مجله علوم پزشکی رازی
سال هفدهم شماره 6 (پیاپی 75، شهریور 1389)

Studies showed that Verapamil as a calcium channel blocker, potentiates the analgesic effects of local anesthesia; however there is controversy regarding the dosage of Verapamil in this regard. In this study, we evaluated the effect of two doses of Verapamil (5 and 10 mg) in combination with Lidocaine, on quality of local axillary blockage in comparison with placebo. The present study was a double blind placebo –controlled clinical trial. Ninety two patients candidate for upper limb orthopedic and plastic surgery with axillary block were enrolled and divided in three groups randomly. In group A, the patients received only lidocaine 1.5%; in group B, the patients received Verapamil 5 mg plus lidocaine 1.5%; and in group C, the patients received Verapamil 10 mg plus lidocaine 1.5%. Time of onset and duration of analgesia, sympathetic, sensory and motor blocks as well as hemodynamic changes (heart rate, blood pressure and mean arterial pressure) before, during and after surgery were evaluated and compared in the three groups. SPSS V.13, Chi2 and One way ANOVA tests were used for data analysis. P= 0.05 was considered as statistically significant. Systolic, diastolic and mid arterial blood pressures significantly decreased during 15-60 min in both groups receiving Verapamil (5 and 10 mg); after which the blood pressure remained similar in the three groups. Mean onset of sympathetic, sensory and motor block was shorter in patients who received Verapamil (5 and 10 mg) than those who received Lidocaine alone (p<0.001). There was no difference in regard to the onset of sympathetic block in the groups receiving Verapamil (p=0.18). Meanwhile duration of motor and sensory block in Verapamil groups was greater than Lidocaine group. Patients who received Verapamil experienced less post-operative (6 hours) pain than those in placebo group, which was statistically significant. Our finding showed that Verapamil 10 mg could amplify quality of axillary blockage (prolonged duration of analgesia, sensory and motor block and reduced post operation pain) without significant changes in hemodynamic situations in comparison with patient who received Verapamil 5 mg.

Post operative pain is one of the most common complains in surgery wards especially in orthopedics surgery. Analgesic methods vary and include intravenous, regional (by peripheral nerve block) and epidural. In this study, we evaluated two methods of Patient Controlled Anesthesia (PCA) i.e.intravenously (Patient Controlled Intravenous Analgesia-PCIA) with Morphine 0.2% and regional by peripheral femoral nerve block (Patient Controlled Regional Analgesia-PCRA) with Bupivacaine 0.1%, to reduce post-operative pain after Anterior Cruciate Ligamentum (ACL) repair. The study was a randomized clinical trial. Seventy patients candidates of ACL repair surgery were re-enrolled and assigned in two PCIA and PCRA groups, randomly. In PCIA group the patients received Morphine 0.2% and in PCRA group, after femoral nerve block in recovery and insertion of the catheter, the PCRA pump was filled with Bupivacaine 0.1%. Visual analogue scale for pain severity was measured and recorded 1, 8, 16, 24, 32 and 40 hours post-operatively. Statistical analysis was performed by Chi square, t-test, and analysis of variance. SPSS V.13 was used for data analysis. Demographic data was the same in both groups. Although the pain score was less than 3 during all follow-ups in both groups, pain score in PCRA in the first hour postoperative time was less than that in the PCIA. However, the pain severity at other times (8, 16, 24, 32, 40 hours after the surgery) in PCIA group was significantly less than that in PCRA group. No side effects were observed in the patients. Our finding showed that postoperative pain was favorably reduced in both PCIA and PCRA groups after ACL repair; however pain relief was better in PCIA than PCRA group.

Job related Low Back Pain (LBP) is considered as the most common disabling musculoskeletal complaint that can lead to compensation claims by workers. Although physical injuries at work place have been known as a reason for LBP, other factors such as a low pain threshold may contribute to the chronicity of LBP. This study aimed to determine the frequency of Fibromyalgia Syndrome (FMS) in workers with chronic LBP in a large industrial community and evaluate whether those with chronic LBPhad a lower pain threshold compared to other workers. This cross-sectional study was performed in a large steel manufacturing plant between Sep. 2005 and Jan. 2006. Workers suffering from LBP most of the time for the past 3 months, with a severity index of ≥3 in numerical rating scale were recruited. Those with a history of taking corticosteroids, malignancy, severe kyphoscoliosis, inflammatory spinal diseases, or describing the maximum painful area above T12 were excluded. Workers without LBP presented for the routine annual examinations were selected as control group. Eighteen tender points were assessed by dolorimetry in case and control groups to determine the total myalgic score and the frequency of FMS according to American College of Rheumatology (ACR) classification criteria (1990). Descriptive statistics were used for expressing the data and Student t-test and chi-square were applied for comparing the variables, whenever appropriate. SPSS V.11.5 was used for data analysis. Forty-five out of 150 workers with LBP met the study inclusion criteria and were enrolled into the study. Seventy-two workers were enrolled as control group. The mean (±SD) total myalgic scores were 1.4±0.5 and 1.2±0.2 in case and control groups, respectively (p=0.002). Four of the participants fulfilled the ACR 1990 criteria for FMS; all in the case group. Lower pain threshold and higher prevalence of FMS in case group suggest that an overall susceptibility to pain may be a factor to chronicity of job related LBP. Clarification of this hypothesis would be important for further understanding of the pathophysiology of job related LBP. Subsequent studies are required to validate our findings.

Despite the progression in diagnosis and medical treatment of Congestive Heart Failure (CHF), readmission rate and complications of this disease are yet high. Accomplished studies on applying native caring models are rare. So, for controlling this disease, using "caring models" should be considered as a necessity. The goal of this study is to investigate the effectiveness of applying “making sensitivity to re-admission” caring model in controlling CHF complications. This is a quasi-experimental research which was done on 120 patients (62 patients as intervention and 58 as control groups) during 90 days in two cardiovascular specialized hospitals in Tehran. Data gathering tools were two questionnaires; a questionnaire considering demographic, readmission rate, blood indices, and body mass indices and Lawton Activity of Daily Living scale (LADL) which were completed before and after the intervention in both groups. Data were analyzed with SPSS V.17, Independent t, Mann-Whitney, and repeated measure ANOVA tests. The results showed that the means of re-admission rates in intervention and control groups have changed from before intervention (2.58 and 2.59) to (0.33 and 2.62) after intervention, respectively. Body mass indices have also changed in intervention and control groups before intervention from (28.72 and 28.39) to (26.55 and 29.46) after intervention. The means of Lawton ADL scales have also changed in intervention and control groups before intervention from(2.9 and 3) to (4.13 and 2.3)after intervention in men and from (before intervention 4.89 and 5) to (6.52 and 4.3 after intervention) in women, respectively. The results of statistical test like Independent t test and Man Whitney U test showed a significant difference in re-admission rates, body mass indices and blood indices (Na, K, and creatinine) between two groups(p≤ 0.001). On the other hand, the results of repeated measure ANOVAtests showed that there are significant differences in ADL means between two groups, and it is increased in intervention group. Applying “making sensitivity to re-admission” caring model has had positive effects on controlling CHF complications (re-admission rate, body mass index, blood indices and ADL of the patients). It means that using this model has made participants sensitive to re-admission (as a problem) and has controlled the complications. Thus considering the burden of CHF disease, expenditures of treatment and health promotion of the afflicted persons using this native model (because of its efficacy in controlling the complications of CHF) is recommended.

Fecal incontinence after repair of imperfoate anus is one of the major complications of the anorectoplasty surgery in children. Mental and emotinal distress of fecal incontinence can be problematic and therefore appropriate surgical management is essential. Rectal mislocation is a common cause of fecal incotinence after anorctoplasty in patients with imperfoate anus. Complete mislocation of the rectum is a term used when the rectum is totally displaced from the anal sphincter and partial mislocation is refered mostly to the partial defect of the anal sphincter. Surgical treatment of complete and partial mislocation of the anorectum may lead to fecal continence. The aim of this research was to evaluate the cause of the fecal incontinency and the therapeutic outcome of it in patients operated for imperforate anus and mislocation of the anorectum after anorectoplasey. The study was of descriptive and retrospective type. Eleven patients(7 boys, 4 girls) with mean age of 4.5 years who had fecal incontinence after anorectoplasty were evaluated. The diagnosis of fecal incontinence was based on EMG, MRI, and endoanal sonograply. The author used muscle stimulator under general anesthesia as a final assessment for drawing sphincter mapping to identify the location ofthe defect of anal sphincter. Two patients had complete mislocotion and 9 had partial mislocation of the sphincter muscle. Four patients had surgical repair without colostomy and 7 underwent repair together with colostomy. In 2 patients with complete mislocation, fecal incontinence was treated with anorectum relocation. Nine patients who had sphincter muscle defect (partial mislocation) underwent sphincter repair. Out of 11 patients, nine had adequate control of their bowel movenment (were continent). Meanwhile two patients (6 and 11 years old) had occasional(2 to 3 times/week)involuntary gas passing (for 8 and 48 months after operation, respectively) which was treated medically with Dimethicone. Biofeedback therapy was also taught to enhance anal-sphincter muscle function. All patients had goodsocial inteaction and and their behavior showed a high level of self confidence. Most of sphincter defects occur at 6 and 12 oclock in lithotomy position. So pediatric surgeons have to operate carefully an anal sphincter repair during anorectoplasty procedure.

Allergic rhinitis (AR), the most prevalent allergic disease, has a rising trend in the world and has significantly impaired the quality of life of the patients. Aeroallergens are the major cause of allergic rhinitis and among them pollens are the main allergens responsible for allergic rhinitis in Iran.There is a little information about the role of different pollens in allergic rhinitis, in our country.Therefore, this study was conducted to determine the prevalence of allergy to autumn pollens in allergic rhinitis patients. In this retrospective cross-sectional study, the medical records of 245 allergic rhinitis patients referred to Immunology-allergy clinic of Hazrat Rasool-e-Akram Hospital in Tehran during 2005- 06 were assessed. Required information about allergic rhinitis sign and symptoms, laboratory data (total serum Ig E level and eosinophilia in nose smear) and Skin Prick Test (SPT) results for autumn pollens were obtained from the medical records of each patient. Finally, data were analyzed using SPSS V.14 software and Chi2 and Mann-Whitney U tests were performed in analysis. Out of 245 allergic rhinitis patients, 238 patients (97.1%) had positive skin prick test for at least one aeroallergen and the prevalence of allergy to autumn pollens (weeds) was 87.3% (214 cases). Among autumn pollens, Lamb’s Quarter caused the most positive skin prick test (74.7%). Moreover, nasal smear eosinophilia was present in 35.9% of patients and the mean of total serum Ig E level was 219.06 IU/mLit. There was no statistical difference in the prevalence of allergy to these pollens betweentwo sexes; whereas, adults had significantly higher rates of allergy to autumn pollens (89.6% versus 73.5%, p=0.009). According to our results, pollens especially autumn pollens, were the main aeroallergens responsible for allergic rhinitis in our area, which is compatible with other studies conducted in similar geographical regions. Considering the high rate of allergy to autumn pollens in our area, in addition to the usage of prophylactic medication in allergic rhinitis patients, advices should be made in regard to avoiding the exposure to this allergen. Also specific immunotherapy could be effective in some cases.

Squamous Cell Carcinoma of the Head and Neck (HNSCC) is a disease of older adults, but recently there have been reports of a rising incidence in young adults. There are several etiological factors for HNSCC. The use of cigarette and alcohol are two main risk factors of tumors of the HNSCC. Chronic anemia which leads to mucosal atrophy may increase the susceptibility to carcinogenesis especially tongue cancer. The purpose of this research is to study the incidence of SCC of head and neckand relationship of this tumor to the risk factors in patients 40 years old or less in comparison to patient over 40 years old. In this retrospective, descriptive study medical files of 262 patients with SCC of the head and neck were studied (a 15 year period -from 1982 to 2007) in Hazrat Rasool-e- Akram hospital in Tehran. Fifteen patients were young and aged less than 40 years old. This study compared sex, tumor site, risk factors, stage and grade of tumor, cervical node involvement and hematologic statues. All data were analyzed using Chi2 and Mann-Whitney tests. SPSS V.15 software was also used. Probability of less than 0.05% was considered as significant. There was significant statically association between site of tumor and age, sex, consumption of cigarette, consumption of alcohol, anemia and cervical node involvement. Larynx was the most common site of involvement in both sexes. Laryngeal involvement was more common in men (92%) and involvement of hypopharynx was more in women (61%). Tongue involvement was the same in both sexes. The most common site of involvement in young patients was larynx (40%) and tongue (40%) andin patients older than 40 years it was larynx (82.5%). In this study 5.8% of patients were 40 years or less, 66.6% had never smoked and 53.3% had not shown any exposure to two major risk factors, alcohol and cigarette. Due to absence of two major risk factors in head and neck SCC of young patients it seems that biology of SCC of the head and neck in young and old adults could be different. Other risk factors may play a role in development of SCC of head and neck in former group.

Beta thalassemia major is a severe hemolytic anemia due to inadequate synthesis of beta chain globin. Splenomegaly secondary to extramedullary hematopoiesis and iron overload is one of the most prominent findings and makes splenectomy inevitable in majority of these patients. For many reasons these patients are at risk of hypercoagulation. Portal vein thrombosis is a rare consequence of splenectomy. We report a 24 year old thalassemic patient that developed portal vein thrombosis following splenectomy.Case Report: A 24 year old man was diagnosed with thalassemia major at 2 years of age. Regular transfusion regimen was initiated at the time of the diagnosis. At this age, patient underwent open splenectomy secondary to hypersplenism with a smooth postoperative recovery. Twelve days later, he developed severe abdominal pain with fever. Portal vein thrombosis was detected by Color Doppler ultrasonography. Therapy with heparin which was replaced by low molecular weight heparin after 4 dayswas begun, and was followed by the addition of warfarin on day 5. The patient was discharged on the 12th day of admission with good condition, and with instructions to continue warfarin and to follow up with a hematologist. Four months later the patient remained well. This case suggests that thalassemia major patients undergoing splenectomy have an increased risk of Portal Vein Thrombosis (PVT). We recommend that PVT should be considered in a patient with abdominal pain and fever after splenectomy. Color Doppler ultrasonography imaging is the best non-invasive study for the diagnosis at onset of presentation. Treatment with anticoagulants is safe and highly recommended.