مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال شصت و نهم شماره 6 (پیاپی 126، شهریور 1390)

With approximately 386,000 deaths per year, esophageal cancer is the 6th most common cause of death due to cancer in the world. This cancer, like any other cancer, is the outcome of genetic alterations or environmental factors such as tobacco smoke and gastro-esophageal reflux. Tobacco smoking is a major etiologic factor for esophageal squamous cell carcinoma in western countries, and it increases the risk by approximately 3 to 5 folds. Chronic gastro-esophageal reflux usually leads to the replacement of squamous mucosa by intestinal-type Barrett’s metaplastic mucosa which is considered the most important factor causing esophageal adenocarcinoma. In contrast to esophageal adenocarcinoma, different risk factors and mechanisms, such as mutations in oncogenes and tumor suppressor genes, play an important role in causing esophageal squamous cell carcinoma. Molecular studies on esophageal cancers have revealed frequent genetic abnormalities in esophageal squamous cell carcinoma and adenocarcinoma, including altered expression of p53, p16, cyclin D1, EGFR, E-cadherin, COX-2, iNOS, RARs, Rb, hTERT, p21, APC, c-MYC, VEGF, TGT-α and NF-κB. Many studies have focused on the role of different polymorphisms such as aldehyde dehydrogenase 2 and alcohol dehydrogenase 2 in causing esophageal cancer. Different agents including bestatin, curcumin, black raspberries, 5-lipoxygenase (LOX) and COX-2 inhibitors have been found to play a role in inhibiting esophageal carcinogenesis. Different gene therapy approaches including p53 and p21WAF1 replacement gene therapies and therapy by suicide genes have also been experimented. Moreover, efforts have been made to use nanotechnology and aptamer technology in this regard.

Staphylococcus aureus infection pervasively occurs in communities and hospitals and observing related guidelines is essential in preventing development of antibiotic resistance in Hospitals. In this study we tried to determine the prevalence of Methicillin and vancomycine resistant staphylococcus aureus (MRSA & VRSA) and find the most suitable diagnostic tool and treatment in affected patients. This study was performed on hospitalized patients in Sina Hospital in Tehran, Iran during 2009-2010. Eighty-five staphylococcus aureus samples were evaluated for resistance to oxacillin and vancomycine by both disc diffusion and E-test methods. The study population included 46 male and 39 female patients. The mean age of the participants was 51.46±19.21 years. The MRSA frequency was 50%. 67 (78.8%) patients had hospital-acquired staphylococcus infection. The rate of hospital-acquired MRSA was 93%. Length of hospital stay, undergoing invasive methods, history of antibiotic use three months prior to hospitalization and its kind were recognized as MRSA risk factors. There were no reports of VRSA except one case of vancomycine-intermediate S. aureus (VISA). The results of disk effusion and E-test methods were consistent. Considering the prevalence of methicillin resistance in hospital-acquired infections, it seems that oxacillin should not be used as the first-line option for empiric therapy against S. aureus till antibiogram results are available. Disc diffusion can also be reliably used instead of the more expensive E-test.

The current treatment of IBS is often unsatisfactory and frustrating. Several controlled trials have demonstrated benefits of tricyclic antidepressants for irritable bowel syndrome, especially when pain is a prominent symptom but the efficacy of antidepressants in irritable bowel syndrome is controversial. The aim of this study was to compare the effect of doxepin and nortriptyline on diarrhea-predominant irritable bowel syndrome. Seventy-five patients with IBS according to Rome III criteria were treated for two months. The patients were randomly assigned to one of three groups treated with doxepin, nortriptyline or placebo. Subjects were assessed clinically one month and two months after treatment. The symptoms and adverse effects of the drugs were recorded in the questionnaire. The total score was considered as the number of the symptoms for each patient, which ranged between zero and six. Improvements in abdominal pain and bloating in the doxepin group were significantly higher than the nortriptyline or the placebo groups (P=0.001 and P=0.012, respectively). However, improvement in diarrhea in patients on nortriptyline was significantly higher than the other groups (P=0.018). The average improvement of symptoms in the patients after two months of treatment in doxepin, nortriptyline and placebo groups, respectively were 2.56, 2 and 0.6 (P<0.05). Both doxepin and nortriptyline are effective for the treatment of diarrhea-predominant irritable bowel syndrome in a period of two months but doxepin seems to be more efficacious than nortriptyline in this regard. However, larger comparative trials are suggested.

Anthropometric facial analysis and quantitative measurements are useful methods for diagnosis, as well as planning in plastic surgery. The literature is replete with numerous related studies, few of which are about the Iranian population. This study was conducted to determine the average facial proportions of Iranians and compare it with that of Caucasians. This cross-sectional study was conducted on a convenient sample of 212 Iranians (male=108, female=104) aged 18-30 years who did not have any previous major facial surgery or trauma and their past two generations were Iranian. Measurements between facial landmarks were determined and compared with Caucasians with Student and one sample t-tests (P<0.05, 95% CI). The intercanthal (en-en) and eye widths (ex-en/R), forehead height 2 (tr-n), trichion-endocanthion (tr-en) and nasofacial and nasofrontal angles were not significantly different between the participating men and women but other facial measurements were significantly different (Р<0.05). The head (ft-ft), eye (ex-en/R/L) and nose widths (al-al) and upper face height (n-sto), nasofrontal angle and nasal tip protrusion in the study population were not significantly different from Caucasians. The upper lip (sn-sto), lower face (sn-gn) and forehead heights (tr-n) and nasofacial angle of the female participants were not significantly different from Caucasian women but other facial measurements were significantly different (Р<0.05). Most facial anthropometric measurements of Iranian subjects were significantly different from those of Caucasians. More precise studies with larger sample sizes are warranted to reach a common conclusion on the facial anthropometric similarities or differences between the two populations.

Diabetes is a metabolic disorder affecting the whole body systems including the female reproductive organs. Moreover, diabetes is an important cause of infertility. Metformin is commonly used to control hyperglycemia in patients with diabetes. This study was done to evaluate the ultrastructural changes of ovarian follicles in diabetic rats and their response to metformin. Thirty-six adult Sprague-Dawley female rats (170-210 g) were studied in three groups (Control, diabetic and metformin-treated rats). In the second and third groups, diabetes was induced by injection of streptozotocin (45 mg/kg). The rats in the third group were later treated by metformin monohydrochloride (100 mg/kg). At the end of the experiment, rats were sacrificed and their right ovaries were observed under transmission electron microscope. Quantitative data were analyzed by student t-test in SAS software. In comparison with the control group, significant decreases in zona pellucida thickness and the mean number of microvilli were observed (respectively, P<0.01 and P<0.001) in diabetic rats. Significant decreases in zona pellucida thickness were also observed in metformin-treated rats (P<0.05) but changes in the number of microvilli were non-significant. The number of organelles in oocyte cytoplasm was higher and they were natural or natural-looking in metformin-treated rats versus the diabetic ones. Reduction in the number of mitochondria and their ballooning cristae were of the most noticeable changes in diabetic rats. Diabetes decreases the number of microvilli and oocyte organelles and diminishes zona pellucida thickness leading to structural changes in the organelles but metformin could improve the aforesaid conditions.

Abnormal iron homeostasis such as iron deficiency or iron excess is associated with the pathogenesis of many chronic diseases including diabetes and cardiovascular disease (CVD). Iron may stimulate the progression of atherosclerosis by increasing the oxidative stress. Changes in carotid intima-media thickness (CIMT) have been validated as a vascular indicator of atherosclerosis progression. The purpose of this study was to apply CIMT to investigate the association between iron status and the initial stages of atherosclerosis. 140 healthy premenopausal women aged 18 to 50 years who had no chronic or acute disease were selected randomly from one of the Tabriz university sub specialized clinics. Blood samples were taken to assay iron status parameters. CIMT was measured noninvasively by ultrasonography. Based on CIMT results, the subjects were classified as "healthy" (CIMT ≤0.8 mm) or "at risk" (CIMT >0.8 mm). Student's t-test was used to determine the mean differences between the two groups. The mean±SD age of the participants was 32.76±8.1 years. The mean iron, ferritin, hematocrit and mean corpuscular volume (MCV) were significantly higher and the total iron binding capacity (TIBC) was lower (P<0.05) among the "at risk" group. However, there was no significant differences in red blood cell count or hemoglobin levels between the two groups (P>0.05). Results of this study showed a relative correlation between iron status parameters and CIMT as the initial indicator of CVD. Regarding the contradictions found in the literature, more research is needed to clarify the situation.

Shoulder pain is a common complication of cerebrovascular accidents. This study was conducted to assess the effects of local injections of bupivacaine and triamcinolone acetate on shoulder joint pain and on restricted range of motion following brain events. This single-blind clinical trial study included 35 patients with chronic shoulder pain (the controls) and 35 patients with chronic shoulder pain due to brain events (the case group). The study was done at Imam Hossein Hospital & Gandhi Day Clinic during the year 2008-2010. The patients in the two groups received bupivacaine and triamcinolone acetate for subacromial bursa injection and suprascapular nerve block by following the protocol described by Dangoisse et al. The patients were followed up for 12 weeks and they were evaluated for pain and range of motion 1, 6, and 12 weeks after the injections. The mean age of the patients was 60.9±9.07 years. Statistically significant improvements in pain score (P=0.001) and shoulder joint range of motion (P=0.001) were observed in patients with chronic shoulder pain versus patients with brain events 12 weeks after suprascapulare nerve block and subacromial bours injections by bupivacaine and triamcinolone acetate. Suprascapular nerve block and subacromial bursa injections of bupivacaine and triamcinolone acetate is a safe and efficacious treatment for the treatment of chronic shoulder pain and restricted range of motion but it is not efficacious or of significant value for the treatment of shoulder pain in patients with brain events.

This study was designed to explore the contribution of risk factors for coronary artery disease (CAD) in patients with indication for coronary angiography. Coronary angiography is defined as the radiographic visualization of the coronary vessels after injection of radio opaque contrast media. Despite the recognition of risk factors for CAD, the association between related risk factors and angiographic findings remains controversial. The aim of the present study was to explore the association between Gensini scores and major cardiovascular risk factors in patients with indications for coronary angiography. We retrospectively enrolled 495 patients who had been hospitalized at Dr. Shariati Hospital during September 2009 to September 2010 and had undergone coronary angiography. The patients were evaluated for the severity of coronary lesions on the angiogram by Gensini scoring system. The patients were also evaluated for the presence or absence of DM, hypertension, family history of cardiac diseases, low HDL, hyperlipoproteinemia, hypertriglyceridemia and cigarette smoking. Statistical analysis wad done to find any relationship between Gensini scores and cardiovascular risk factors. The study population consisted of 249 men (50.3%) and 245 woman (49.5%) with a mean age of 58.1±10.3 years. A positive correlation was found between age (P=0.04), sex (P=0.008), HDL (P=0.04) smoking (P=0.0001) and diabetes (P<0.013) with Gensini scores. In patients with indications of angiography, Gensini scores provide valuable prognostic information on cardiovascular risk factors. Age, sex, HDL, smoking and diabetes are related to the severity of coronary lesions on the angiograms.

Calcium metabolism disorders can be acute or chronic and chronic disorders can cause different disease states such as dental problems. In this descriptive cross-sectional study done in Children's Medical Center affiliated to Tehran University of Medical Sciences during 2005-2009, all (93) patients with hypoparathyroidism, nutritional rickets, hypophosphatemic rickets and renal osteodysthrophy from the endocrinology and nephrology departments of the Center were referred to a dentist there for orodental examination. Subsequently, the frequency of dental problems including taurodontism, enamel hypoplasia, dental abscess, dental caries and gingivitis were recorded and analyzed. Nutritional rickets was the most common disorder in this study and delay in dentition was the most frequent dental problem in the patients (61.9%). Most cases of taurdontism and enamel hypoplasia were seen in patients with hypoparathyroidism (33% and 50%, respectively). Dental abscess, dental caries and gingivitis were more common in patients with renal osteodysthrophia (50%, 90% and 20%, respectively). In addition, dental caries and delay in dentition were the most prevalent disorders in this study (69.8% and 49.5%, respectively). According to the above findings, it seems that effective screening, regular periodic examinations, proper diagnosis and timely treatment of dental diseases are the main principles of prevention of orodental problems. Moreover, dentists as well as pediatricians should be aware of the features of the aforesaid disorders which lead to dental problems so that early intervention could prevent subsequent serious and more invasive dental problems.

Placenta accreta is a life-threatening complication after previous cesarean delivery. The aim of this case report is to present a case of placenta percreta with bladder involvement and subsequent maternal death.

The patient was a 37-year old who had an unwanted pregnancy due to tubectomy failure two years afterwards. She was hospitalized at 26th and 30th week of gestation because of gross hematuria. Sonography reported placenta previa. Cesarean section was performed at 34th gestational week. Due to severe hemorrhage, hysterectomy with resection of some part of the bladder was done. Died at the operating room after four hours of severe uncontrollable hemorrhage.

The increasing prevalence of different forms of placenta accreta is the result of the ever-increasing rate of cesarean deliveries. One of the strategies to prevent this catastrophic obstetric complication is decreasing the number of cesarean deliveries without appropriate indications.

Burning is one of the commonest causes of death. Due to the high rate of death among burn victims epidemiological investigation of burning, burning agents and the relevant motivations can be of great preventive value.1 In this cross-sectional study all the hospitalized patients in Shahid Motahari Burn Hospital at Tehran city in the year 2009 were included in the study. The collected data were analyzed by SPSS (ver. 17) software. Out of the 1548 hospitalized patients for burn, 1134 (73.3%) left hospital in good conditions, 47 (3%) left in relatively good conditions, 289 (18.7%) died and 78 (5%) persons left the Hospital satisfactorily on their own volition. About two-thirds of the patients were men. The mean age of the burn victims was 27.9±18.3 years, 16% of them being 5 years old or younger. The highest percentage of burn area was 30% of the total body surface which was seen in 20 to 30-year old patients. 58.7% of burns had been caused by fire. 94% of the burns had happened accidentally, 5% by suicidal and 1% by homicidal acts. The highest percentage of burn was observed in patients in whom the burn agent was fire. Six (4%) persons had first degree, 820 (53%) persons had second degree and 722 (46.6%) had third degree burns. In patients who had committed suicide third degree burns were higher than second degree burns (7.7% vs. 2%). 24.4% of women and 16.6% of men died due to the burns. The rate of death in patients less than 50 years of age was 18% but the figure increased to 24% in those above 50. A burn area less than or more than 10% was, respectively correlated with 2.1% and 22.1% of deaths. 34.8% of the patients with third degree burns and 4.6% of those with second and first degree burns died. 58.3% of the suicidal patient died due to the severity of the burns relative to 16.7% due to other causes. 89 (5.7%) patients had respiratory tract burns and the death rate was 58.4% among these patients while the death rate was 16.2% in patients without respiratory tract involvement. The results of logistic regression analysis revealed that age more than 50 years, female sex, burn area greater than 10% (previous studies 40%), 2 third degree burns, respiratory tract involvement and suicide increased the risk of death in burn patients.