is a genetic deficiency in repairing DNA that has been damaged by ultraviolet(UV) radiation. Xeroderma pigmentosum is one of the diseases that occurs with genetic deficiency in children. The patient of the present study was a five-year-old girl who faced with brown ulcerated mass between her two eyebrows at the age of four. Xeroderma pigmentosum was diagnosed by biopsy when she was 6 months old. The ulcerated mass was SCC. Patients’ skin disorder was diagnosed to be xeroderma pigmentosum which is a genetic disease. Although the patient was five years old, she did not have appropriate weight and stature.

Despite advances in antiviral therapy over the past two decades, herpes simplex encephalitis(HSE) is still a serious illness with significant risks of morbidity and mortality. Mortality rate in untreated and treated patients is 70% and 19% respectively and more than 50% of survivors are left with moderate or severe neurologic deficits. However, with the advent of very sensitive noninvasive diagnostic methodologies, a subset of patients with a milder atypical presentation has been recognized. In this cross-sectional study, the frequency of HSE was described by PCR method in CSF of 71 children with meningoencephalitis who were admitted to pediatric ward of Rasoul-e-Akram and Mofid hospitals. The patients were selected by simple sampling. The most frequent findings on physical examination were fever and mental status abnormalities and meningismus was uncommon. The age of the studied patients with ME was 4.83±3.5(Range 1-15y) and male to female ratio was 42/29. HSV-PCR were positive in 5.6% and negative in 93% of patients. PCR is a fast and relatively simple in vitro method used to detect very few numbers of viruses in clinical specimens by means of a biochemical process that replicates minute quantities of viral DNA until detection is possible. No pathognomonic clinical findings were associated with HSE. Empiric treatment of patients with suspected HSE is recommended until a firm diagnosis is confirmed, since acyclovir is a relatively nontoxic drug and the prognosis for untreated HSE is so poor.

This cross-sectional study was carried out on 23 patients who underwent total hip arthroplasty(THA) following unsuccessful treatment of femoral neck fracture. The goal of the present study was to determine the results of THA as a therapeutic choice for patients with failed treatment of femoral neck fracture and to compare the results of THA in two groups of treated patients with two different techniques: internal fixation of fracture and hemiarthroplasty(HA). Therefore, patients were divided into two groups depending on the treatment they had originally received: those treated by hemiarthroplasty and those who were treated by internal fixation of fracture(IF). In both groups the pain and disability were compared before and after the operation and the results were compared across the two groups. The obtained results showed that pain and disability were remarkably reduced and Harris Hip Score(HHS) remarkably improved, especially in the second group(P<0.05). Complications like bleeding during the operation or dislocation after the operation were more numerous in group 2, but on the whole their incidence was at an acceptable level. It is believed that THA can be a suitable option in managing the patients in whom the treatment of the femoral neck fracture is failed.