Archives of Iranian Medicine
Volume:17 Issue: 11, Nov 2014

Responsiveness refers to non-clinical aspects of the health system and responds to this question that whether health system is responsive to rightful expectations of people. The present study was conducted to determine the health system responsiveness about chronic heart failure patients in one of the main heart centers in Tehran during 2012 – 2013. In this cross-sectional study 300 patients have completed a valid questionnaire that designed with WHO for measurement of responsiveness. Analysis of data was based on analysis WHO multi-country study that was designed to evaluate responsiveness in health care systems. In outpatient services، worst performance was related to choice and prompt attention domains (35. 8% and 35. 1%). Autonomy (31. 5%) has the worst performance of inpatient services. Both in outpatient and inpatient services «confidentiality of information» has the best performance (87. 8% and 85. 6%). Responsiveness of the health system in inpatient services has the worst performance comparing to outpatient services (57. 2% versus 66. 5%). Most important domains from patient''s view were prompt attention and dignity (47% and 23%). More attention to patient’s rights، giving them opportunity to choose health care services (choice)، providing fast access to emergency care (prompt attention) and considering autonomy are most important aspects of health responsiveness. From patient''s view «prompt attention” was reported as the most important aspect of responsiveness.

Electroencephalography (EEG) is a useful diagnostic tool in the diagnosis of seizure and differentiating it from seizure-like attacks. Cooperation and immobility of the patient is crucial and in children who do not naturally sleep, pharmacological agents and procedural sedation should be used for sleep inducement. The purpose of this study was to compare efficacy and safety of melatonin and intravenous solution of midazolam administered orally in sedation induction for EEG of children. In a parallel single-blinded randomized clinical trial, sixty 1 – 8 year old children who were referred to EEG Unit of Shahid Sadoughi Hospital, Yazd, Iran from September 2011 to March 2012 were evaluated. The Children were randomly assigned into two groups to receive orally 0.3 mg/kg melatonin or 0.75 mg/kg ampoule of midazolam. The primary outcome was efficacy in adequate sedation (Ramsay sedation score of four) and recording of EEG. Secondary outcome was clinical side effects. Nineteen girls (31.7%) and 41 boys (68.3%) with the mean age of 2.8 ±1.8 years were evaluated. Adequate sedation and recording of EEG was achieved in 36.7% of midazolam group and in 73.3% of melatonin group, (p = 0.004). Transient agitation was seen in 6.6% of midazolam group. No significant difference was observed from the viewpoint of side effects frequency between the two drugs, (p = 0.15). CONCULSION: Melatonin is a safe and an effective drug in sedation induction for EEG in children.

Giant cell fibroma (GCF) is a distinct type of fibroma with characteristic large, stellate mononuclear or multinucleated giant fibroblasts; the stroma of GCF is relatively unexplored. The Picrosirus red polarizing microscopy technique is used to characterize the collagen fibers. The aim of this study was to evaluate the staining properties of collagen fibers in GCF and to correlate it with fibroma using Picrosirius red under the polarizing microscope and van Gieson under bright field microscope. In the present study van Gieson and picrosirius red stained slides of 7 cases each of GCF and fibroma were compared for the staining properties of collagen. Using picrosirus red polarizing microscopy; colors noted in fibroma included yellow, yellowish-orange and green, whereas the GCF showed predominantly yellow and orange colors. In Van Gieson stained sections it was observed that the collagen in GCF was densely packed and arranged perpendicular to the epithelium while the collagen in fibroma was loosely packed and arranged parallel to the epithelium. Observable differences in the stroma of the collagen of GCF and fibroma were noted. Collagen in GCF was more mature and dense. The Picrosirius red polarizing technique can be used to assess the collagen in GCF.

Cholelithiasis is one of the most prevalent gastrointestinal disorders requiring hospitalization. While different factors influence gallstone formation in patients, these factors are not the same in different societies or in different geographical locations. To evaluate the epidemiology and risk factors associated with gallstone formation in a large population group, the present survey was conducted in northern Iran. In 6143 asymptomatic subjects, the incidence of gallstone formation as well as risk factors were evaluated through a structured questionnaire, physical examination and ultrasonography study. Sample selection was based on stratified cluster systemic randomization. Of these enrolled subjects 3507 (57.1%) were male and 2636 (42.9%) were female with a mean age of 42.71 ± 17.1 years. The prevalence of gallstones was 0.80%. On multivariate analysis, the risk of gallstone disease is correlated to rural locale, diastolic hypertension, age, and TG levels. However, systolic hypertension, glucose serum levels and obesity were also significantly associated with the presence of gallstones. The present study proposes that the rate of gallstone disease in northern Iran is lower than previous studies have reported, and that most of the risk factors can be prevented by changes in lifestyle and diet.

Wilson disease is a rare autosomal recessive disorder of copper metabolism caused by mutation in the ATP7B gene. The combination of markers (such as SNPs) on a single chromosome can be used to understand the structure of haplotype in the human genome, in which provide notable information on the origin of the mutation in human genetic disorders. The purpose of this study was to determine a haplotype analysis of two unrelated Wilson disease patients with the same missense mutation, c.2335T>G (g.58164 T>G) in exon 8.

DNA was prepared from two patients with the c.2335T>G mutation, their first-degree relatives, and 50 selected homozygous individuals from consanguineous marriage for eight SNPs around this particular ATP7B mutation. PCR was performed for SNPs of exons 4 (g.47964 C>T), 5 (g.51482G>A), 6 (g.54622A>G), 7 (g.56255G>A), 9 (g.59042G>T), 11 (g.66363G>A), 13 (g.70004 G>C), and 14 (g.72244 A>G), which are located in upstream and downstream of this mutation. Then, restriction fragment length polymorphism (RFLP) for these eight SNPs was designed and performed using eight different restriction enzymes.

Eight different haplotypes were found in the present study and the patients with the same missense mutation had the same haplotype. The most prevalent haplotype in 100 normal studied ATP7B alleles was the same as reference haplotype (C G A G T G G G A) for ATP7B gene (NG_008806.1).

As these two geographically separated families with the same mutation had the same haplotype, we concluded that this mutation possibly had the same origin in this population.

Mutations in the core promoter and precore regions of HBV cause down-regulation of HBeAg. These mutations are associated with chronic hepatitis, cirrhosis and Hepato Cellular Carcinoma (HCC). This study was carried out to sequence analysis of HBV core gene in HBsAg- positive blood donors in Iran. A total of 50 HBsAg- positive blood donor samples were examined in this study. Serological markers of hepatitis B including: HBsAg, HBeAg, HBeAb and HBcAb were measured by ELISA method. HBV-DNA was extracted from the sera, and then PCR was performed on extracted HBV-DNA using specific primer of gene C. After direct sequencing, the nucleotide sequences from 50 blood donors were analyzed using a reference sequences and then phylogenetic analysis was performed. Also, the line probe assay was used to detect mutations. The majority of donors (62.5%) were in the age group of 29 – 40 years old. Among all the HBV DNA positive cases, 87.8% were HBeAg negative. The prevalence of PC and BCP mutants were 12% and 55% respectively, among asymptomatic HBV infected blood donors by direct sequencing method. The results of this study showed that some of HBV infected blood donors had mutation in core gene of HBV and amino acid changes in B cell, T helper and CTL epitopes that can cause reducing HBe and HBc antigenicity in asymptomatic HBV infected blood donors and the development of escape mutants from host immune.

Intraosseous ganglion (IOG) cysts rarely have been reported in the carpal bones and lunate is the most common area of involvement. They can present as chronic wrist pain accompanied by a radiolucent lytic lesion in the lunate bone. We provided a retrospective review of six cases of intraosseous ganglion cysts within the lunate bones that all of the patients presented with chronic wrist pain. We retrospectively reviewed the medical records, pathologic reports and imaging files of the six patients who were referred and treated due to chronic wrist pain with final diagnosis of the lunate intraosseous ganglion. All cases were treated by curettage and autologous cancellous bone grafting. There were six patients with final diagnosis of the lunate IOG who received surgical treatment. Four out of six patients were female and the remaining was male. Mean age of the patients was 33 years (22 – 56). Right wrist was involved in four patients. Pain was the chief complain in all patients. Mean time of suffering from the wrist pain till referring to hand clinic for definite treatment was nine months (3 – 24). Mean duration of follow up was 30.6 months (6 – 48). The wrists became pain free after surgical treatment and no graft absorption or recurrences were seen in the control radiographs obtained throughout the follow-up period. Diagnosis of intraosseous ganglion was based on the imaging features and clinical presentation. Although most cases of the lunate bone IOGs are symptom free and found incidentally after wrist imaging performed for other reasons, these lytic lesions should be included in differential diagnosis list of chronic wrist pain especially in the presence of increased uptake in bone scan located on the lunate area.

BACKGROUND/ Gastric cancer (GC) is the second leading cause of cancer-related deaths worldwide and is the most frequent cancer in Iran. Epstein-Barr virus (EBV) has been shown to be associated with gastric cancer. The present study was carried out to investigate the prevalence of Epstein-Barr virus (EBV) associated gastric cancer among Iranian patients. Ninety formalin fixed paraffin-embedded cases of gastric cancer were studied. The specimens were investigated for the presence of the EBV genome by quantitative real-time polymerase chain reaction. Of ninety specimens, EBV was detected in six cases (6.66%). The mean age for patients EBV-positive gastric carcinomas was 72.1 years, whereas the mean age for the entire group was 65.7 years. Four out of 64 (6.25%) male patients and 2 out of 26 (7.69%) female cases were positive for EBV. According to anatomic location, EBV was detected in 4 out of 39 (10.25%) gastric cancer were located in cardia and 2 out of 26 (7.69%) gastric cancer were located in middle/corpus. The present study shows that the frequency of EBV-associated gastric carcinoma in Iran is low. Differences of EBV-associated gastric carcinoma incidence in different countries may reflect the epidemiologic factors and dietary habits. Further analysis of clinical pathology features of EBV-associated gastric carcinoma using a larger number of cases would give invaluable insights into its etiology.

Over the past 35 years Iran had significant quantitative progress in postgraduate medical education; and growth in specialist’s physician workforce supply. Health and medical education policy makers have struggled with many issues related to physician supply, such as determining the sufficient number of physicians workforce and the appropriate number to train; establishing new medical schools; the diversity of specialty programs; efforts to increase the supply of physicians in specialty level in remote and rural areas; and the growing number of female physicians and its impact on health services. After establishment of Ministry of Health and Medical Education (MoHME) in Iran, expansion of medical specialty education was a priority. Since then, great advances have been made in training of new specialty programs. Despite of these brilliant advances during the last decades in Iran, there has been no integrated and comprehensive documentation of previous and current growth trend, yet. To understand where Iranian physician supply and specialty training is headed, we examined the Iranian medical specialist’s trends from 1979 to 2013 in a national study by support of Iranian academy of medicine. This paper documents the growth trend of medical specialist’s workforce over the past 35 years. Examining the health manpower growth trends allow health and medical education policy makers to plan innovative strategies for the purposeful development of postgraduate medical education to ensure that in future there would be sufficient physicians supply, with the right skills, in the right places in response to population demands.

Nationwide implementation of Family Physician (FP) program started in 2005 and targeted almost 25,000,000 citizens residing in rural areas and cities with less than 20,000 populations in Iran. Despite its blatant initiation that resulted in some modest achievements, the future of FP looks unclear in Iran. Thus far, no longitudinal evaluation of the implementation and impact of FP program has been conducted. However, meager evidence highlights the facilitating role of an existing and strong Primary Health Care (PHC) network in the implementation of FP in rural areas in Iran. A longstanding challenge, however, as emphasized by most stakeholders, remains to be the expansion of FP program into urban settings, where the PHC is undeveloped and fragile as well as the powerful private sector is resistant. Using an adapted conceptual framework of institutions, ideas, and interests, this policy perspective aims to shed light on main difficulties of FP implementation in urban areas of Iran. We analyze FP policy in the context of ongoing interactions and conflicts among institutions (the structures and rules that shape policies), interests (the groups and individuals influencing policy), and ideas (discourses around policies). Our argument will, we envisage, help plan for more appropriate implementation of FP in cities in Iran, and hopefully beyond.

Schwannomas are rare neurogenic tumor originating from Schwann cells of the nerve sheath, most frequently encountered type of posterior mediastinal tumors. In most cases, schwannomas are benign, malignant and multiple schwannomas are rare. Histopathologically, the tumor is composed of fascicles of spindle cells, which are strongly positive for S–100 proteins. Surgical resection is a treatment of choice, and prognosis is excellent. Here, we report a case of posterior mediastinal schwannoma in a 20- years old male patient who complained of right-sided back pain and two episodes of massive hemoptysis of recent onset. Contrast enhanced computed tomography (CECT) and magnetic resonance imaging of the chest showed a well circumscribed, heterogeneous mass in the posterior mediastinum, compressing the right lower lobe with widening of intervertebral foramens. CT-guided trucut biopsy revealed spindle cell neoplasm. On immunohistochemistry, tumor cells expressed strong positivity for S–100 protein. Final diagnosis was schwannoma, probably originating from the right vagus nerve. Surgical resection of the encapsulated tumor resulted in the successful recovery, without any recurrence over next one year follow up.

Choriocarcinoma is the most aggressive, malignant form of gestational trophoblastic disease and has varying incidence, increasing in patients older than 40 years. It usually develops after a malignant alteration in a molar pregnancy, but rarely after an abortion or normal or ectopic pregnancies. The most common localization is the uterus, but it can also be found rarely in the ovaries, fallopian tubes, vagina, vulva, cervix or pelvic region. A 38-year-old multiparous woman, with no complications in three previous labors and four miscarriages, presented to her gynecologist one year after the last miscarriage complaining of abnormal vaginal bleeding. Clinical examinations showed normal ultrasound and histopathology findings. Blood analysis demonstrated moderate anemia and low elevated serum b-human chorionic gonadotropin. Due to profuse hemorrhage and anemia after the curettage, the medical council decided that a total hysterectomy should be performed. Macroscopic examination of the post-operative material showed regular morphology of the uterus, fallopian tubes and ovaries. However, a whitish brown lesion with a maximum diameter of 22 mm was noted in a longitudinal section of the cervix. Using standard histopathology and immunohistochemical analysis, a cervical gestational choriocarcinoma was diagnosed. Knowledge of the characteristics of the choriocarcinoma is very important for accurate diagnosis and treatment, especially when the tumor is localized on the rare locations and where a high level of serum b-human chorionic gonadotropin is absent.

Aortobronchial (AB) fistula is a rare disease, which is presented with massive hemoptysis; lethal if not treated. It should be suspected in any patient who presents with massive hemoptysis and had previous thoracic aortic surgery, but even it may be seen in patients without any history of operation on the thoracic aorta. Although, today in many centers endovascular therapy is done for these patients, but it is not the standard approach. Surgery in urgent situations has an essential role in saving the patients. Operative management consists of double lumen intubation and one lung ventilation, followed by femoral artery and vein cannulation posterolateral thoracotomy and achieving proximal and distal control on the aorta, applying cardiopulmonary bypass (CPB), separation the lesion, and bypass the segment of the diseased aorta by a synthetic graft.