مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و دوم شماره 10 (پیاپی 166، دی 1393)

Eyes and the vision system allow the human being to receive information from the environment to the extent that 90% of the man’s information is acquired through observation، thus health and correct function of this organ have always been important. Diseases threatening vision such as Acute Macular Degeneration and Diabetic Retinopathy deprive millions of people of seeing every year while access to proper cures can prevent many ocular damages. Despite scientific progress in the medical fields over the recent decades there still exist many challenges in the field of ophthalmology and ocular diseases. As for ocular treatments، major challenges stem from pharmaceutical weaknesses، in other words in spite of access to the suitable drugs for ocular complications we have not yet succeeded to achieve an appropriate method to apply these drugs. By appropriate application of drugs we may deliver the active pharmaceutical ingredient to the target organ with the least side-effect، the most benefit and the highest level of patient compliance. Incapability of effective delivery of drug to the eye arises from the special physiology and anatomy of this organ. The static barriers such as Blood-Aqueous and Blood-Retinal and dynamic barriers such as conjunctival blood circulation and lymphatic clearance will reduce the bioavailability of ocular drugs. Overcoming the above-mentioned weaknesses requires a complete knowledge of the eye characteristics as well as acquaintance with novel drug delivery system. When speaking of drug delivery system (DDS) it means employing a two-part structure consist of active pharmaceutical ingredient (API) and carrier that in fact characteristics of formulated DDS will determine by the carrier. We may hope that by applying and designing modern pharmaceutical systems that mainly take advantage of nanoparticles we would be able to overcome many challenges of ocular drug delivery. The present study is aimed at reviewing the eye structure، challenges faced by ocular drug delivery، familiarity with nanotechnology and approaches of this science in the area of ophthalmology as well as mechanisms of designing a local system for effective drug delivery to the eye tissue.

Uterine myomas are benign tumors of the uterus and the most common solid pelvic tumors causing symptoms in approximately 25% of women in their reproductive years. However, its etiology and pathogenesis remain obscure; there is increasing evidence that endometriosis is inherited as a complex genetic trait. Recent studies indicated the involvement of glutathione S-transferase M1 (GSTM1) gene in the pathogenesis of this disease and current investigations are devoted to the other members of phase II detoxification system genes such as glutathione S-transferase T1 (GSTT1). Therefore, current study was carried out to investigate the distribution of GSTM1 and GSTT1polymorphisms in Iranian population in order to estimate possible impact of null-alleles of each gene in development of this disease. In this study, 50 patients with endometriosis diagnosed by both pathology and laparoscopic findings according to the revised American Fertility Society classification of endometriosis were recruited from subjects referred to the Pasteur Institute of Iran between November 2012 to September 2013. Accordingly, controls (n=50) were subjects without any of aforementioned gynecologic conditions. The genomic DNA was extracted from peripheral blood leucocytes using the salting out method and GSTM1 and GSTT1 genotyping for gene deletions were carried out using Gap-polymerase chain re-action. Logistic regression analysis was applied to assess whether there was any significant risk increase between the case group with higher null genotypes compared to control group. The level of statistical significance was set at 0.05 and all analyses were conducted using the SPSS version 18.0 (SPSS Inc., Chicago, IL). There was significant evidence that the distribution of the GSTM1 and GSTT1 genotypes differed between the patients and the controls with an allelic odds ratio (OR) of 3.56 (95%CI: 1.35-9.37, P=0.01) and 3.92 (95%CI: 1.4-10; P=0.009) respectively. Data analysis also revealed that individuals with both GSTM1 and GSTT1 null genotypes (-/-) had higher risk to develop the disease in comparison to the people with the both present (+/+) genotype (OR:19.23, P=0.007). The findings suggest that the GSTM1 and GSTT1 genetic polymorphisms are associated with the development of endometriosis in Iranian women which is in agreement with previous results obtained in other populations. However, the ethnic variations of polymorphisms should be evaluated in detail and differences should be incorporated into investigations of susceptibility variants for this disease.

Preterm premature rupture of membranes (PPROM) occurs in 17% of pregnancies, which leads to 20% of perinatal death. According to previous studies uterine anomalies are one of the risk factors for preterm birth, PPROM and pregnancies complications. The aim of this study was to evaluate the relationship between PPROM and rupture of membrane (ROM) with uterine cavity anomalies based on hysteroscopic findings. This cross-sectional study was conducted in Imam Khomeini Hospital, Ahvaz, Iran, from May 2011 to May 2012. After conducting a pilot study, 66 nulliparous pregnant women at 14-37 weeks of pregnancy with PPROM and ROM were selected randomly. Then the women were evaluated by hysteroscopy at least six weeks after delivery or miscarriage. The control group includes 66 women with at least one normal pregnancy (without history of PPROM, secondary infertility or recurrent abortion), who underwent diagnostic or therapeutic hysteroscopy for other reasons than PPROM. The hysteroscope instrument specifications were KARL STORZ model (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany), inner sheet 26153 BI, outer sheet 26153 BO, and BA lens with 30 degree. Normal saline solution (Sodium Chloride 0.9%) also was applied as distention medium. The study was approved by Ethic Committee of Ahvaz Jundihspur University of Medical Sciences. Informed consent was obtained for all participants. Overall, the frequency of uterine anomalies in case and control groups was 12.12% and 3%, respectively (P<0.05 based on Chi-square test). Possibility of uterine cavity anomalies in the women with preterm premature rupture of membranes (PPROM) was significantly higher than the women with normal pregnancy (OR=4.41, CI 95%: 0.9-21/63). About 3% of patients in the case group had undefined uterine anomalies. This anomaly was not in mentioned uterine anomalies classification of American fertility association. We did not observe such anomaly in control group. In conclusion, we found that the possibility of occurring PPROM in women with uterine cavity anomaly was four-fold more than women without these anomalies. Hence, we recommend women with history of PPROM to undergo diagnostic hysteroscopy for detecting uterine anomalies before next pregnancy.

Wrist arthroscopy is an evolving diagnostic and therapeutic modality which is progressively used by Iranian surgeons. Little data is published about the procedure’s indications, outcomes, complications and prognostic factors. In following study we evaluate the outcome and complications of diagnostic and therapeutic arthroscopy in our patients. In a prospective study from September 2009 to March 2013, 100 patients entered in the study. All the patients had chronic wrist pain without any sign of improvement despite at list three months non-operative treatment and underwent diagnostic and therapeutic wrist arthroscopy. All patients were evaluated by wrist range of motion, visual analogue scale (VAS), the quick-disabilities of the arm, shoulder and hand (Q-DASH), and Mayo wrist functional score before and after arthroscopy. Patients were visited at 3, 6, 12 weeks intervals after surgery and every six months thereafter. The most frequent diagnoses were triangular fibrocartilage complex (TFCC) injury, dorsal wrist ganglion cyst and Kienbock disease which were treated with accordant arthroscopic methods. Major and minor complications of arthroscopy and prognostic factors were evaluated. Eighty nine patients participated in long term follow-up. The follow-up duration was 19±13 months. At final fallow-up there were 28.6±9.6 degrees improvement in wrist range of motion, 5.1±3.4 reduction in VAS score (P<0.04), 37.9±30 improvement in Mayo functional wrist score (P<0.02) and 47.5±33 reduction in Q-DASH score (P=0.009). 82% of patients were satisfied with postoperative results and 16% experienced recurrence. The preoperative diagnosis was not a prognostic factor for outcome of arthroscopic treatment. The rate of postoperative complications was 31.4%, which most of them were minor and transient complications. The most frequent complication of wrist arthroscopy in our patients was transient hypoesthesia in superficial ulnar nerve territory. According to our results, wrist arthroscopy have acceptable outcome in TFCC injuries and Kienbock disease. With the ever-expanding list of indications and procedures that can be performed with wrist arthroscopy, it can be considered as an essential diagnostic and therapeutic tool for the orthopedic surgeon.

Short-stem prosthesis for total hip arthroplasty (THA) have been designed to overcome the weakness of standard-stem prostheses and improve surgical outcomes. The aim of this study was to compare short-stem with standard-stem prosthesis outcomes. This study was performed as a randomized clinical trial. Subjects were selected among patients referred to Sina University Hospital, Tehran, Iran from April 2010 to 2012. THA were performed with short-stem or standard-stem prostheses after obtaining written informed consent from patients. Balanced block randomization method was used to get a random sample in each group. Clinical outcomes were evaluated based on Harris Hip Score (HHS). Patients were followed up for at least one year. All patients were examined at 2 weeks, 6 weeks, 3 months, 6 months and one year after surgery. In each visit, Control X-ray was obtained and bone and prosthetic position were assessed. Also, the symptoms such as infection, pain, claudication, ability to climb stairs, using crutches and weight bearing were rechecked. Student t-test was used to compare outcomes in the two groups. A total of eighty four THA were studied. 13 patients were lost to follow-up or had infection and failure. One patient died with the prosthesis in situ from causes not related to the surgery. Therefore, a total of 70 patients were analyzed. Of these, 34 and 36 hips underwent small stem and standard stem THA, respectively. The mean age of the patients at the time of operation was 61.1±8.68 years (range, 48-86 years). Most common reasons for arthroplasty were osteoarthritis, avascular necrosis and dysplasia of hip. There were significant differences between the two study groups in bleeding during surgery (P=0.001). There were no significant differences among the study groups in HHS except for 6th week and 3th month (P=0.000). The use of short-stem prosthesis can improve the performance of patients in short-term but no significant difference with standard-stem prosthesis in long- term.

Nausea and vomiting is one of the most important complications in chemotherapy. Serotonin and dopamine are important neurotransmitters in nausea and vomiting. It seems that oxygen therapy and increase oxygen saturation can cause decrease these neurotransmitters. The aim of this study was to investigate the relationship between arterial oxygen saturation (SaO2) of patients and chemotherapy-induced nausea and vomiting. A descriptive-analytical study was performed in Koosar Hospital in Semnan, Iran, from 19 September 2013 to 25 April. At first, SaO2 of 30 patients in three periods (pre, during and post chemotherapy) were measured. Severity of nausea and vomiting in three days after chemotherapy was measured with an index of nausea, vomiting and retching (Rhodes Index). Also during chemotherapy, anxiety and depression of patients was measured with Hospital Anxiety and Depression Scale (HADS). In this study thirty patients were evaluated. Most of them were women (66%) with mean age of 55.07±11.9 years old. The most common cancer in patients was breast cancer (46.7%). Mean of SaO2 was 92.1%±3.4 that was not significant difference during the chemotherapy. Mean of nausea and vomiting severity in first day of chemotherapy was (3.27±5.5), in second day was (4.5±6.2) and in third day was (7.2±8.7). The Pearson correlation coefficient did not show the relationship between oxygen saturation with severity of nausea and vomiting (P>0.05). Although severity of anxiety of patients was significant relationship with nausea and vomiting in third day (P=0.03). In this study there was no significant relationship between oxygen saturation and severity of nausea and vomiting, but anxiety of patients was related to nausea and vomiting in third day. Chemotherapy-induced nausea and vomiting was more common in third day and it seems that further research is needed for relationship between oxygen saturation and nausea and vomiting in third day of treatment.

Fibromatosis includes a variety of fibroblastic proliferation whose biological trend and histopathological patterns are at intermediate level between benign fibroblastic lesions and fibrosarcoma. Accordingly, because of overlapping of histopathologic features of fibrosarcoma, particularly low-grade type, with fibromatosis, the present study was conducted to find more precise criteria for histopathological and immunohistochemical (IHC) differentiation of these lesions. In this cross-sectional descriptive analytical study, a total of 40 specimens from pathology department archives in hospitals of Isfahan and Tehran universities from 2003 to 2013, including 20 fibrosarcoma and 20 fibromatosis biopsies, were selected. First, histopathologic characteristics were identified using H&E slides and an optical microscope H&E slides and then they were stained through immunohistochemical staining technique using the EnVision for markers Ki-67 and β-catenin. Afterward the samples were examined by optical microscope and positively stained cells were counted. There was no significant difference between fibromatosis and fibrosarcoma in terms of a mean age (P=0.063), distribution of gender frequency (P=0.197), necrotic rate (P=0.602), clarity of nucleolus (P=0.799) and SID mean of β-catenin marker (0.369). However, it was seen a meaningful difference between fibromatosis and fibrosarcoma in terms of frequency distribution (P=0.017), rate of mitotic figures (P<0.001), rate of herring-bone pattern (P=0.043), rate of cellularity (P<0.001), rate of nucleus overlapping (P<0.001), mean of Ki-67 (P=0.046), mean of Ki-67-limit (P=0.001) and atypia rate (P<0.001). There was a meaningful difference between fibrosarcoma and fibromatosis in terms of mitotic figures, expression of Ki-67 mitotic marker, herring bone pattern, cellularity and atypia. Therefore these features can be used to differentiate the relevant pathological lesions. However, no meaningful difference between two tumors in terms of expression and intensity of β-catenin, clarity of nucleoli and necrosis. This indicates that they are not reliable criteria of differentiation between fibrosarcoma and fibromatosis.

Respecting gestational age and medical intervention at birth, Combined Apgar score, a new method proposed by American Academy of Pediatrics (AAP) may better evaluate neonatal condition at birth compared with conventional Apgar score. The combined Apgar consists of the Specified and the Expanded Apgar describe a more detailed condition at birth. In Expanded Apgar, administered intervention and in Specified Apgar, infant`s condition regardelless of gestational age and intervention are emphesised. To evaluate combined Apgar score in perinatal asphyxia, we compared conventional versus Combined Apgar scores to anticipated neonatal asphyxial complications. In a prospective cohort study, we assessed 464 neonates admitted in, Vali-e-Asr University Hospital, during one year from September 2012 to September 2013. We assessed neonates by Conventional and Combined Apgar scoring at 1, 5 and 10 minutes after birth. Asphyxia was recognized based on newborn`s records. Diagnostic criteria for asphyxia include, occurrence of metabolic or mixed acidosis, apgar score less than three in 5th minute, occurrence of neurological complications like seizure, hypotonia, coma and multiple organ failure. Then we used SPSS V16 for data analysis and compare sensitivity between two methods of Apgar scoring. From 2200 delivered neonates, we assessed 464 neonates. 9.3% of studied neonates had Asphyxia, which equals 2% of live births. The Apgar score was lower in asphyxiated neonates by both methods (6±1 vs. 9±1 according to conventional method and 9±1 vs. 16±1 scored in combined method). Combined method was more sensitive than the Conventional Apgar scoring (99% vs. 88%). In asphyxiated neonates sensitivity and specificity of combined apgar were more than conventional apgar. With respect to this study, better assessment could be achieved by combined apgar score method instead of conventional Apgar.

Diabetes can cause undesirable changes in structure of the placenta, re-sulting increase in size and weight of placenta. The aim of this study was, to investigate the placenta weight, size and birth weight of infants in pregnant women with controlled gestational diabetes compared with normal pregnancy. This study was conducted from October, 2012 to February, 2014 in two dif-ferent hospitals, Valiasr and Shariati Hospitals in Tehran. Sixty-seven healthy singleton pregnant and 42 pregnant women with diabetes were selected during 26-28 weeks of gestational ages. Glucose tolerance tests (GTT) were performed to evaluate blood glu-coses. Blood glucoses were controlled in diabetic cases very well. Length and width of the placentas were measured using ultrasonography during pregnancy. After termina-tion of pregnancy, placental weights were measured and recorded using weighting scale with 10 gram accuracy by someone who didnt know about diabetes status. Baby weights were measured after birth and initial stabilisation. In this study, there were no significant differences between gestational diabe-tes mellitus (GDM) and healthy groups in Body Mass Index (BMI) factors. There was no statistically significant differences between the mean weight of infants born with gestational diabetes and control groups. There were no statistically significant differ-ences between the mean placental weights between two groups. Ratio of the placental weights to the birth weights between the two groups were not statistically significant. The mean placental length, width and placenta length times by width in two groups had no significant differences, but the mean gravidities in healthy group was 1.7910 and in gestational diabetes mellitus was 1.9762 that are significantly different (P=0.0217). The mean parities respectively were 0.6567 and 0.8100 which was not sig-nificantly different (P=0.0183). The present study has shown there was no significant differences between fetal and placental weights in normal pregnancies and women with controlled gesta-tional diabetes.

Cervix is a rare and dangerous site for ectopic pregnancy. When the placenta is implanted lower than internal cervical os, it is called “cervical pregnancy”. Known risk factors for cervical pregnancy are previous cesarean section, cigarette smoking, premature transfer of fertilized ovum before having suitable endometrium and pelvic inflammatory disease. In the past, hysterectomy was the usual treatment. Nowadays, with the newer diagnostic and therapeutic managements, cases of cervical pregnancy treated by fertility sparing methods have been reported. Conservative treatments include using methotrexate and KCl, hyperosmolar glucose, and prostaglandins. Also, surgical methods with fertility sparing have been reported. The purpose of this study is introducing two cases of cervical pregnancies treated by fertility sparing. The first patient had six weeks pregnancy with live fetus and detectable fetal heart beat. There was six weeks menstrual retard and βhCG titer was 10.000 UI/ml. Two doses of methotrexate were prescribed and pregnancy terminated successfully. The other patient had eight weeks pregnancy with fetal heart beat. There was eight weeks retardation and βhCG titer was 70379 UI/ml with no gestational sac in sonography in both patients. After prescribing two doses of methotrexate and doing curettage three days after the last dose of methotrexate, pregnancy terminated. The known risk factors for our patients were history of endometrial curettage in one and history of cesarean section in both of them. Conservative method may be considered for the treatment of cervical pregnancy in patients who desire to preserve their fertility. The treatment is associated with high success rates. Methotrexate (MTX) is the most common medicine for resolving ectopic cervical pregnancy, other medications such as KCl, hyperosmolar glucose, RU486 and prostaglandins have also been used with different success rate. Methotrexate may be administered systemic (intramuscular or intravenous) or local (intra-amniotic transfusion or intrauterine).