Journal of Research in Medical Sciences
Volume:16 Issue: 3, Mar 2011

• The celebrated generalized estimating equations (GEE) approach is often used in longitudinal data analysis. While this method behaves robustly against misspecification of the working correlation structure, it has some limitations on efficacy of estimators, goodness-of-fit tests and model selection criteria. The quadratic inference functions (QIF) is a new statistical methodology that overcomes these limitations.• We administered the use of QIF and GEE in comparing the superior and inferior Ahmed glaucoma valve (AGV) implantation, while our focus was on the efficiency of estimation and using model selection criteria; we compared the effect of implant location on intraocular pressure (IOP) in refractory glaucoma patients. We modeled the relationship between IOP and implant location, patient's sex and age, best corrected visual acuity, history of cataract surgery, preoperative IOP and months after surgery with assuming unstructured working correlation.• 63 eyes of 63 patients were included in this study; 28 eyes in inferior group and 35 eyes in superior group. The GEE analysis revealed that preoperative IOP has a significant effect on IOP (p = 0.011). However, QIF showed that preoperative IOP, months after surgery and squared months are significantly associated with IOP after surgery (p < 0.05). Overall, estimates from QIF are more efficient than GEE (RE = 1.272).• In the case of unstructured working correlation, the QIF is more efficient than GEE. There were no considerable difference between these locations; our results confirmed previously published works which mentioned it is better that glaucoma patients undergo superior AGV implantation.

This study aimed to determine the short- and long-term effects of consumption of grape and pomegranate juices on markers of endothelial function and inflammation in adolescents with metabolic syndrome (MetS). In a non-pharmacologic randomized controlled trial, 30 individuals were randomly assigned to two groups of drinking natural grape or pomegranate juice for 1 month. Measurements of inflammatory factors [Hs-CRP, sE-selectin, sICAM-1, sVCAM, and interleukin 6 (IL-6)] and flow-mediated dilation (FMD) were made at baseline, 4 hours after first juice consumption and after one month of juice consumption. The percent changes of FMD were significant in both groups in the short- and long-term. Hs-CRP had a non-significant decrease. sE selectin had a significant decrease after 4 hours in total and in the pomegranate juice group, followed by a significant decrease after 1 month in both groups. After 4 hours, sICAM-1 significantly decreased in the pomegranate juice group, and after 1 month it decreased in total and pomegranate juice group. Interleulkin-6 (IL-6) had a significant constant decrease at 4-hour and 1-month measurements after drinking pomegranate juice, and in both groups after 1 month. Significant negative correlations of changes in sICAM-1 and sE-selectin with changes in FMD were found in both periods of follow-up; and at 1 month for IL-6. Decline in inflammation was associated with improvement in FMD without changes in conventional risk factors. Daily consumption of natural antioxidants may improve endothelial function in adolescents with MetS.

To investigate the association between Metabolic syndrome (MetS) and Health related quality of life (QoL) in Iranian population. We used data from the post-intervention phase of Isfahan Healthy Heart Program (IHHP), a community trial for cardiovascular disease (CVD) prevention and control. We recruited 9570 healthy adults, aged ≥ 19 years who were randomly selected using multistage random sampling method. World Health Organization QoL questionnaire (WHOQOL-BREF) which contains 26 items was used to assess QoL. It assesses four domains of QoL; Physical health, Psychological health, Social relationship and Environmental issues. MetS was defined based on ATP III criteria. The mean age of participants was 38.8±15.6 years (mean ± SD) and the prevalence of MetS was 22.5%. From all participant 18.2% were illiterate and 13.2% had university educational level. Two way multivariate analyses of covariance (MANCOVA) test after adjusting age showed significant difference between women with and without Mets in regard to physical health and social relations domains, while none of QoL domains was different in men with Mets in comparison to men without it. After adjusting the role of socio-demographic factors as components of QoL score, no association was observed between QoL domains and MetS in men, while only social relations and physical health scores were higher in women with Mets compared to those without Mets. Other variety of health-related QoL assessment tools or definitions of MetS may show different relationship in the Iranian socio-cultural context.

Ischemic heart disease (IHD) is the main cause of morbidity and mortality worldwide, and a considerable part of these patients attend to emergency departments, which increases the burden to these busy departments. The aim of this study was to develop a prediction model enabling prediction of all cause emergency department (ED) visits in patients with documented coronary stenosis in a derivation set, and then to determine its accuracy in a validation set. In a prospective study at outpatient setting of Baqiyatallah hospital, Tehran, Iran, 502 patients with IHD were followed for 6 months for observing the outcome of ED visits for all causes. They were divided in two random groups of derivation set (n = 335) and validation set (n = 167). In the derivation set, to achieve an all cause ED visits prediction model, a prediction model was reached by entering demographic data, clinical variables, somatic comorbidity (Ifudu index), level of anxiety and depression (Hospital Anxiety Depression Scale (HADS) questionnaire), and angina grade (WHO Rose Angina) to a logistic regression. Then in the validation set, the sensitivity, specificity, and the accuracy of that model was tested. A novel model for prediction of all cause ED visits in IHD patients in six months was presented with gender, anxiety, WHO angina grade and somatic comorbidity as inputs. Sensitivity, specificity, and accuracy of the model were 63.0%, 68.6%, and 67.7%, respectively. Testing and using the achieved model is suggested to health care providers in other settings.

We investigated coronary angiogenesis and serum vascular endothelial growth factor (VEGF) and its soluble receptor-1 (sFlt-1) concentrations in two-kidney one-clip (2K1C) hypertensive rats before and after reversal of hypertension. The animal groups were: (i) sham-clipped for 12 weeks; (ii) 2K1C for 12 weeks; (iii) sham-clipped for 12 weeks and unclipped for 12 weeks; and (iv) 2K1C for 12 weeks and unclipped for 12 weeks. Blood samples were taken before experiments and after clipping and unclipping; capillary density was also evaluated. Our results showed that blood pressure in hypertensive animals was higher than sham group (175 ± 10 vs. 110.3 ± 11.3 mmHg; p < 0.05). Unclipping significantly reduced blood pressure in hypertensive rats (p < 0.05). Serum VEGF and sFlt-1 levels in hypertensive group was significantly lower than sham group (VEGF: 74.36 ± 5.85 vs. 104.07 ± 7.75 pg/ml; sFlt-1: 426.67 ± 25.74 vs. 690.76 ± 41.14 pg/ml, respectively; p < 0.05). Unclipping in hypertensive animals increased serum VEGF and sFlt-1 concentrations (VEGF: 93.65 ± 8.61 vs. 74.36 ± 5.85 pg/ml; sFlt-1: 742.05 ± 79.23 vs. 426.67 ± 25.74 pg/ml, respectively; p < 0.05). In hypertensive animals, capillary density in the heart was higher than sham group, non-significantly (p > 0.05) and after unclipping, it reached to sham group level. It seems that changes in capillary density and serum VEGF and sFlt-1 concentrations in renovascular hypertension are reversible by removing the cause of hypertension and it shows the importance of early diagnosis and treatment of hypertension in clinical condition.

This study aimed to compare the timing of puberty between various geographic locations and different ethnicities. This national survey was conducted in 20 provinces in Iran. Healthy Iranian girls were selected from public schools using cluster random sampling. A total number of 30 clusters including 7493 girls, aged 6.0–20 years, were selected. In order to compare different areas, the national classification of the provinces based on climate, ethnicity, geographic locations, and socioeconomic variables were used. Accordingly, there are 11 regions in Iran. Analysis of variance was used to compare the mean ages of menarche, pubarche, and thelarche in different regions. Tehranian girls, with 11.99 ± 1.35 years (mean ± SD), had the lowest age of menarche which was statistically significantly. The second region with lowest age at menarche was Fars (12.40 ± 1.27 years). The mean age at breast bud stage (B2) was significantly lower in Ghazvin-Zanjan region (8.97 ± 1.45 years). In Fars region, the mean age at B2 stage of breast development (11.01 ± 1.88 years) was higher than other regions except for Mazendran-Guilan and Tehran-related cities. The mean age at public hair development at Tanner stage 2 (PH2) in Kordestan-Lorestan-Ilam region (10.70 ± 1.23 years) was significantly higher than other regions. We found significant differences in the age of pubertal stages of girls living in various regions with different ethnicity and geographic characteristics. Considering the impact of pubertal age on general health, more studies should be done about the lifestyle and environmental factors affecting the onset of puberty.

The most common complication of lumbar puncture (LP) occurring in over thirty percent of patients is headache. The position after lumbar puncture, needle type and size, and volume of the extracted cerebrospinal fluid (CSF) have been evaluated as contributory factors in occurrence of post lumbar puncture headache (PLPH), but the position before lumbar puncture has not been evaluated. The occurrence of post lumbar puncture headache was evaluated in 125 patients undergoing lumbar puncture, divided randomly into sitting and lateral decubitus groups in the following five days. Chi-square test was used for statistical analysis. Thirty eight patients (30.4%) reported headache after lumbar puncture in the two groups, and post lumbar puncture headache was significantly lower in the lateral decubitus position (p = 0.001). There was no significant difference between genders in the post lumbar puncture headache occurrence (p = 0.767). Lumbar puncture in sitting position could produce more post lumbar puncture headache in comparison with lateral decubitus position.

Silymarin derived from silybum marianum (milk thistle), a flowering member of the daisy family, may benefit liver function in people infected with the hepatitis C virus. The aims of this pilot study were to assess the efficacy and safety of silymarin on serum hepatitis C virus (HCV) RNA, serum aminotransferases (ALT, AST) levels, liver fibrosis and well-being in patients with chronic hepatitis C (CHC). This prospective self-controlled trial study was conducted from March to September 2006 at Department of Gastroenterology, Isfahan University of Medical Sciences, Isfahan, Iran. 55 patients with HCV (10 female and 45 male) with a mean age of 31.8 ± 6.4 years (10-67 years) were participated in the study. Patients received 24 weeks of silymarin (630 mg/day). Baseline virological biochemical, liver fibrosis (by a serum fibrosis markers, including YKL–40 and Hyaluronic acid), and SF-36 questionnaire were performed with biochemical tests repeated at the end of the treatment period. There was statistically difference in mean of ALT (108.7 ± 86.6 vs 70.3 ± 57.7) before and after the treatment (p < 0.001). The means of AST were 99.4 ± 139.7 and 59.7 ± 64.32 before and after the treatment with statistically differences (p = 0.004). After the treatment, nine patients were found with negative HCV-RNA (p = 0.004) and statistically significant improvement in results of liver fibrosis markers were found only in fibrosis group (p = 0.015). Quality of life was improved significantly (p < 0.001). This study indicated that in patients with CHC performing silymarin (650 mg/day) for 6 months, improved serum HCV-RNA titer, serum aminotransferases (ALT, AST), hepatic fibrosis and patient’s quality of life. More future studies are warranted.

The peroxisome proliferator-activated receptor-γ (PPAR-γ) is a nuclear hormone receptor. It is predominantly expressed in adipose tissue and as a receptor for thiazolidinediones, it has drawn attentions towards itself as a key molecule to trigger pathways involving in some diseases such as cancers, type 2 diabetes, inflammations and osteoporosis. A proline changed to alanine in codon 12 of PPAR-γ gene (Pro12Ala) has been known to be responsible for decreased risk of type 2 diabetes. The aim of the present study is to investigate the frequency of Pro12Ala polymorphism in PPAR-γ in healthy Iranian population to compare with other populations. Understanding this polymorphism may help us in better diagnosis, prevention, and therapeutic approaches toward a better management of diseases such as type 2 diabetes and osteoporosis. 128 healthy volunteers were enrolled in this study. To determine single nucleotide polymorphisms (SNPs), we did real time polymerase chain reaction (RT-PCR), using TaqMan allelic discrimination assays. Genotype frequencies for PPAR-γ gene Pro12Ala (rs1801282) polymorphism were 0.86 for CC, 0.14 for CG, 0.00 for GG while allelic frequencies were 0.93 and 0.0.07 for C and G, respectively. There are statistical differences between the distribution of the PPAR-γ-2 Pro12Ala polymorphism in other populations and Iranian population.

Phytoestrogens are a group of plants derived compounds with weekly estrogen effect that appear to have protective effects on metabolic and hormonal abnormalities of women with polycystic ovary syndrome (PCOS). So the aim of this study was to investigate the effect of soy phytoestrogens on reproductive hormones and lipid profiles in PCOS women. In this quasi-randomized trial, 146 subjects with PCOS were divided into two groups; the experimental group who received Genistein (Bergamon, Italy) 18 mg twice a day orally and the control group that received similar capsules with cellulose for 3 months. Hormonal features and lipid profiles were measured before and after 3 months of supplement therapy. After 3 months of supplement therapy there were no statistically significant differences in high density lipoprotein cholesterol (HDL) and follicle stimulating hormone (FSH) serum levels in Genistein and placebo group before and after treatment; however serum levels of luteinizing hormone (LH), triglyceride (TG), low density lipoprotein cholesterol (LDL), dehydroepiandrostrone sulfate (DHEAS) and testosterone were significantly decreased after 3 months therapy in Genistein group. Genistein consumption may prevent cardiovascular and metabolic disorders in PCOS patients by improving their reproductive hormonal and lipid profiles.

Chronic hemodialysis patients frequently require vascular access through central venous catheters (CVCs). The most significant complication of these catheters is infection. This risk can be lowered by the use of an antibiotic-Heparin lock. This study focuses on hemodialysis patients using Tunneled-cuffed catheters (TCC), to assess the rate of catheter-related infections (CRI) in catheter-restricted filling with Cefotaxime and Heparin in end stage renal disease patients. A double-blind randomized study was conducted to compare 5000 U/ml Heparin plus10 mg/ml cefotaxime (CE/HS) as catheter-lock solutions, with Heparin (5000 U/ml) alone. A total of 30 patients with end-stage renal disease and different etiologies, were enrolled for chronic hemodialysis with permanent catheters from December 2009 to March 2010. These patients were randomly assigned to two groups of 15 members. Blood samples were collected for culture, sensitivity and colony count, from the catheter lumen and the peripheral vein. CRI was considered as the end point. The rate of CRI was significantly lower in the cefotaxime group versus control group (p < 0.001). No exit site infection was occurred in both groups. Infection-free survival rates at 180 days were 100% for the CE/HS group, and 56% for the HS group. Antibiotic lock therapy using Cefotaxime reduces the risk of CRI in hemodialysis patients.

Local ethical committees in medical sciences in Iran were established in 1999 in order to assess and evaluate the observance of ethical standards throughout the universities and research centers. The purpose of this study is to analyze the situation of local ethical committees in order to develop research ethics guideline. For this cross-sectional study which has been conducted with the support of WHO, 40 local ethical committees in all universities of medical sciences were evaluated by use of determined questionnaires. In this study, 40 universities of medical sciences participated; all of them have established local ethical committees. Each committee has 5 to 11 members and in more than 80% cases, written guidelines for selecting the committee's members are available. The minimum number of members for official session is at least 3 and replacement of absent members, did not take place in more than 85% of the committees. Informed consent in 95% of these local ethical committees is available. In all committees, researches regarding the use of human subjects are under ethical consideration. In half of the local ethical committees, penalties for non-compliance with the regulations are considered. The average number of research project evaluated in last session of these committees was 15.2 and the committees in 50% of cases have provided ethics training specifically for their members. Policymakers should develop a standard guideline for local ethical committees in medical science universities in Iran.

Breast cancer has been considered as a major health problem in females, because of its high incidence in recent years. Due to the role of breast self-examination (BSE) in early diagnosis and prevention of morbidity and mortality rate of breast cancer, promoting student knowledge, capabilities and attitude are required in this regard. This study was conducted to evaluation BSE education in female University students using Health Belief Model. In this semi-experimental study, 243 female students were selected using multi-stage randomized sampling in 2008. The data were collected by validated and reliable questionnaire (43 questions) before intervention and one week after intervention. The intervention program was consisted of one educational session lasting 120 minutes by lecturing and showing a film based on HBM constructs. The obtained data were analyzed by SPSS (version11.5) using statistical paired t-test and ANOVA at the significant level of α = 0.05. 243 female students aged 20.6 ± 2.8 years old were studied. Implementing the educational program resulted in increased knowledge and HBM (perceived susceptibility, severity, benefit and barrier) scores in the students (p ≤ 0.01). Significant increases were also observed in knowledge and perceived benefit after the educational program (p ≤ 0.05). ANOVA statistical test showed significant difference in perceived benefit score in students of different universities (p = 0.05). Due to the positive effects of education on increasing knowledge and attitude of university students about BSE, the efficacy of the HBM in BSE education for female students was confirmed.

Surgery for hip fractures can be done under general or neuraxial anesthesia. This study aimed to compare these two methods concerning their postoperative complications, duration of operation, hospitalization and the mortality rate within a period of one month after surgery. 400 patients aged more than 50 years old and scheduled for elective operative fixation of fractured hip, randomly enrolled in two equal groups of general (GA) and neuraxial (NA) anesthesia. Hemoglobin level was measured before and 6 hours, 2, 3 and 5 days after the surgery. The intra and postoperative blood loss, duration of surgery, the severity of pain at the time of discharge from recovery and at the 2nd, 3rd and 5th postoperative days were recorded. Statistical analysis was performed using SPSS version 12.0 by Mann-Whitney, chi-square, and t tests. P < 0.05 was considered significant. Both groups were similar regarding age, weight, and gender ratio. There was no significant difference in baseline hemoglobin, duration of surgery, length of hospitalization before surgery and the type of surgery. The mean of intraoperative blood loss and visual analogue score (VAS) in recovery and at the 3rd postoperative day, and also the length of hospitalization after surgery were significantly less in neuraxial anesthesia group. Both groups showed a significant decrease in hemoglobin values on the 2nd and 3rd postoperative days comparing to the baseline (p < 0.001). The morbidity and mortality rates of patients undergoing hip surgery were similar in both methods of anesthesia, but postoperative pain, blood loss, and duration of hospitalization were more in patients undergoing general anesthesia.

Accidental dural puncture during epidural blockade is a rare complication. Since postdural puncture headache (PDPH) is the most frequent complication, a wisely management method will also reduce the incidence of PDPH.Five patients who had inadvertent dural puncture during the epidural procedure before hip or knee arthroplasty were included in this study. After dural puncture we drew back the epidural needle and placed an epidural catheter into the epidural space. Epidural anesthesia and postoperative epidural analgesia have been provided successfully in all cases. 20% showed PDPH.These results demonstrate the effectiveness of management skills after inadvertent dural punctures.

Despite an elevated obesity risk in people with spinal cord injury (SCI), investigation on the effects of age, obesity predictors and injury related factors is yet to be unknown within the SCI population. Obesity predictors were measured in 162 patients. 27.5% of the participants were overweight and 5.6% of them were obese. Mean BMI was different between patients with tetraplegia and paraplegia (p < 0.01). More than 20% of participants had central obesity, significantly patients with higher age and time since injury. Significant positive relationship was found between level of injury and BMI. Participants with higher age and time since injury had higher waist circumference.

•Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is a recently increasing diagnosed disease showed by transient apical or mid left ventricular dilation and dysfunction. This sign is similar to acute myocardial infarction but without significant coronary artery stenosis and intra coronary clots. On the other hand there are important and essential differences in their management. Consequently, our physicians should know about its pathophysiology, diagnosis and treatment.

It has been demonstrated that educational programs that focus on study skills could improve learning strategies and academic success of university students. Due to the important role of such supportive programs aimed at the fresh students, this survey was carried out to investigate the effectiveness of an optional course of learning and study skills on learning and study skills of second year medical students. This quasi-experimental research was performed on 32 eligible medical students in Isfahan University of Medical Sciences, who chose the optional course of learning and study skills. Both of intervention and control groups completed Learning and Study Strategies Inventory (LASSI) at the beginning and the end of semester. Students in the intervention group studied different components of reading and learning skills using team working. Their final scores were calculated based on written reports on application of study skills in exams (portfolio), self-evaluation form and their progress in LASSI test. The mean differences of scores before and after intervention in each of ten test scales were compared between two groups. The results showed that the mean difference scores in attitude, time management, information processing, main ideas selection, study aids and self-testing scales were significantly higher in the intervention group (P<0.05 for all). This optional course successfully improved learning strategies in the corresponding classroom activities. However, there was no improvement in the motivational scale which is tightly related to the educational success. Therefore, the implementation of educational programs with an emphasis on meta-cognitional aspects of learning is recommended.

•Thrombotic Thrombocytopenic Purpura (TTP) is a life threatening, multisystem disease characterized by thrombocytopenia, microangiopathic hemolytic anemia, neurological changes, renal failure and fever. These signs and symptoms are thought to be caused by microthrombi, composed of agglutinated platelets and fibrin, which deposit in the arterioles and capillaries without mediation by an inflammatory process. TTP can occur in the first two weeks of initiation of Clopidogrel therapy. Early signs of TTP may be a skin reaction, which may precede the onset of TTP or it may be other type of purpura or neurological changes. We report the clinical and laboratory findings in a 67 years old female patient in whom TTP developed soon after treatment with 40 mg/day oral Clopidogrel after 8 days. She developed thrombocytopenia (platelets count 12000 /mm3). Her clinical signs and symptoms were fever (39.6C), bleeding from the nose and gum, large skin bruises (purpura and ecchymoses), neurological changes including hallucinations, bizarre behavior, altered mental status (fluctuating), headache and renal dysfunction. Physicians should be aware of the possibility early onset of this syndrome when initiate Clopidogrel treatment.

•Intracranial foreign body granulomas are rarely reported. Clinical symptoms caused by foreign body granulomas can be noticed from months to many years after surgical procedure. The most common reported etiology is suture material. A 45-year-old woman was presented with grand mal epilepsy. She was operated for brain tumor 19 years ago. In CT scan, a round radio-dense mass resembling a tumor at anterior fossa was seen. She underwent craniotomy and resected a granuloma with cotton fibers surrounded by yellow capsule without residual or recurrent tumor. Granuloma can mimic intracranial meningioma and special attention should be paid not to leave cotton pledgets during operations.