مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و دوم شماره 9 (پیاپی 165، آذر 1393)

Helicobacter pylori (H. pylori) is the causative agent in development of gastroduode-nal diseases، such as chronic atrophic gastritis، peptic ulcers، mucosa associated lym-phoid tissue (MALT) lymphoma، and gastric cancer. H. pylori has been associated with inflammation in cardia، showing the fact that infection with this bacterium could also be a risk factor for gastric cardia cancer. Gastric cancer is the fourth most common cancer worldwide. This is the second leading cause of cancer-related deaths، and ap-proximately 700،000 people succumb each year to gastric adenocarcinoma. It has been estimated that 69% of the Iranian population currently harbor H. pylori infection. The prevalence of duodenal ulcer and gastric cancer is high in Iranian populations. However، this has been largely influenced by geographic and/or ethnic origin. Epidemi-ology studies have shown that host، environmental، and bacterial factors determine the outcome of H. pylori infection. The bacterium contains allelic diversity and high genet-ic variability into core- and virulence-genes and that this diversity is geographically and ethnically structured. The genetic diversity within H. pylori is greater than within most other bacteria، and its diversity is more than 50-fold higher than that of human DNA. The maintenance of high diversification makes this bacterium to cope with particular challenges in individual hosts. It has been reported that the recombination contributed to the creation of new genes and gene family. Furthermore، the microevolution in cagA and vacA genes is a common event، leading to a change in the virulence phenotype. These factors contribute to the bacterial survival in acidic conditions in stomach and protect it from host immune system، causing tissue damage and clinical disease. In this review article، we discussed the correlation between H. pylori virulence factors and clin-ical outcomes، microevolution of H. pylori virulence genes in a single host، microevolu-tion of H. pylori during primary infection and progression of atrophic gastritis to ade-nocarcinoma، and H. pylori infection status in Iran. Finally، we put forward the hy-pothesis that if the pattern of nucleotide sequence evolution shifts from recombination (r) to mutation (m) and the r/m ratio is reduced، bacterial pathogenicity may be re-duced while maintaining the bacterial life. However، this hypothesis should be further studied with future experiments.

Education is the main mission of teaching hospitals، but the residents’ learning in acquiring new techniques does interfere in the overall treatment process of patients. Studies pertaining to the effect of anesthesia residents’ training in operating room on treatment procedures have reported conflicting results. Therefore، this study was performed to investigate the effects of anesthesia residents’ training on start time operative delays. This cohort study was done in neurosurgical operating room، Imam Khomei-ni Hospital، Tehran، Iran during 2010-2013 on a population study comprising of sec-ond year anesthesia residents. Patients were classified into three groups with 30 cases in each one according to the anesthetic team. Group I: one anesthesiologist in charge of two operating rooms and two anesthesia assistants; Group II: one anesthesiologist in charge of one operating room and one assistant; Group III: one anesthesiologist with-out an assistant. Patients in these groups were compared in terms of American society of anaesthesiologists (ASA) class، induction difficulties and type of surgery. Studied variables included: 1) Interval between the patient lying on the bed to till anesthesia، 2) the time devoted to teaching residents، 3) time from the start of anesthesia until the start of surgery. An observer that was blinded to the type of intervention and the study design، recorded the times. ASA class (P= 0. 94)، induction difficulties (P= 0. 66) and type of surgery (spinal cord or brain operation) (P= 0. 41) were not statistically different between patients in groups. Preoperative preparation time for the first group (23. 5±8. 1 min) was longer than the other two groups (21. 5±6. 2 min and 15. 8±9. 1 min)، respectively (P= 0. 001). Differences between the times from start of anesthesia to surgeries in three groups، based on ASA class and type of surgery were not significant (P> 0. 05). There was no re-lationship between the times devoted to teaching residents in the first and second groups (P> 0. 05). Anesthesia residents’ training in neurosurgery operating room may in-crease the time required for preparing for surgery، but this time expended is hardly of any significance.

Asthma as an airway disease is identified by increase network respon-siveness of the trachea and bronchus to a specific stimulus. Th17 cells through produc-tion of IL-17 have important role in inflammation and autoimmune diseases. In some studies has been shown which IL-17 as major cytokine of Th17 probably has im-portant role in the pathogenesis of allergy and asthma. Total mRNA extracted from whole blood samples and sputum of 23 asthma patients and 23 normal controls. Then، total RNA was converted into cDNA according to the manufacturer’s instructions. Finally، the transcript levels of IL-17 were quanti-fied by the real-time quantitative PCR. Twenty-three patients with asthma were diag-nosed and selected according to the global initiative for asthma (GINA) and none of the patients had taken the medication at least three week before sampling. Healthy in-dividuals did not have any history of allergy، asthma and other inflammatory diseases at the time of sampling. All of experiments have done in Isfahan University of Medical Sciences، Iran during May to February، 2013. This study showed a significant increase in transcript levels of IL-17 in the blood (287±79 versus 1/18±0/13) and sputum samples of the patients (64±28 versus 0/9±0/1) in comparison with normal individuals (P= 0. 000، P= 0. 029 respectively). It al-so revealed that the expression levels of the cytokines in the serum samples of the asthmatics were significantly more than their levels in patient’s sputum samples (P= 0. 000). However، there was no significant difference between the cytokines expression levels in serum samples and sputum samples of the controls (P> 0. 05). In this study، we showed which the expression of IL-17 was increased in serum and sputum of asthmatic patients compared to healthy controls، this could re-sult in elevation of neutrophils population and activation of pulmonary neutrophil.

Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the ureter and toward the kidney. Vesicoureteral reflux is the most com-mon inherited disease in urogenital system. Primary VUR is the most common urologi-cal anomaly in children and it has been reported in 30-50% of those who present with urinary tract infection (UTI). The association of vesicoureteral reflux، urinary tract in-fection and renal damage is well known. ‍Current methods for vesicoureteral reflux di-agnosis are unpleasant. Therefore، human leukocyte antigen system not only might help to detect causative gene but also would assists to establish better prognoses tests of this disease. In this study، the relationship between vesicoureteral reflux and HLA-DRB1 and HLA-DQB1 genes were investigated. This study applied on forty vesicoureteral reflux confirmed children from Kerman province، Iran. These children have been admitted to the Afzalipour Hospital for UTI and primary VUR for them was proved by voiding cystourethrogram (VCUG). Also، forty children without any VUR sign as control group. DNA was extracted from the whole blood sample and was amplified using sequence-specific priming polymerase chain reaction (PCR-SSP) method. Finally PCR products were evaluated by electropho-resis in 1. 5% agarose gel and frequency of alleles and haplotypes were compared by Chi-square test. Significance level was assumed at P< 0. 05. Low-resolution HLA typing showed the frequency of the HLA-DR17 antigen was significantly increased in vesicoureteral reflux children compared to control group (P= 0. 039). On the other hand HLA-DR16 was significantly decreased in vesicoureteral reflux group. Also، frequency of HLA-DQ2 was significantly higher in patients com-pared to control group (P= 0. 002). DRB1 (11، 17) and DQ (2، 7) haplotypes were also higher in vesicoureteral reflux patients (P= 0. 027، P= 0. 01). The HLA cluster might affect on susceptibility to vesicoureteral reflux es-pecially by locus which located close to HLA-DRB1 and HLA-DQB1 genes. This study demonstrates for the first time in Iran. However، further extensive researches with a large number of samples from different populations and ethnicities are required to val-idate the results obtained in this study.

Chronic spinal cord injury has an important role in sensorimotor disor-ders which is associated with many complications and the rate of these complications should be certainly considered. The most important complications are the changes in bones and joints which come with pain and lead to increase in their motor disability. In this paper، the radiographic images were studied and the ossifications of spinal cord and pelvis were described and also the type of changes and their prevalence was eval-uated. In this study، 500 patients and veterans with spinal cord injuries who were hospitalized in Khatam-Ol-Anbia Hospital were examined. The spinal and pelvis x-ray of the patients have been studied for spinal cord ossification، the hip joint narrowing، sacroiliitis، heterotopic ossification، osteophyte and the presence of quiver in the graph. Among the patients، 485 cases were males and 15 cases were females، the av-erage age was 50. 26 and the mean duration of injury was 26 years. Four hundred and forty six patients were paraplegic and 54 cases were quadriplegic. There was a signifi-cant relationship between age and the number of involved vertebrae (P= 0. 000)، psori-asis like ossifications (P= 0. 048) and large osteophytes (P= 0. 037)، also between the du-ration of the injury and the hip joint narrowing (P= 0. 008)، the number of involved ver-tebrae (P= 0. 008). In addition the presence of shrapnel in the graph is correlated with large osteophytes and more heterotopic ossification. The most frequent cause of chronic spinal injuries of our patients has been the injury by quiver، it seems our results may not be extended to all patients with spinal cord injury. In lumbar spine radiography of the patients، osteophytes، the quiver and psoriasis like ossifications were mostly seen. In the pelvis x-rays the most changes were hip joint narrowing، sacroiliitis and the heterotopic ossification.

Endometrial carcinoma is considered the most common gynecological cancer in the world. Pelvic and para-aortic lymphadenectomy is widely advised based on FIGO staging system. Intra-operative frozen sections analysis is used to identify pa-tients at high risk for pelvic and para-aortic nodal metastasis evading lymphadenec-tomy in low-risk patients. However there is still some controversy concerning the effi-ciency of IFS. The aim of this study was to determine the validity and precision of fro-zen section diagnosis and gross examination of uterine specimen compared to the final histological results in patients with endometrial cancer. Patients diagnosed as endometrial cancer based on office biopsy using a Pipelle or D&C who underwent surgical staging were compared for frozen section anal-ysis and permanent diagnosis. Patients with the history of radiotherapy or other types of cancer or co existence malignancies were excluded. There was no relation between the tumor size and lymph node involvement and the results were not significant (P= 0. 1). Frozen section analysis was significantly accurate and correct in predicting final histopathological results (P< 0. 0001). It has been shown that in more than 90% of patients the diagnosis made by frozen section analysis was in accordance with final pathology with considerable sensitivity and spec-ificity. Gross examination was also precise in determining myometrial microscopic in-vasions (P< 0. 0001). Although the sample size of the studied population was small but our study results support the previous data and suggest that in early stages and low grade tumors، gross examination and frozen section diagnosis are conveniently predictive of lymph node metastasis. These data might be useful for prediction of tumor invasion using frozen section and gross examination in low grade tumors and early stages and for doing complete surgical staging and lymph node sampling. However the im-portance of surgical staging always must be considered in patients who need systemat-ic lymphadenectomy. In overall these data might help to come up with new guidelines for surgical risk assessment in endometrial cancer.

Maternal mortality is one of the most important indicators of women health standard in developing countries. This study aimed to determine the prevalence of risk factors and etiology of maternal mortality in a geographic region of Iran. This descriptive- analytic cross sectional study included all pregnant women who died during pregnancy and six weeks after delivery due to pregnancy related fac-tor. The study was done in Sistan region in the north of Sistan and Baluchestan Prov-ince of Iran from April 2002 to March 2014. The immigrant women were excluded. Data were collected using 3 parts questionnaire. The validity and reliability of ques-tioner were approved by experts in this field. Data were analyzed using the statistical software SPSS version 18، Chi-square test and ANOVA analysis were performed. The total number of deliveries during this time period was 60496. The total number of maternal mortality was 57 patients which means 94. 2 out of 100. 000 live births. Most of the dead mothers had more than 35 years old (46. 9%)، gestational age was more than 22 weeks (77. 2%)، gravidity more than 4 (21. 1%)، pregnancy interval lower than two years (46. 9%) and 75. 4% of death was in post-partum. The main cause of mortality was post-partum hemorrhage (19. 3%). Based on our findings، some factors including multiparity، pregnancy his-tory more than 4 times، short interval between pregnancies lower than 2 years and ma-ternal age more than 35 years were some risk factors for maternal death. Maternal mortality in the postpartum period was more than pre-delivery period. Bleeding was the main cause of maternal mortality. Therefore monitoring of vital signs in the post-partum period and the proper management of bleeding are very important. It is sug-gested that risk assessment should be done for pregnant women in delivery ward for detecting high risk pregnant women. Suitable management for these women especially for patients with postpartum hemorrhage plays an important role to decrease the ma-ternal mortality.

The rabies is a deadly disease and if its symptoms break out in a person، he will certainly die. However، the deaths caused rabies can be prevented by post-exposure prophylaxis (PEP). In this study، subjects were recruited through census and with respect to in-formation which gathered from Fars Province health centers، Pasteur institution and previous studies In Iran. The mortalities for age groups and by sex type have been cal-culated. The decision tree model using probabilities، which the effectiveness of PEP treatment after getting bitten by an animal suspected، persons to receive specified. Dis-ability adjusted life year score (DALY) was applied to estimate the DALYs saved from PEP. In this study it was assumed that if a person suffering with rabies، a few days af-ter the onset of symptoms، death is compulsory. Therefore YLD rabies was considered zero. Finally، to increasing the accuracy and because inherent uncertainty of the data، and the increase the power of analysis، one-way sensitivity analysis was used. From March 2011 to March 2012، in Fars Province، total cases of animal bites were reported and received PEP treatment. The cases were 5394 (75. 85%) male and 1717 (24. 15%) female. PEP generally prevented from 177. 076 deaths which 134. 096 (75. 72%) were men and 42. 98 (24. 27%) of them were women. The age distribution of suspected animal bites in youth more than adults، and in men higher than women. Also due to prevented mortality caused by PEP، it is prevented from 4455. 71 DALYs. Based on the sensitivity analysis DALY prevented، except for dogs and cats، there was no change in the other animals. The implementation of PEP for animal bitten people remarkably reduced the burden of disease in community. Calculations with primitive cost estimations im-plicitly revealed that this intervention is a most cost-effectiveness program.

Helicobacter pylori vacA (vacuolating toxin A) gene is comprised of mid- (m)، intermediate- (i) and signal-regions. Recently، the vacA-i region genotype has been suggested to be a better predictor of disease severity than either the s- or m-region. The main aim of the present study was to determine the associations of i region poly-morphisms of vacA gene with gastric cancer (GC) and peptic ulcer disease (PUD) in Azerbaijan Province patients. A number of 89 patients were enrolled. The biopsy samples were taken from patients referring to the endoscopy units of Imam Reza and Shahid Madani Hospitals، Tabriz، Iran from August 2012 to May 2013. The genotype frequencies of vacA-i1 and i2 in were studied using polymerase chain reaction (PCR). The frequency of vacA-i1 and i2 was 51. 68% and 48. 31%، respectively. The genotypic frequency of vacA-i1 in patients with GC (21/24، 87. 5%) was significantly higher than in those with non-atrophic gastritis، NAG (19/48، 39. 58%). In contrast، the genotypic frequency of vacA-i2 in patients with NAG، PUD، and GC was 60. 42%، 64. 70%، and 14. 28%، respectively. The results of multiple linear and logistic regression analyses confirmed the intensity of correlation of vacA-i1 allele with GC compared with control group (NAG). No significant correlation was found between the vacA-i-region alleles and PUD risk. We have proposed that the H. pylori vacA-i1 genotype could be an im-portant biomarker for predicting the gastric cancer risk in Azerbaijan Province in Iran. However، due to the difference in the allelic frequency of this gene in H. pylori strains from different parts of the world، the vacA-i1 genotype usefulness in predicting the gas-trointestinal diseases is dependent to the geographic origin of the strains.

This study aims to evaluate the outcomes and late complications of open Roux-en-Y gastric bypass surgery in the treatment of morbid obesity. Over a 15 year-period between May 1997 and May 2012، we reviewed our experiments with 39 patients who underwent open gastric bypass for morbid obesity. The weight of the patient and surgical complications were recorded. Ideal weight، body mass index، weight loss and excess weight loss were calculated. The follow up period ranged from 6 to 180 months with a mean of 100 months after operation. Average weight loss was 3. 9 and 0. 28 kg per month during the first and second years after operation weight loss was slower from the third year on-wards. Weight loss generally was stabilized between 12 and 18 months after operation. Only one patient (2. 6%) had a weight loss failure criterion. Concomitant condition ex-isted in 14 patients (48. 2%) of our series. These included hypertension in 3 cases (10. 3%) that was resolved in 100%، diabetes mellitus in 4 (13. 7%) that was resolved in 75%، cholelithiasis in 7 cases (24. 1%) that was resolved by cholecystectomy during the operation. There was no early postoperative death. Early complications occurred in 2 patients (5. 1%)، including pulmonary embolism (2. 6%) and gastrointestinal bleeding (2. 6%). The late complications occurred in 7 patients (17. 9%) involved 2 patients with anastomotic stricture at the gastrojejunostomy (5. 1%)، One patient with symptomatic cholelithiasis (2. 6%)، three patient with anemia (7. 7%)، and one patient had Wernicke ’s disease who died of this complication (2. 6%). The results of the study showed that the open Roux-en-Y gastric bypass surgery is an effective procedure in the treatment of morbid obesity with minimal late complications.