مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و یکم شماره 7 (پیاپی 151، مهر 1392)

In the Mediterranean region، Kaposi''s sarcoma (KS) has a high prevalence especially in patients with AIDS. Iran is located close to the Mediterranean region and the HIV prevalence is increasing in our country. In some stages، Kaposi''s sarcoma is morphologically similar to other vascular tumors. Owing to the presence of human herpesvirus 8 (HHV-8) in all cases of Kaposi''s sarcoma، detection of virus DNA by PCR method can help in the identification of non-diagnostic cases. Moreover، the prevalence of HHV-8 genotypes is different in various regions of the world and in different races. There are limited studies performed on the HHV-8 genotypes in Iranian population. Patients with Kaposi''s sarcoma from 2001 to 2011 who refer to Tehran Razi Hospital were enrolled in this study. HHV-8 DNA was extracted from paraffin blocks and amplification of the virus genome was performed by PCR method. Finally، the target DNA fragment was used for sequencing and genotype determination. PCR was performed on 53 cases. In 8 cases with suspicious morphology، PCR was negative and they were excluded from study. Of remaining 45 cases، 35 had positive PCR results، 7 had negative results and 3 had low PCR product. Samples from 28 cases that had positive PCR results، which were acceptable for genotyping، were chosen for sequencing. Twenty cases had genotype C، 7 cases had genotype A and one case was negative. The results are consistent with other studies in our geographical area. No correlation was found between the different microscopic stages and HHV-8 Genotypes. Since the HHV-8 is obtained in almost 100% of KS lesions and PCR s ensitivity in detection of the virus is close to 100 %، KS diagnosis can be confirmed in suspicious cases by detection of HHV-8 DNA on paraffin blocks. Moreover the prevalence of HHV-8 genotype was determined in Iran.

Pain is one of the greatest concerns of patients undergoing total knee arthroplasty (TKA); which is severe and intolerable within 72 hours post-surgery. Appropriate pain management is a key factor in patient''s early mobilization، launching physiotherapy، less hospital length of stay and more importantly، patient''s satisfaction. New studies with the infiltration of combined analgesic agents peri and intra-articularly has shown encouraging results in pain reduction، good clinical outcome and patient''s satisfaction. The purpose of this study was to compare the analgesic effect of locally infiltrated analgesia (I) compared with single injection femoral nerve block (F) and its impact on pain relief، patient''s satisfaction، morphine consumption and clinical outcome. This research was a double-blind randomized clinical trial on 36 consecutive patients undergone TKA divided into group (F) in which the ipsilateral femoral nerve in the inguinal area was blocked by a single injection of 20 ml ropivacaine (10 mg/ml) and group (I) which a combination of ketorolac، ropivacaine and epinephrine was injected peri and intra-articularly on the knee during TKA. Pain intensity measured by visual analog scale (VAS)، clinical outcome (based on range of motion)، morphine consumption and patient''s satisfaction of pain management after TKA were compared between the two groups. Pain intensity score (VAS) and Morphine consumption were statistically less in group I than group F during the first 6 hours and 24 hours post surgery respectively (P< 0. 05); however، group F had 12-hour VAS score of 5 which was less than group (I) by 1 grade in pain scale (VAS) (P< 0. 05). Other parameters were not statistically different in the two groups and patients'' response to our pain management protocols proved to be satisfactory in both groups. Lower level of pain and morphine consumption in group (I) during the first 24 hours post-surgery in contrast to group (F) and its ease of use by a surgeon intra-operatively، introduce local infiltration analgesia as an effective method to decrease the patient''s pain and improve patient''s satisfaction in early post-surgery period after total knee arthroplasty.

The aim of this study was to assess the association of serum adiponectin and a set of traditional cardiovascular risk factors with carotid artery intimal-medial thickness (CIMT) and coronary artery calcium score (CACS)، as markers of subclinical atherosclerosis in subjects with early type 2 diabetes mellitus. Carotid artery intima- media thickness (measured by B-mode ultrsonography)، coronary artery calcium score (determined by high resolution computed tomography)، serum adiponectin، Fasting blood sugar، serum lipids، body mass index (BMI)، systolic blood pressure، diastolic blood pressure and mean arterial pressure were measured in 123 asymptomatic newly diagnosed cases of type 2 diabetes mellituss and 152 age and sex matched healthy control subjects. Serum adiponectin and lipids were significantly lower in those with type 2 diabetes mellitus (P<0. 01). Left، right and mean carotid artery intima- media thickness، coronary artery calcium score، fasting blood sugar، systolic blood pressure، diastolic blood pressure and mean arterial pressure were significantly higher among diabetic patients compared to healthy controls (P<0. 05). Mean carotid artery intima- media thickness was positively and independently related to age (P<0. 001) and triglyceride (P=0. 01) in diabetic group. Coronary artery calcium score was associated positively with age (P=0. 004) and inversely with high density lipoprotein (HDL) cholesterol (P=0. 002) among diabetics. Although adiponectin was lower in diabetics compared to controls، it had no significant association with carotid artery intima- media thickness and coronary artery calcium score as markers of subclinical atherosclerosis. In patients with type 2 diabetes in addition to age، serum triglyceride levels are correlated with carotid artery intima- media thickness، while HDL cholesterol is inversely correlated with coronary artery calcium score.

Velopharyngeal insufficiency causes hypernasal vocal quality and can also result in audible nasal air emission and difficulty in producing pressure consonants. The resulting speech is often socially unacceptable and can be difficult to understand. Platelet-rich plasma is an autologous derivative of whole blood. Today، the importance of clinical use of Platelet-rich plasma in the plastic surgery is considered. This study was designed to evaluate the effectiveness of combined Platelet-rich plasma and fat injection in the treatment of velopharyngeal insufficiency. In this prospective clinicaltrial study، of 15 patients including 9 males and 6 females and aged 15-20 years with mild/ moderate velopharyngeal insufficiency who were injected with 5 mL of combined Platelet-rich plasma (1 mL) and fat (4 mL) in the front volume in the posterior pharyngeal wall in the pre-vertebral fascia under sedation. Speech samples were recorded by nasoendoscopy before the injection، and at 6 weeks and 6 months after the injection. Assessment of pathologic speech was done by speech therapist. Velar displacement showed significantly increased at 6 weeks after the injection (P=0. 049). Velopharyngeal gap disappeared in 60% of patients at 6 weeks after the injection (P=0. 019). Lateral pharyngeal wall movement showed significantly increased in 73. 3% of the patients at 6 months after the injection (P=0. 04). After the treatment، aerodynamic assessment showed significantly decreased in nasal air escape during phonation and repeat the words (P<0. 05). Assessment speech therapist showed significantly improve quality of phonation in these patients (P<0. 05). It seems that، combined Platelet-rich plasma and fat injection lead to improve voice resonance and reduce nasal air escape in all treated cases. It can be a promising alternative to major procedures، such as velopharyngoplasties، for the treatment of mild/ moderate velopharyngeal insufficiency.

Damages caused by scald burns are common and can cause severe complications and death. The purpose of this study was to define risk groups and then methods of prevention and treatment is designed to fit. Data for this retrospective study of hospitalized patients in Shahid Motahari Hospital in Tehran from 2007-2011 were compiled. Data including age، sex، cause of burn، and degree of burn and ultimate fate of the victims were collected from scald burns. Burns caused by boiling water and hot food (Scald)، in two age groups: 12 and under 12 years (children) and more than 12 years (adults) were compared in terms of statistics. A total of 1150 patients consisting of males (57. 9%) and females (42. 1%) were studied. The most common age was 1 year old and 50% of patients were under 3 years of age. 87. 9% burned with boiling water and 12. 1% had experienced burns with hot food. Incentive to burn was 0. 3% cross burning and 99. 7% incident. A maximum number of burns in children 12 years and younger males (42. 1%) and a minimum number in men over 12 years (15. 7%) were observed. Mean percentage of burns was 11% in over 12 years group and 30. 9% in 12 and under 12 years group. The average hospital stay was 11. 4 days and the mortality rate was 4. 8%. The final status of the patients was as fallows: full recovery 904 cases (78. 6%)، partial recovery 134 (11. 7%)، clearance with personal consent 41 (3. 6%)، death 55 (4. 8%) and 16 cases (3. 1%) were among other reasons. In general it can be said، scald burns incidence in individuals aged 12 and younger were more than the older ones and the mean of burns was lower in individuals with over 12 years old. There was a sexual preference for males under 12 years. Mortality rate in the two groups has not any statistically significant difference. There was no statistically significant association between sex and mortality rate. Some of our findings are depending on cultural، social and economic conditions، so generalized this findings to other geographical areas should be done with caution.

Arterial insufficiency is a well-recognized etiology of erectile dysfunction. Moreover، nowadays it is appreciated that it can herald silent coronary artery disease in involved patients. However color Doppler study of penis with intracavernosal injection (ICI) of Papaverin، as a helpful diagnostic study، is somehow time consuming and technically demanding، as a result، radiologists are reluctant to accomplish. Hence، in a search for more plausible parameters، we were determined to validate PSV in flaccid state for predicting possible arterial insufficiency in patients.

In a cross sectional study to evaluate diagnostic tests، accomplished in Hasheminejad Urology center in Tehran throughout 2011، we studied 59 patients with the complaint of erectile dysfunction. They were referred to our ultrasound clinics by urologists in order to undergo color Doppler study of penis by ICI of Papaverin. They were studied comprehensively before and after injection. Primary and secondary diagnostic criteria of arterial disease in color Doppler and consequently the physiologic event of full erection were designated as gold standard diagnostic considerations. The resulted data were matched and analyzed with SPSS software.

Fifty nine patients underwent the study، with the mean age of 45. 6 ± 13. 1 (24 to 74 year old). Twenty two cases revealed normal study (non-organic causes as 37. 3%)، 29 were classified as venous leakage، and eight of them demonstrate arterial insufficiency in the study. A flaccid state PSV of 10. 5 cm/s as cut off had a sensitivity of 93. 8%، specifity of 91. 3% and negative predictive value of 93. 8% to predict arterial disease.

A flaccid state PSV of 10. 5 has a suitable statistical value to proclaim arterial insufficiency in cavernosal arteries in patients with erectile dysfunction as a complaint.

HIV infection reduces the immune system and is the most significant factor in the spread of TB in recent years and one of the causes of death in HIV -seropositive patients. TB is the most commonly diagnosed opportunistic infection and the most frequent direct cause of death among HIV infected patients. The HIV infection can accelerate progression of TB infection to active TB disease. Among patients with active TB، those with HIV co-infection have the greatest risk for relapse. Regardless of increasing rate of TB and HIV in Iran، we decided to s urvey outcome of TB in HIV positive patients who treated with standard regimens in the years 2003-2012. This retrospective cohort study was conducted on HIV-positive patients with TB referred to Behavioral Diseases Consultation Center and Infectious Diseases Ward of Imam Khomeini Hospital from 2003 to 2012. Outcome was defined as failure، relapse and mortality. Moreover، the relationship between outcomes and number of CD4، co-trimoxazole and antiretroviral intake، type of TB and AIDS defining illness was studied. This study had 135 patients، 8 (5. 9%) were females and 127 (94. 1%) were males. The mean age of the patients was 40. 14+10. 02 and the most way to catch HIV in this study was intravenous drug user. There were 3 (2. 22%) cases of failure، 15 (11. 1%) relapse، and 21 (15. 8%) deaths. Antiretroviral therapy، AIDS defining illness، type of TB and co-trimoxazole intake did not soley affect relapse. CD4 level was the most effective variables in relapse [Hazard ratio: 0. 392 (0. 11-1. 4); Relative Risk: 0. 809 (0. 593-1. 103) (P=0. 068)]. However، regard to CI95%، the impact of CD4 on relapse is not significant and antiretroviral intake was the most important and effective variable in increasing their survival. Hazard ratio: 0. 137 (0. 141-0. 45); Relative Risk: 0. 686 (0. 513-0. 918) (P=0. 001) Overall، receiving antiretroviral was the most important factor influencing the outcome of patients.

On of the most common gasterointrestinal disease is gallstone disease and it`s prevalence is 11%-36%in autopsies. If gallstone leads to symptoms and side effect cholecystectomy will be inevitable. Gastric infection due to H. P will cause several symptoms of which dyspepsia and epigastric pain are outstanding. Gall stones also usually causes epigastric and/or right upper quadrant pain. Pain in other abdominal quadrant is less common. In this study we investigated the coincidence of gall stone and gastro intestinal H. P regarding the common symptom، between these two conditions to prevent unnecessary operation. The cases were adopted from cholecystectomy candidates due to gall stone disease (proved by ultrasonography). The control group were normal people who proved to be gall stone free ultrasonographicly. Serum IgG anti H. P was checked and compared between the two groups. Seventy percent of patients entered into the study which consisted of 35 case and 35 controls. The two groups were not significantly different in age and gender. There were 22 (68. 8%) and 10 (31. 2%) H. P positive cases in case and control groups respectively. Thirteen (34. 2%) and 25 (65. 8%) cases were H. P negative in case and control groups respectively. Comparing these results will reveal a statistically significant difference (P=0. 004). The relationship between gastric H. P and gall stone in this study supports the role of H. P in gall stone formation. According to our results and the common symptoms of two conditions specially in atypic biliary colic، it seems that in many cases gastrointestinal H. P causes the pain. Prospective studies are recommended.

Nocardia species are Gram-positive، partially acid fast، non-motile، catalase positive، aerobic and saprophytic actinomycetes found all around the world. They invade the human body from the environment via trauma and respiratory tract and cause cutaneous، pulmonary and systemic diseases. They are able to grow in various media. The organisms opportunistically infect both immunocompromised and immunocompetent individuals. Behcet''s disease is an autoimmune disease and immunocompromised patient which may suitable host for Nocardia bacterium. The present study is the first case report of isolation of Nocardia from the thigh abscess in a patient with behcet’s disease from Iran. A 39-year-old man with Behcet’s disease in August 2011 was admitted to Shariati hospital Tehran، with swelling and pain in the left flank and left thigh. Microscopic identification from direct microbiological slide of thigh abscess discharge demonstrated number of lymphocytes، neutrophils and macrophages foamy and white blood cells together with filamentous bacteria. Further microbiological characterization using phenotypic and antibiogram tests with disk diffusion method، demonstrated that the isolated bacterium is Nocardia asteroides complex. The bacteria were sensitive to ampicillin، vancomycin، ceftriaxone، amikacin and cotrimoxazole but it was resistant to clindamycin، erythromycin، penicillin G، cephalothin and gentamicin. The patient was treated with cotrimoxazole. Because of the high incidence and high mortality of Nocardia infection in immunocompromised cases، rapid detection and timely treatment for these patients is necessary.

It is rare to find squamous metaplasia in the thyroid gland. Its existence is usually seen in association with a pathological lesion such as mucoepidermoid carcinoma، squamous cell carcinoma and diffuse sclerosing variant of papillary thyroid carcinoma. In most cases the squamous cells are few in number and squamous metaplasia is focal and small in size. Extensive squamous metaplasia of the thyroid gland is a very rare finding.

We report a case of massive squamous metaplasia in Hashimoto thyroiditis in a 53 year-old- male with a four year history of hypothyroidism. Also seen in the history is impaired thyroid function tests of low T3 and T4 levels with rise in TSH. The patient currently presented with neck discomfort and a somewhat firm nodular neck mass. Ultrasonography revealed heterogeneous nodular enlargement of both thyroid lobes and a calcified nodule of the left lobe. Fine needle aspiration of the thyroid nodule was performed which reported findings suspicious for malignancy. Based on these findings the patient underwent total thyroidectomy.

In this article we address the causes and sources of massive squamous metaplasia in the thyroid gland. We also discuss the histopathologic differential diagnostic lesions which could be the cause of potential pitfalls encountered in the interpretation of the cytopathology and histopathology of such lesions arising in this gland.