مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال شصت و نهم شماره 7 (پیاپی 127، مهر 1390)

Numerous studies have shown the protective effects of saffron against oxidative damage in a global model of cerebral ischemia, but its effects on brain edema and oxidative ischemic injury in focal ischemic stroke are not completely understood. Therefore, this study was designed to investigate the effects of saffron on brain edema, infarct volume, antioxidant enzyme activity (glutathione peroxidase and superoxide dismutase) and concentration of malondialdehyde (MDA) in ischemic brain tissue in an experimental model of stroke. Focal brain ischemia was established with the temporary occlusion of the middle cerebral artery for one hour in rats. Saffron (100 mg/kg) was given intra-peritoneally at the onset of ischemia. 24 hours later, brain edema and infarct volume were evaluated and glutathione peroxidase and superoxide dismutase activities and MDA concentration were measured in the ischemic brain tissue using a specific kit. The results showed that saffron reduced infarct volume by 77% (P<0.001) and brain edema by 60% (P<0.001) compared with the control group in 24 hours following ischemia. Moreover, saffron significantly reduced the content of MDA (P<0.001) and increased the activity of superoxide dismutase (P<0.001) and glutathione peroxidase (P<0.001) in the cortex of the ischemic brain tissue. Saffron has protective effects against oxidative ischemic damage and brain edema in a transient model of focal cerebral ischemia in rats. This protective effect is probably induced by increasing the capacity of antioxidant enzymes and decreasing the production of free radicals.

Uterine contractions and an appropriate cervix are two important factors in labor contributing to good pregnancy outcomes. Oxytocin and prostaglandins, such as misoprostol, are used for the induction of labor. Misoprostol is used for cervical ripening and labor induction. The aim of this trial was to compare the efficacy and safety of titrated oral misoprostol solution with oxytocin for labor induction in pregnant women with an unfavorable cervix. In this randomized double-blind clinical trial, 140 women with a gestational age of 34-42 weeks and an unfavorable cervix were recruited. The participants had an indication for labor induction and had been referred to the Women's Hospital in Tehran, Iran between January 2010 and January 2011. The participants were randomly assigned to receive 20 µg/hour titrated oral misoprostol plus intravenous placebo or 6 mU/min oxytocin plus oral placebo. In case contractions were inadequate, the drug doses were gradually increased. Pharmacological complications, the mean interval from the start of induction till vaginal delivery and delivery type were monitored and analyzed in both groups. The mean interval from the start of induction till vaginal delivery in misoprostol group was shorter than the oxytocin group (11.07±3.42 vs. 14.87±3.21 hours, P=0.001). The frequency of pharmacological complications and vaginal or cesarean deliveries were similar between the two groups (P>0.05). Use of titrated oral misoprostol is a safe and effective method for labor induction in pregnant women with unfavorable cervix. Misoprostol is associated with a shorter interval from induction to vaginal delivery than oxytocin.

Patients who require surgery on the lower extremities are considered to be a high risk group from the point of anesthesia. This study was performed to compare sitting and lateral positions in spinal anesthesia method with hyperbaric bupivacaine 0.5% for hemodynamic status and analgesic period in patients under vascular surgery of the lower limbs in Imam-Khomeini Hospital Complex affiliated to Tehran University of Medical Sciences in 2009. In this study 40 patients were divided into two groups of 20 to undergo spinal anesthesia with 3 ml of hyperbaric bupivacaine 0.5% injected into the subarachnoid space in sitting or lateral positions. The anesthesia was performed at T10 level and the hemodynamic status and analgesic periods were compared in the two groups. The changes in mean arterial blood pressure and systolic and diastolic blood pressures were different between the two groups (P<0.05). Except in the first and thirtieth minutes, the changes in heart rate (HR) were significantly different throughout the study between the two groups (P<0.04) and they were higher in sitting position. The duration of analgesia was significantly longer in lateral position (P<0.04) and the use of fluid was significantly larger in the sitting group (P<0.05). According to the obtained results, the changes in hemodynamic variables were significantly lower in the group in lateral versus sitting position in patients undergoing spinal anesthesia with bupivacaine for vascular surgery of the lower limb.

Studies indicate that obestatin, an anti-hunger peptide, plays an important role in energy balance, GH secretion, and body weight. It has been physiologically shown that obestatin apposes the function of Ghrelin. The purpose of the present study was to investigate the effects of a single session of aerobic exercise in trained women (a 1.5-mile run) on the expression of obestatin gene found in lymphocytes. 16 trained female participants (4±1 years of training experience) were voluntarily selected from Khorasan province in Iran and were randomly divided into two groups: the control and aerobic exercise groups. The participants in the aerobic group were asked to run for 1.5 miles with a fixed speed (70 VO2 max) while the controls were passively present in the exercise environment. Following an overnight fast, blood samples (10 ml from the antecubital vein) were collected before and immediately after the exercise from all the participants. Obestatin expression was investigated after separating the lymphocytes by centrifuge and using semi-quantitative RT-PCR. There was a rise in obestatin gene expression in the case group after one session of aerobic training versus the control group but the changes were not statistically significant. The results indicated that a single aerobic exercise could not significantly increase the expression of obestatin. Perhaps the type, duration and intensity of the applied protocol in this study did not have a cumulative effect on this gene although these results are in harmony with the results of other studies in this regard.

Deposition of bilirubin in neurons causes permanent neuronal injury. Bilirubin exhibits an affinity for the phospholipids of plasma membrane like N-methyl-D-aspartate (NMDA) receptors. Magnesium is an NMDA antagonist and it acts against the neurotoxic effects of bilirubin. We compared pre- and post-phototherapy serum magnesium level of neonates with hyperbilirubinemia to find the best time of discharge and evaluate new management techniques such as magnesium supplementation.

In this semi-experimental study, we evaluated neonates admitted in Ali Asghar Children's Hospital in Tehran, Iran with signs of icter from 2009 to 2010. The inclusion criteria included age less than four weeks, no history of magnesium sulfate administration in the mother and absence of sepsis.

From 106 patients with icter, 50.9% were male and 49.1% were female neonates. Their mean gestational age was 37.341.286 (33-41) weeks and the mean birth weight was 3172.12436.936 (2022-4300) grams. The frequency of underlying causes of hyperbillirubinemia included: ABO mismatch 9.34%, Rh incompatibility 4.7%, breastfeeding 16% and breast milk 44.3%. There was a significant difference (P≤0.001) between serum magnesium levels before (2.24mg/dl) and after phototherapy (2.12mg/dl). There were no significant differences between serum magnesium values in the two sexes (male=2.28, female=2.19), among different gestational age groups (<34 wks=2.35, 35-37 wks=2.27, >38 wks=2.17), between different birth weight groups (1500-2500 g=2.4 and >2500 g=2.23) or severity of hyperbilirubinemia (mild=2.23, moderate=2.21 and severe=2.29).

Phototherapy decreases the total magnesium concentration and magnesium administration will prevent bilirubin neurotoxicity in icteric neonates.

Gastrointestinal mesenchymal tumors are classified as tumors that originate from smooth muscles. Gastrointestinal stromal tumors (GIST) are the most common types of the proposed tumors and can be seen in the GI tract from the esophagus to the anus, but they are mostly seen in the stomach. Mostly from the stomach and asymptomatic, the majority of patients would benefit from surgery as the best method of treatment. In this retrospective study we evaluated the data of patients with the diagnosis of esophageal or gastric mesenchymal tumors admitted in Ghaem and Omid Hospitals affiliated to Mashhad University of Medical Sciences in Iran, from 1992 to 2010. We analyzed factors such as age, sex, presenting symptoms and signs, diagnostic methods, types of pathology, types of treatment, morbidity, mortality and 3-year survival rates. Twenty four patients (16 male, 8 female) with a mean age of 50 were included in the study. The common site of tumor was gastric fundus. The most common symptom at the time of diagnosis was epigastric fullness which was observed in almost 50% of the patients. The most common type of surgery in the patients was subtotal gastrectomy and no hospital mortality was recorded. Paralytic ileus was the commonest complication seen in five patients (20.5%). Adjuvant therapy had been performed in eight patients (33.1%). Following the patients three years postoperatively, there were only three deaths (12.45%). Regarding to the low mortality and morbidity of the surgeries, surgical treatment, if tolerated, is recommended for all Esophagogastric mesenchymal tumors patients.

Vascular complications, as the most common complications of diagnostic catheterization and percutaneous coronary intervention (PCI), are important factors in the morbidity of patients undergoing such procedures; thus, this study was done to evaluate the prevalence of these complications and their related factors. This is a descriptive study composed of 2097 consecutive patients who underwent percutaneous coronary intervention in Shahid Rajaei Cardiovascular Center in Tehran, Iran from January 2008 to January 2009. Occurrence of vascular complications in course of hospitalization and the related factors leading to the complications were investigated. Out of 2097 patients, 1544 (73.6%) were male and 553 (26.4%) were female, and the mean age of the participants was 57±10 years. Vascular complications from the time of PCI to the time discharge were observed in 19 (0.9%) patients. The other complications included: hematoma in 10 cases (52.6%), pseudoaneurysm in five cases (26.3%), retroperitoneal hemorrhage and arteriovenous fistula in 2 (10.5%) patients each. The complications were significantly more common in female patients (P=0.003), in patients with a history of hypertension (P=0.02), people of shorter stature (P=0.004), and being on gp IIIa/IIb inhibitors (P=0.003). The rate of vascular complications post-percutaneous coronary interventions is low and it is considered to be a good treatment option for patients with coronary stenosis; provided that sufficient compression is applied on the vascular access point in the right time after removal of the arterial sheath. PCI is of fewer vascular complications, especially in female patients, history of hypertension, and higher anticoagulant concentrations.

Choanal atresia was first described by Roeder in 1755.1 Choanal atresia is the narrowing or obstruction of the posterior nasal fossa. This anomaly could be congenital or acquired. Most patients are female.2 Choanal atresia might be isolated or associated with other anomalies like CHARGE syndrome and 20-50% of congenital cases have this company.3 Choanal atresia could be unilateral or bilateral; while bilateral cases are emergent surgical conditions, unilateral cases are more frequent and mostly right-sided. Choanal atresia may be osseous, membranous or mixed.2 The definite treatment for choanal atresia is surgery and transpalatal, transseptal and transnasal (with endoscope) are the three preferable approaches.3 The medical records of fifty-four patients diagnosed with choanal atresia and admitted in Amiralam university hospital during the years 1998 to 2010 were evaluated. The patients were 2 to 29 years old with a mean and median age of 12.4 and 12, respectively. Female to male ratio was 2:1 and unilateral to bilateral involvement ratio was 1.9:1. Among unilateral cases, 19 cases had right-sided involvement. Forty cases had mixed, 13 had osseous, and one of them had membranous choanal atresia. Five patients had undergone transplatal surgery and the rest had their choanal atresia repaired by endoscopic approach. 80% of the cases had revisited for symptoms of nasal obstruction among which 18% had bilateral obstruction and presented with cyanosis and 64% had rhinorrhea.In comparison to similar studies, our patients had a higher mean age. This could be due to late referral, the patient's unfamiliarity with the symptoms and inadequacy of specialized treatment centers.Transpalatal approach was the most common surgical approach till late 80s as it provided better access due to the provision of a wider opening. Providing direct access to the surgical field and causing the least trauma to the site, endoscopic approach has been the most preferable option during the last two decades. In this approach, the exact site of resection can be determined and surgical safety will be increased.4Use of stents in the surgery of choanal atresia is still controversial. Some authors believe in the prevention of recurrence with stents while some think about higher probability of infection and scar.5Regarding the mentioned issues above, more research is needed to find the best surgical approaches and techniques for the early detection and treatment of choanal atresia.

Burning Transient Neurologic Syndrome (TNS) which was first described by Schneider et al in 1993, is defined as a transient pain and dysesthesia in waist, buttocks and the lower limbs after spinal anesthesia.1,2 The incidence of TNS after spinal anesthesia with lidocaine is reported to be as high as 10-40%.3,4 This prospective study was designed to determine the incidence of TNS with two different types of drugs, lidocaine and bupivacaine, in lithotomy or supine positions as the primary outcomes and to determine the association between two different types of needles and surgical positions with the occurrence of TNS as the secondary outcome.The present study was conducted on 250 patients (ASA I-II), aged 18-60 years old, who were candidates for surgery in supine or lithotomy positions. According to the needle type (Sprotte or Quincke) and the local anesthetic (lidocaine or bupivacaine) all patients were randomly divided into four groups. After establishing standard monitoring, spinal anesthesia was performed in all sitting patients by attending anesthesiologists at L2-L3 or L3-L4 levels. The patients were placed in supine or lithotomy position, in regards to the surgical procedure. During the first three postoperative days, patients were observed for post spinal anesthesia complications, especially TNS. Any sensation of pain, dysesthesia, paresthesia or hyperalgesia in the low back area, buttocks, the anterior or posterior thigh, knees, either foot or both feet were recorded. Moreover, duration of pain, its radiation and its relation to sleep and the patient's position were all carefully considered. Ultimately, the patient's response to opioid (pethidine) for analgesia was determined.The incidence of TNS was higher when spinal anesthesia was induced with lidocaine (68% vs. 22%, P=0.003). TNS developed in 85% of the patients in lidocaine group and 58% in bupivacaine group after surgery in lithotomy position (P=0.002). In 77 patients pain was in lumbosacral area that radiated to lower limbs and was aggravated in sitting position but in 22 patients pain was in thighs with no radiation. The mean visual analogue scale (VAS) for the determination of pain severity was six in all patients. Pain was alleviated by the administration of pethidine. With regard to the needle type, there were no significant differences between the two types of needles (P=0.7).According to the results of this prospective study, it seems that induction of spinal anesthesia by lidocaine combined with surgical lithotomy position increases the risk of TNS. Our study is in concordance with Keld's study.5 Higher neurotoxicity of lidocaine in comparison with bopivacaine may justify the higher incidence of TNS in the lidocaine group. Moreover, natural lumbar lordosis is maintained better in supine position while it is lost in lithothomy position which may lay traction forces on cauda equina or other nerve roots in the lumbar area leading to neuropraxia.