مجله علوم پزشکی رازی
سال شانزدهم شماره 8 (پیاپی 65، آبان 1388)

Pain due to cancer is one of the major problems of patients affected by malignancies. There are many methods for management of cancer pain and opioid consumption is the most important method. Fentanyl is a synthetic opioid which is represented as a transdermal patch used for chronic cancer pain relief. In this study we evaluated the effectiveness of transdermal fentanyl patch as compared to placebo in cancer pain. Patients and This study was designed and performed as a double blind randomized clinical trial. Patients affected by soft tissue tumors with chronic pain who had referred to Cancer institute of Imam Khomini Hospital during 2006-07 were included and divided randomly into transdermal fentanyl patch and placebo groups. The appearance of the patches in both groups was the same. Pain severity was measured with Visual Analogue Scale(VAS) 24, 48 and 72 hours after the initiation of treatment. Data analysis was done by SPSS V. 13 software.Quantitative data were shown with mean(SD) and qualitative data were presented with frequency. Chi- square and t-tests were used for comparison of the data between the two groups.Repeated measurement analysis of variance was used for evaluating the effect of time and its relation with the medicine. p<0.05 was considerd as statistically significant. A sum of 166 patients affected by cancer were divided in two groups –transderamal group(86 patient) and placebo group(80 patients).There was the same age and sex distribution in both the groups. According to repeated measurement analysis, the pain severity was significantly reduced in the transdermal fentanyl group as compared to the placebo group(p=0.07). The incidence of side effects was observed in 62 patients (72%) in fentanyl patch group and 31 patients (39%) in placebo group emphasizing the fact that the side effects were significantly more in the transdermal fentanyl patch group as compared to the placebo group (p=0.001) The data suggest that transdermal fentanyl patch is an effective and safe method in reducing pain in patients affected by soft tissue tumors.Also it can improve the quality of life in this group of patients.

Excellent results are obtained with high tibial osteotomy in patients suffering from the osteoarthritis of the medial compartment of the knee however, poor results have been reported in 10 to 50 percent of the cases. The aim of this study was to evaluate the probable factors influencing the outcome of high tibial osteotomy to let us select the proper cases for this surgery. Patients and In this retrospective case – control study,57 high tibial osteotomies were performed by the open wedge method in 43 patients (16 males and 27 females, mean age = 54.5±7.8 years) between 2005 and 2007 as the treatment of medial compartment osteoarthritis of the knee. Mean follow-up time was 25±5 months. Factors including age, sex, previous lower limb surgery, history of long-term pain of the knee, obesity, smoking, widening of the medial compartment, tibial exophyte, complete tibial chondral destruction, medial meniscus damage, varus angle of more than 10 degrees, severe instability of the medial collateral ligament, and concurrent lateral compartment osteoarthritis were assessed and recorded before and after the surgery. Comparison between pre-operative and post-operative situations were performed using statistical analysis by scores obtained from KOOS in patients with or without the said factors. Data analysis was done using One-way ANOVA, independent samples t-test, and Mann-Whitney U-test.The difference between outcomes (with KOOS score) due to probable predicting factors was evaluated in patients with high tibial osteotomies. Eight complications were seen due to the surgery in one case reoperation was needed and one case underwent total knee replacement due to sustained severe pain. Mean angle of correction was 8.8±3.4 degree and mean time for healing of the osteotomy was 3.1±1.4 months. History of knee pain of more than 2 years and concurrent lateral compartment osteoarthritis were present along with many other factors in patients with poor results. Choosing high tibial osteotomy as a method of treatment for osteoarthritis in cases which are predicted to have poor results, is only a costly decision and a delay in the correct therapeutic procedure. In this study we identified several factors that would influence the outcome.In this way, it could be used to screen patients and in case poor results are predicted, it would be better to carry out total knee replacement to prevent costly procedures and the burden of several surgeries.

Cancer associated malnutrition and depletion of nutritional reserves can lead to an increased risk of morbidity, reduced response to anticancer therapies and shorter survival in patients with cancer. The aim of this study was to assess the nutritional status of cancer patients during chemotherapy in hospitals affiliated to Iran University of Medical Sciences. In this longitudinal study 71 adult patients with different kinds of malignancies were selected through a stratified sampling method from Hazrat-e-Rasool Akram and Firoozgar hospitals. Nutritional status was evaluated by anthropometric indices (BMI, MAC, AMA, and TSF), biochemical parameters (Albumin, Total Protein), nutritional intake (24hours-Food Recall Questionnaire and 3days-Food Record) and Ottery’s PG-SGA questionnaire at the beginning, middle and end of chemotherapy period. Data were analyzed by Repeated Measure ANOVA, Wilcoxon and Kruskal-Wallis tests of SPSS V.12 software. A nonsignificant increasing trend was observed for the anthropometric and biochemical data and a nonsignificant decreasing trend was observed in macronutrients and energy consumption of 50 patients who successfully finished the treatment duration. Twenty one patients who expired during the treatment period had a significant decreasing trend for BMI and MAC (p=0.01 and p=0.02, respectively).The frequency of malnutrition varied from 0 to 100% according to different indices that used to identify the nutritional status. According to the Ottery’s PG-SGA questionnaire, 80% of the survived cases and 100% of the deceased patients required nutritional intervention. Our results demonstrate that the highest rate of malnutrition prevailed among patients who died during the treatment period had stage IV of the disease, Malignancy with Unknown Origin (MUO), upper GI and/or lung cancers. The frequency of malnutrition depends on stage and kind of malignancy and the methods used to assess the patients. Appropriate and early nutritional assessment is critical after the diagnosis of cancer and during anticancer treatments with the aim of using proper nutritional recommendations/interventions for cancer patients.

Candidial vulvovaginitis (CVV) is a female genital system infection that occurs due to the overgrowth of Candida species,especially with Candida albicans.This condition may become recurrent.The long administration of the current antifungal drugs may cause resistance. Therefore it is essential to understand the efficacy pattern of therapeutic agents against the isolated Candida species from vaginitis. The aim of this research was the investigation of the antifungal drug resistance pattern in Candida species isolated from vaginitis against azole current drugs. This was an experimental-descriptive study that was performed on 150 suspected patients.All specimens were examined under direct microscopy and culturing. Furthermore, complimentary tests such as culture on candida chrom agar, corn meal agar, germ tube test, susceptibility to cycloheximide, temperature test and sugar assimilation test (with API 20 kit) were performed to differentiate the Candida species from each other.The effect of the current azole drugs by micro dilution broth method was also tested. Out of 150 specimens, 80 cases of vaginal candidiasis were diagnosed. In order of frequency the isolated pathogens were Candida albicans, Candida glabrata, Candida parapsilosis, Candida krusei and Candida giullermondi, respectively.From "drug effect" point of view, Imidazoles (Ketoconazole, Clotrimazole, Miconazole) were more effective than Triazoles (Fluconazole). Drug resistance pattern of various Candida species isolated from patients was different.

Febrile convulsion is one of the common problems in children aged between 5 months to 6 years old.While some areas have a prevalence rate of 10%, world prevalence is only 2-4%. Although world wide studies show that the use of anticonvulsive drugs like Phenobarbital may decrease the rate of seizure attacks, but it may be associated with multiple complication such as behavior disorders, learning disability, drowsiness, dizziness and ataxia. Positive family history, severity and frequency of seizure, degree of fever, age of onset of seizure, developmental delay, and abnormal neurological exam are the factors that influence the recurrence of seizure. The goal of this study is the evaluation of the risk factors for recurrence of febrile convulsion, its correct management, prevention of the future attacks and its complication. This is a prospective discretional study. Out of 432 patients aged under 15 yrs that had referred with febrile convulsions to the Neurology clinic of Hazrat-e Ali Asghar Hospital in a period from December 2003- December 2005, 103 children with "recurrent febrile convulsion" were selected on the basis of history, physical examination, clinical and paraclinical findings recorded in a questionnaire especially prepared for the recognition of risk factors for recurrence of febrile convulsion. In this study, 62% were males and 34% (39) were girls.As the tables show, patients under the age of one year made up most of the cases (37 patients, 35%).Meanwhile, 48 patients had temperatures between 38 to 39 ° c at the onset of the seizure and time duration between the fever and oset of seizure in 44% of the cases was more than 1 hour. In 24(23.5%) of cases, the first episode of seizure lasted for 15-20 minutes and in less than 10% of patients the duration of the seizure was less than 5 minutes. Also, 57.5 % of the patients had generalized tonic-clonic seizures and in 68.5% seizure attacks recurred twice.The most frequent causes of fever in this study were upper respiratory tract infections (31.75%) and lower respiratory tract infection (14.5%), respectively. In paraclinical evaluation, 72% of the EEGs, 41% of the MRIs and 34% of the CTscans were abnormal. Forty eight patients (46.5%) had problems such as asphyxia and meconium aspiration at the time of birth, 25% had developmental delay and 42% has abnormal neurological examination. Finally, 37.8% of the children were the result of familial marriage. This study shows that positive family history of febrile seizure, young age, short duration between fever and onset of seizure, abnormal neurological examination, developmental delay, and abnormal EEG can be risk factors in recurrence of febrile convulsion, and it is necessary to consider these factors in children with febrile convulsion.

Urologic infections are common infections, among which pyelonephritis is the most common. Only in United States of America they cause more than 1.1 million patient referral annually. Treatment costs for these infections are about 180 million dollars a year. Although mortality and morbidity caused by theses diseases are high, but the treatment, if done on time, is not hard and could prevent from irreversible complications such as chronic renal failure and scar. The aim of this study was to identify the reasons of delayed referral and underlying risk factors for this delay in children with urinary tract infection, in order to find a solution and decrease the associated complications and cost fees. Patients and This study is a case series study. Our target groups were children with urinary tract infections that had referred to Sina and Bahrami Hospitals. Inclusion criteria included: 1- age between 1-10 years, 2- no functional complications of urinary tract, 3- a positive urine culture. Then questioned variants (age, sex, pathogen, etc) were gathered and later analyzed and the results were reported. To analyze our data we used SPSS V. 11.5. Descriptive data were shown as mean and standard deviation. To compare the data we used Chi2 and t test. p= 0.05 was considered as meaningful. Among our 185 patients with age range of 1 to 10 years (mean age of 5.4 yr), 57% were females and 43% were male. Meanwhile 15.9% of our patients had referred to hospital with symptoms of sepsis and 2.2% with septic shock. Our results did not suggest sex as a risk factor for referral delay. We observed that 2.2% of the children in our study were hospitalized with septic shock. Other results are shown in tables. Generally, the most useful method in preventing referral delays of children to hospitals and care centers are parental and prenatal education, education through mass media and informing them of the complications due to referral delay of a simple infections such as UTI.These methods can easily lessen the number of referral delay among children and thus decrease the complications and hospital costs.

About 13 beta-globin mutations encompass 70-90% of the mutation spectrum in Iran. These mutations are called common beta-globin mutations. The rest are rare or unknown mutations. The objective of this study was to identify the rare or unknown beta-globin mutations in Qazvin province. In this descriptive-analytic study, EDTA-containing venous blood samples were collected from 100 patients with transfusion-dependent beta-thalassemia referring to Qods hospital of Qazvin. Age, sex, ethnicity, history and consanguinity between parents were recorded by reviewing the patients files. Screening for causal mutations was carried out on DNA isolated from WBCs of the patients by using ARMS technique. To explore the other mutations in the beta globin gene, direct sequencing analysis was applied for DNA samples when no mutation was detected with ARMS. For data analysis SPSS V. 13.5 was used. Based on the results, 85.9% of alleles were identified by ARMS technique, while direct sequencing uncovered the remaining alleles (14.1%). Total 20 different mutations discovered by this two-step approach (11 mutations with ARMS and 9 mutations with sequencing). Abundant alleles (IVS-II-1, IVS-I-110, FSC8/9) accounted for 59.3 % of the mutations. IVS-II-1 with a frequency of 31.3% was the most common, while nt-30, IVS-I-6, Cd5, IVS-II-745, 5´ UTR, Cd15, Cd39, IVS-I-130, Cd24, Cd74/75, HbS and Hb Monroe mutations were observed with the least frequency (each about 1% or less). Molecular analysis of beta thalassemia has shown that in addition to the common mutations, many rare beta-globin mutations responsible for the disease are present in the Qazvin population.We have revealed the existence of 8 rare mutations from Qazvin, two of which (Cd74/75 and Hb Monroe) are the first reported in Iran.

Although rare, inflammation of the appendiceal stump can occur and is still an important clinical entity. Recently there has been an increase in stump appendicitis.

Case report:

In this study, appendiceal stump was observed in an 18-year-old man who had presented with right lower quadrant abdominal pain and had history of appendicectomy 7 months earlier. Recurrent appendicitis was noted in the appendiceal stump.

Stump appendicitis should be considered by the surgeon when presented with a patient with acute abdominal pain and a past history of appendectomy.