Archives of Iranian Medicine
Volume:11 Issue: 5, Sep 2008

Pancreas transplantation is the treatment of choice for selected patients with type 1 diabetes mellitus. We reviewed our first 40 patients who underwent pancreas transplantation in Shiraz Organ Transplant Center. Between April 2006 and April 2008, we performed pancreas transplantation on 40 recipients. The operation included portal venous drainage and exocrine enteric drainage. Immunosuppressive therapy included prednisolone, tacrolimus, and mycophenolate mofetil. Ganciclovir was administered as prophylaxis for cytomegalovirus. Peri-operative and regular follow up data on survival and complication were gathered and analyzed. The mean follow-up was 10.1±6.5 months (range: 1 – 24 months). Mean age of donors and recipients was 23.6±8.2 and 32.30±8.9 years, respectively. The mean pretransplant insulin consumption was 43.75±17.4 IU. Fasting blood glucose before transplantation was 275.5±72.3 mg/dL that decreased to 95.6±7.01 at six months follow-up (P<0.001). Complications were as follows: re-exploration (n=9), gastrointestinal complications (n=10), acute rejection episodes (n=12), and chronic rejection (n=4). We lost one patient due to diffuse cytomegalovirus and aspergillus infection three months after the operation with a functioning graft. Overall graft survival was 84.9% and patient survival 97.5%. Good patient and graft survival in these series encouraged us to continue the program with all its difficulties.

Left ventricular myocardial performance index is a Doppler-derived parameter of nongeometrical ventricular function that measures both systolic and diastolic function of the left ventricle. The objective of this study was to compare prognostic value of left ventricular myocardial performance index with global left ventricle function in patients undergoing coronary artery bypass graft surgery. One hundred consecutive patients who underwent coronary artery bypass graft surgery for coronary artery disease were studied from March 2004 through September 2006. Recovery of global left ventricle function and left ventricular myocardial performance index were measured serially by Doppler echocardiography after coronary artery bypass graft surgery. The patients were under supervision for four months after discharging from hospital. We studied the incidence of atrial fibrillation, postoperative myocardial infarction, pericardial and pleural effusion, infection, and also ventilation time and intensive care unit stay. For analysis of the events, we divided the patients into two groups. Group A was considered with left ventricle ejection fraction of <40% and group B had a left ventricle ejection fraction of >40%. Global left ventricle ejection fraction and left ventricular myocardial performance index were not related to pericardial effusion, pleural effusion, and postoperative infection. In group A, left ventricular myocardial performance index had more prognostic value for prediction of incidence of atrial fibrillation rhythm and postoperative myocardial infarction than the global left ventricle ejection fraction. But global left ventricle ejection fraction had more prognostic value for ventilation time and intensive care unit stay in comparison with left ventricular myocardial performance index. These associations were not seen in group B. The prognostic effect of left ventricular myocardial performance index was no more than global left ventricle ejection fraction in early and late complications of coronary artery bypass graft surgery but only affirm global left ventricle ejection fraction in some situations.

The mutations in p53 gene and accumulation of p53 protein are the most common genetic events in gastric carcinomas. The present study was conducted to compare the frequency of p53 gene overexpression in a consecutive series of adenocarcinomas arising from the cardia and the antrum. This study also evaluates the associations of this gene expression with demographic and clinicopathologic findings (age, sex, histology, and grade of tumor). Retrospective analysis was performed on 111 patients with gastric cancer who had undergone upper gastrointestinal endoscopies in 5th Azar Medical Center (northeastern, Iran), during 1998-2005. The series comprised of 25 patients with cardia adenocarcinoma and 86 patients with antral adenocarcinoma. p53 alteration (nuclear p53 overexpression) was detected by immunohistochemistry. Nuclear p53 overexpression was found in 14 (56%) out of the 25 and 27 (31.3%) out of the 86 patients with cardia and antral adenocarcinomas, respectively. p53 gene overexpression was significantly more frequent in adenocarcinomas of the cardia than the antrum. There were no differences in the clinicopathologic characteristics of the tumors between p53-positive and p53-negative cases in both types of the cancer. This study shows that p53 alterations correlate well with gastric location, and they are more frequent in adenocarcinoma of the cardia than the antrum. This result reinforce the hypothesis that the cancers of the lower esophagus and upper stomach have distinct epidemiologic, pathogenesis, and molecular characteristics from that observed in cancers of the lower part of the stomach.

Active smoking and passive exposure to environmental tobacco smoke cause respiratory symptoms as well as long-term complications. We know little about the sources of exposure to tobacco smoke in our population and the symptoms that can be related to smoking in adults and children. A survey on the range of symptoms relevant to smoke exposure was conducted. Residents of Tehran were interviewed by telephone through random digit dialing. Exposure to tobacco smoke and other environmental pollutants were sought at individual level. A geographical information system was used to determine the levels of the pollutants corresponding to addresses of the participants. We interviewed 34,121 individuals. Of the male and female adults, 21.3% and 3.4% were current smokers, respectively. About one third of the children and teenagers were exposed to smoking in one way or the other. In regression analysis, respiratory symptoms such as cough, phlegm, breathlessness, chest tightness, and throat discomfort were consistently associated with smoking in adults. In teenage group, cough and phlegm were related to habitual smoking. We failed to find a significant relation between passive smoking and symptoms in children. The range of respiratory symptoms associated with smoking is different in various age groups. The high percentage of children exposed to passive smoking expedites rigorous educational measures.

Blood and body fluid exposures place healthcare workers at risk for blood-borne infections. To determine the extent of the problem in Iran, we assessed blood and body fluid exposure in healthcare workers in Fars Province hospitals. We distributed 2,118 questionnaires using a stratified random sampling method among nurses of these hospitals. We used Chi-square test, Student’s t-test, and multiple logistic regression analysis for determining risk factors for exposure. The overall prevalence of blood and body fluid exposures was 79% with a rate of exposure to sharps devices of 50%. Hypodermic needles were involved in most exposures (73%) with the most common source of injury being needle recapping (35%). Blood was the most frequent contaminant (87%) in mucocutaneous exposures, most commonly associated with inserting and removing intravenous lines (50%). Sharps injuries were independently associated with gender, professional level, and hospital location; mucocutaneous exposures were related to professional level and hospital location. Only 28% of nurses reported their exposures. The high level of risk found among nurses in Fars Province highlights the urgent need for interventions to enhance their occupational safety and to prevent unnecessary transmission of blood-borne viruses.

Obsessive-compulsive disorder typically begins early in life and has a chronic course. Despite the need for long-term treatment, the information about therapeutic effect on different clinical subtypes is limited. Consecutive outpatients with obsessive-compulsive disorder were evaluated for response to a two-month fluoxetine therapy course by Yale-Brown obsessive -compulsive scale according to the clinical subtype of the disease. Of 265 patients, fluoxetine significantly decreased the symptoms in general. The mean Yale-Brown obsessive- compulsive scale in washers and patients with obsessive thoughts was significantly decreased after the intervention. The decrease in Yale-Brown obsessive- compulsive scale in checkers was not statistically significance. Fluoxetine has sustained efficacy on patients with obsessive-compulsive disorder and is generally well tolerated. Fluoxetine has greater efficacy on washers and on obsessive thoughts than checkers.

Human rotavirus has now been established as the most important cause of childhood gastroenteritis worldwide. The RNA genomic electrophoretic diversity of group A rotavirus strains in Tehran, Iran, during April 2002 through March 2005, was investigated in 1250 stool specimens. Stool samples were obtained from young children with acute gastroenteritis. RNA electrophoretype of group A rotavirus strains was determined using RNA polyacrylamide gel electrophoresis in those samples found to be positive for rotavirus by enzyme immunoassay. The predominant RNA profile detected was the long electrophoretype (90%) followed by the short profile (8.8%). Four patients (1.1 %) had patterns of mixed infection. Fourteen different electrophoretic RNA patterns, eight of long and six of short, were detected in the study area. A long RNA electrophoretype persisted during the years of the study with peak incidence in cool seasons. The long pattern occurred throughout the study period and in patients aged one to 60 months, but the short profile identified only in infants at varying intervals. Our data demonstrate epidemiologic differences between the incidence of long and short electrophoretypes. The long profiles appear to circulate continuously in the area, whereas the short patterns appear in an episodic fashion.

Minichromosome maintenance protein 6 (MCM6) is one of the six proteins of minichromosome maintenance family that are involved in the initiation of DNA replication and thus represent a marker for proliferating cells. The aim of this study was to determine the proliferation characteristics of neoplastic cells in patients with classic Hodgkin''s lymphoma. Paraffin-embedded blocks of lymph node, mediastinal, subcutaneous chest wall, and lung mass biopsies of 55 patients with classic Hodgkin''s lymphoma were immunostained by the proliferation-associated monoclonal antibodies; Ki-S5 (Ki-67 antigen) and Ki-MCM6 (MCM6 antigen). High MCM6 antigen expression was a striking feature of Hodgkin''s and Reed-Sternberg cells (median: 85%, range: 35 – 99%) in comparison with lower Ki-67 expression (median: 63.5%, range: 1 – 98%, P<0.001). This indicates that MCM6 is already expressed in the early G1 phase, a cell cycle fraction that is not covered by antibodies specific to the Ki-67 antigen. The proliferation rates were determined by two markers, independent of histologic subtype, stage, presence of B symptoms, and size. These data show that a subset of Reed-Sternberg and Hodgkin’s cells is arrested in the early G1 phase and the MCM6-positive cells do not necessarily represent the real proliferating compartment of Hodgkin''s lymphoma. Clinical relevance of this marker in patients with Hodgkin''s lymphoma should be investigated.

To compare the long-term effect of dalteparin in the prevention of neovascularization of iris in recent-onset central retinal vein occlusion with that of aspirin. A randomized controlled clinical trial was conducted on patients with central retinal vein occlusion of less than 30 days duration. Patients in the dalteparin group received subcutaneous dalteparin 100 IU/kg twice a day for 10 days, and then 100 IU/kg once a day for another ten days. In the aspirin group the patients received 100 mg aspirin daily throughout the study. Forty seven patients were enrolled, 24 in the dalteparin group and 23 in the aspirin group, and were followed up for one year. One (4.1%) of the 24 patients in dalteparin group, and 9 (39.1%) of 23 patients in aspirin group developed iris neovascularization. the difference was significant (P=0.0001). The visual outcomes of the two groups were compared, and a significant difference was found (P=0.016). Patients treated with dalteparin within 30 days of the onset of central retinal vein occlusion were less likely to develop neovascularization of iris. There was also a significant difference in the visual acuity between two groups.

Recently another member of the paraoxonase gene family designated paraoxonase-2 has been identified. Paraoxonase-2 has antioxidant properties similar to paraoxonase-1 and paraoxonase-3. However, in contrast to paraoxonase-1 and paraoxonase-3, paraoxonase-2 is not associated with high-density lipoprotein and may only exert its antioxidant function at the cellular level. We assessed the frequency and genotype distribution of cys 311 ser paraoxonase-2 polymorphism in 300 subjects (>40 years old) with angiographic documentation of coronary artery disease (150 patients with >50% stenosis served as cases and 150 individuals with <20% stenosis served as controls) to determine the possible association between this mutation and susceptibility for coronary artery disease. The paraoxonase-2 genotypes were determined by polymerase chain reaction and DdeI restriction enzyme digestion. The cases (coronary artery disease positive patients) showed significant differences in the distribution of cys 311 ser paraoxonase-2 genotypes as compared with the controls (coronary artery disease negative subjects, P=0.015). The analysis of paraoxonase-2 genotypes distribution showed higher percentage of CC genotype among coronary artery disease positive compared with coronary artery disease negative (P=0.008). After controlling for other risk factors, the cys 311 ser polymorphism had not correlation with age, body mass index, gender, smoking, diabetes, level of high-density lipoprotein, low-density lipoprotein, triglyceride, and total cholesterol. Our data indicate a major effect of the paraoxonase-2 polymorphism on coronary artery disease risk in patients referred to Shariati Hospital in Tehran.

Chronic anal fissure is one of the most common causes of anal pain and surgical therapy is the treatment of choice. There is scarce information regarding the prophylactic effects of oral metronidazole on postoperative complications of anal fissure. The objective of this study was to determine the effects of metronidazole as a prophylactic measure for postoperative anal fissure complications. In a numerical randomized clinical trial, 311 patients with anal fissure were randomized into two groups. The group which received prophylactic oral metronidazole was compared to the control group regarding wound dehiscence, bleeding, discharge, and pain after one and two weeks of operation. One hundred fifty-six patients with mean±SD age of 36±7.3 years were in metronidazole group and 155 patients with mean±SD age of 38±7.1 years were in the control group. Regarding the studied outcome variables, the patients in both groups did not have any significant differences after one and two weeks. Our results did not support the prophylactic use of metronidazole in reducing postsurgical complications after internal sphincterotomy of anal fissure.

Opium addiction is a common form of addiction in Middle East countries such as Iran. Recently several reports suggested some kinds of pathologic findings such as abdominal pain, nephropathy, and anemia in opium addict patients. Such pathologic findings suggest lead poisoning in the patients. In this study, the concentration of lead in 10 opium samples was evaluated. The mean concentration of lead in the opium samples was 1.88 ppm. This may explain some of the pathologic findings found in addict patients. The authors would suggest further investigations to evaluate the lead concentration in opium addicts'' sera and also routine screening for lead poisoning in opium addict patients.

Assessment of nasal airway is helpful in understanding nasal breathing function. Acoustic rhinometry is one of the most commonly-used objective measurements of nasal airway. This test has the ability to measure the volume and the cross-sectional area of the nose in different distances. It also determines the site of minimal cross-sectional area. These variables are different in various races. Defining these normal values in adult Iranian population, as a criterion for diagnosis and treatment of nasal diseases can be very helpful.One hundred eighty adult Iranians (18 – 60 years old) without nasal breathing complaints underwent acoustic rhinometry. The mean volume and minimal cross-sectional area of the nose and also correlation of these variables with age, sex, height, weight, smoking habit, and topical nasal decongestion were assessed. In this sample, total nasal volume was 8.12±0.94 cm3 and total minimal cross-sectional area was 0.9±0.17 cm2 before decongestion. There was no correlation between these values and age, sex, height, weight, and smoking habit. There was a significant increase in volume and cross-sectional area after decongestion. Because of the differences in volume and minimal cross-sectional area in various races, measurement of these values in Iranian population is a proper way for diagnosis of rhinologic diseases and planning the appropriate treatment (medical or surgical). It is also helpful for comparison of preoperative and postoperative results after nasal surgeries.

Sclerosing stromal tumors are benign ovarian neoplasms of the sex cord stromal category which occur predominantly in the second and third decades of life. Herein, we report a 26-year-old woman who developed a sclerosing stromal tumor of the ovary with irregular menses but normal hormonal status. She was suspected to have a malignant tumor and underwent bilateral oophorectomy. Other ovarian stromal tumors include fibroma and thecoma which tend to occur in the fifth and sixth decades of life. It is,therefore, necessary to keep in mind the possibility of a sclerosing stromal tumor in a young woman.

A 20-year-old woman was brought to the surgical outpatient department with the strange history of irresistible desire to ingest metallic substances, mainly nails and pins. Her problems were initiated after she was forced to marry against her wish. She had no abdominal complaints and on examination the abdomen appeared absolutely normal. Plain radiograph confirmed numerous nails and pins inside her GI tract. On detailed psychologic evaluation, she was found to be suffering from deviant sexual behavior and marriage against her wish acted as a stressor in the development of this habit.

Actinomycotic infections are known to be associated with difficulties in making the diagnosis and treatment. Actinomycosis of the tongue is rare and of great importance, not only because it can mimic many other diseases, but also because the tongue itself has some histophysiologic features that make it resistant to infections. In this report, we present a case of lingual actinomycosis and discuss the predisposing factors as well as the diagnostic methods and therapeutic modalities.

Arthrogryposis-renal tubular dysfunction-cholestasis syndrome is a rare multisystem disorder, originally described in 1973 and to date only 62 patients have been reported. Herein, we reported on a neonate with arthrogryposis-renal tubular dysfunction-cholestasis syndrome presenting very early after birth. Recurrent febrile illnesses, failure to thrive, ichthyosis, hypothyroidism, and bilateral hearing loss were among other associated findings. Blood films revealed abnormally large platelets. Polyhydramnios, hybrid type of renal tubular acidosis and hypothyroidism found in this case are not usually seen. We propose to expand the acronym of this syndrome and name it as arthrogryposis-renal dysfunction-cholestasis-hypothyroidism-ichthyosis-deafness or dysmorphic features syndrome.

Cancer registry is an important tool for any successful cancer control program. The first formal cancer related data from Iran were published in 1956. In 1969, observations documenting a high incidence of esophageal cancer in the Caspian Littoral, urged researchers to set up the first population-based cancer registry in this region. This cancer registry was established jointly by University of Tehran and the International Agency for Research on Cancer (IARC). In 1976, another cancer registry started its activities in Fars Province. In 1984, the Parliament passed a bill mandating the report of all tissues “diagnosed or suspected as cancer tissue” to the Ministry of Health. While only 18% of all estimated cancer cases were reported in first reports, this rate increased to 81% in 2005 In 1998, Tehran Population-Based Cancer Registry started to collect data from cases of cancer referred to the treatment and diagnostic facilities throughout the Tehran metropolis. Digestive Disease Research Center, Tehran University of Medical Sciences, established four new population-based cancer registries in Northern Iran and another in Kerman Province in the south. These five provinces have a total population of about 9.5 million, and constitute about 16% of the total population of Iran. While the pathology-based cancer registration is in place, we hope that the addition of the population-based cancer registries, and establishment of new registries in poorly-covered areas, will improve cancer reporting in the country.