Acta Medica Iranica
Volume:52 Issue: 7, Jul 2014

There is a number of models and strategies for improving the quality of care such as total quality management, continuous quality improvement and clinical governance. The policy of clinical governance is part of the governments overall strategy for monitoring, assuring and improving in the national health services organization. Clinical governance has been introduced as a bridge between managerial and clinical approaches to quality. For successful implementing of clinical governance, it is necessary to pay attention to firm foundations of the structure, including equipment, staffing arrangement, supporting specialties, and staff training. Therefore, as clinical governance improves safety and quality in health care services, the current situation in hospitals should be evaluated before any intervention while barriers and blocks on structure and process should be determined to select a method for changing them. Considering these points could guarantee success in implementation of clinical governance; otherwise there would be a little chance to achieve the desired results despite consumption of plenty of time and huge paper works.

This study investigates the effects of melatonin on the sperm quality and testis weight after the combination of swimming exercise and nandrolone decanoate (DECA). Two groups of male Wistar rats were treated for eight weeks as follows; group A consist of CO (control), Sham, N (DECA), S (swimming) and NS (DECA plus swimming); and group B: Sham M (sham melatonin), M (melatonin), MN (melatonin plus DECA), MS (melatonin plus swimming), MNS (melatonin, DECA plus swimming). The motility of sperm was significantly improved in melatonin groups in comparison to N, S and NS groups (P≤0.05). The left testes weight was decreased in N, NS and MNS groups, and the right testes weight was decreased in N,S,NS, MS and MNS groups in compare with the control group. This study concluded that melatonin probably could improve the sperm motility and sex organs weight after the combination of DECA and exercise.

Osteoporosis is a common health concern in both developed and developing countries. In this study the association between anthropometric measures and osteoporosis was investigated in 3630 males and females visiting BMD clinic of Shariati Hospital, Tehran, Iran, a teaching hospital and referral center for osteoporosis affiliated to the Tehran University of Medical Sciences. Anthropometric measurements obtained and also Bone Mineral Density (BMD) measurement was done using a Lunar DPXMD densitometer. Data were analyzed using SPSS with Chi-square and ANOVA with post-hoc tests. Results showed that the weight, BMI and age had the strongest correlation with the BMD values in the studied people. While age is negatively correlated with BMD in all the studied people, a positive association was noted between weight, height and BMI and BMD parameters (P<0,01). It was concluded that certain anthropometric parameters (BMI and weight) can considerably affect one''s risk of developing osteoporosis. Further research on the effect of these variables on the association of weight and BMD is needed.

Most obsessive-compulsive disorder (OCD) patients meet psychiatrists 5 to 10 years after onset of OCD. Its relatively high prevalence ratio and the delay in seeking help suggest that patients with OCD may seek help at non-psychiatric clinics. The present study was undertaken to provide some epidemiological data on the prevalence and severity of OCD in dermatological patients. The participants included 265 consecutive patients with primary dermatologic chief complaint. They were visited by a dermatologist and diagnosis of dermatological lesion was done according to ICD-10. All patients were visited by a psychiatry resident and were screened for OCD using the structured clinical interview for DSM-IV-TR (SCID-I). If the diagnosis of OCD has been made, the Yale-Brown obsessive compulsive scale(Y-BOCS) was used to evaluate the severity of OCD. To analyze the data student t-test for quantitative variables and X2 tests for categorical variables. From the total of 265 patients, 24 (9.1%) met the DSM-IV-TR criteria for OCD and 9 (37.5%) with OCD had previously been diagnosed with OCD, however, only three were treated pharmacologically. The most symptoms were pathological doubt (29.1%), fear of contamination (29.1%) and washing (54.16%). Severity of OCD according to Y-BOCS was evaluated among patients with OCD. Six (25%) were found with subclinical OCD, 11(45.8%) had mild OCD, six (25%) had moderate OCD, and one (4.2%) was detected with severe OCD. prevalence of OCD in dermatology clinic was higher compared with general population.

Psoriasis is a chronic relapsing disorder that involves the skin, nails and joints. With regard to the role of the immune system in psoriasis, the current study compared serum IgE concentration in patients with psoriasis with control group. Current case-control study was conducted in Dermatology clinic of Razi hospital, Tehran University of medical sciences, Tehran, Iran in 2012. Fifty-eight patients with psoriasis e referred to the clinic were assigned as patient group and 58 healthy subjects with matched age and sex as a control group. Patient''s history, family history and demographic characteristics such as age and sex, duration and severity of disease using PASI, were collected and entered into a form. Consent form was obtained from participants. Serum IgE concentrations of both study groups were measured by electrochemiluminescence assay in the laboratory A total number of 58 patients with psoriasis, mean age of 44.15 (19-76 years) and 58 controls with matched age and sex were studied. Mean average of serum IgE concentration in the control group was 115.13 versus 200/06 concentration in patients group (P=0.16). Serum IgE concentration in 22.4% of patients versus 17.2% in controls was greater than normal concentration (P=0.48). No significant correlation was between serum IgE concentration and disease severity using PASI (P= 0.11, r = 0.21), neither a significant correlation with disease duration, age and gender. According to the present study, serum IgE concentrations are not greater in patients with psoriasis. IgE concentration is also not associated with the severity of psoriasis based on the PASI score, therefore, the role of IgE in psoriasis can be considered insignificant as some previous studies indicate.

Clinical assessment of distal symmetric polyneuropathy (DPN) involves the evaluation of symptoms and signs. Although there are numerous tools to evaluate DPN, there is still a need to determine the most sensitive, specific, and accurate tests to detect DPN in a busy outpatient clinical setting. A total of 107 patients with type 2 diabetes were examined using Michigan Neuropathy Screening Instrument (MNSI). Total score of the instrument was used as a standard to calculate sensitivity, specificity and diagnostic accuracy of every single item of MNSI to find the most accurate and applicable test for evaluation of DPN. In patients’ history, the most sensitive (99.4%) and accurate (78%) symptoms were muscle cramp and weakness. Numbness and prickling had lower sensitivity (72.6% and 67.9%, respectively) but greater specificity (65.2% and 47.8%). In physical assessment, the most accurate signs were appearance of feet (81.3%), ankle reflexes (67.2%), and vibration perception (63.5%). Monofilament test had a sensitivity of 16.7%, accuracy of 31.7% with specificity of 87%. Findings show that symptoms such as a muscle cramp, weakness, numbness, and prickling, as well as signs such as ankle reflexes, appearance of feet, and vibration could be used as the most accurate tests for rapid diagnosis of DPN. In addition, the results suggest that monofilament examination may not be the optimum test to detect high risk patients.

Hand eczema is a common distressing skin problem. It is an immune reaction to haptens. Thus, substances that inhibit Immune system can be effective in the treatment of hand eczema. In this study, topical fumaric acid 5% cream is compared with topical steroid in the treatment of hand eczema. Patients with hand eczema were randomly divided into two groups. One group received fumaric acid 5% in a cream base, and the other received triamcinolone 0.1% in the same cream base. Both groups used creams twice daily for one month. Patients were checked for erythema, excoriation, population and lichenification, EASI score, and pruritus before and after treatment. In both groups, the mean of all signs of the disease and EASI score decreased after one month of treatment. There was no significant difference between the two treatments in decreasing erythema, but excoriation, population, lichenification, EASI score and itching were all decreased more in triamcinolone 0.1 % group. Although fumaric acid can inhibit the immune system; it was less effective for the treatment of all signs of hand eczema except erythema in comparison to triamcinolone. These results may be justified for two reasons: low penetration of topical fumaric acid through the skin or a low concentration used in this study.

Readiness assessment provides a proper image of the existing conditions and an explanation of facilitated operational plans and functional approaches to successful implementation of electronic health record. Readiness assessment requires indices adjusted to particular conditions in each country. Therefore, the present study attempts to provide an acceptable model in Iran and to provide an assessment of public and teaching hospitals in medical education university. After reviewing related papers and descriptive study of five selected countries, the initial model was designed in the form of a questionnaire for analysis through Delphi and distributed among 30 experts nationwide. Along identification of components in the proposed method, a 7-point Likert scale was used to determine priority of each component. Then, all general -education hospitals at Tehran University of Medical Education were examined based on this model in terms of total, relative, or no readiness. The final model was designed in five dimensions: cultural, leadership and management, technical infrastructure, governance and operational dimensions; Educational Hospitals were evaluated in this dimension. 28.6 % of general – teaching hospitals are ready for pre-implementation. It seems to establish uniform strategic and executive team in Health center is essential for the preparation them in abovementioned area in the least possible time.

Congenital nasolacrimal duct obstruction (CNLDO) is a common disease in children. The classic treatment of CNLDO is probing that was done around one year old. However, controversy exists regarding the outcome of probing in children older than one year. This study aimed to find the cure rate of initial probing for CNLDO and identify factors producing the failure rate in old age. In this retrospective interventional case series study, 100 eyes of 92 patients aged 9-48months with CNLDO underwent probing with general anesthesia. According to the intraoperative results of probing, CNLDO were categorized in two groups of membranous obstruction at the end of nasolacrimal duct obstruction (NLD) and complex obstruction at canaliculus, lacrimal sac and N LD. Patients were categorized in three groups according to the age of probing into under 12, 12 to 24 and over 24 months. Success rate was defined as successful irrigation of NLD intraoperatively and absence of lacrimation and discharge at 1week, one, three and six months postoperatively. The average age of patients and probing were 47.35±25.59 and 17.32±7.85 months respectively. Membranous obstruction accounted for 72% of patients and remainder had complex type. An overall cure rate of 91%, 89% and 60% was found in patients aged 9-12, 12-24 and 24-48 months respectively. Surgery success rate after six months was 91% in membranous group and 52% in complex group. There was a significant relation between the type of obstruction and opening of NLD (p<0.O01). This study showed that the probing failure of probing after one year was related to the complexity of obstruction rather than the age of the patient. It is recommended that probing could safely be done in under 4years old.

This study was designed to assess the frequency of exclusive breastfeeding in two health centers of Shahid Beheshti University of Medical sciences in Khak Sefid, Tehran, Iran. A total of 175 mothers, referred for the third dose of their infants’ DPT vaccination program participated in the study by completing a questionnaire regarding characteristics of their pregnancy, delivery and exclusive breastfeeding within the first six months of birth. Two-variable analysis and logistic regression test were applied to evaluate factors influencing exclusive breastfeeding. Results indicated that the frequency of exclusive breastfeeding, i.e., breastfeeding within the first six months of birth without the use of any other food with or without vitamin supplementation, was 31.17% (95% CI=23.77% - 38.57%), which means 48 infants of 154 >179 days old Among 154 infants (>179 days old) 48 did not have a history of being separated from their mothers. In logistic regression analysis, the variables which were directly associated with exclusive breastfeeding, with 0.05 significance level of alpha, included breastfeeding within the first hour of birth, eight times or more breastfeeding per day and receiving breastfeeding education during pregnancy. Variables with a negative association with breastfeeding included lack of breast milk, presence of a breast problem that could hinder breastfeeding, bottle feeding, physician or family’s advice not to breastfeed and infant’s refusal to breastfeed. Frequency of breastfeeding within the six months of birth is less than similar frequencies which are obtained by asking about breastfeeding on the day of the interview. It is recommended to apply real frequency for assessment, evaluation and programming of exclusive breastfeeding during the first six months of birth.

To evaluate theeffect of frequent feedback on residents'' communication skills as measured by astandardized checklist. Five medical students were recruited in order to assesstwelve emergency medicine residents'' communication skills during a one-yearperiod. Students employed a modified checklist based on Calgary-Cambridgeobservation guide. The checklist was designed by faculty members of TehranUniversity of Medical Science, used for assessment of students’ communicationskills. 24 items from 71 items of observational guide were selected, considering study setting and objects. Every two months an expert faculty, based on descriptive results of observation, gave structured feedback to each residentduring a 15-minute private session. Total mean score for baseline observationstanding at 20. 58 was increased significantly to 28. 75 after feedbacks. Resultsmarkedly improved on «gathering information» (T1=5. 5, T6=8. 33, P=0. 001), «building relationship» (T1=1. 5, T6=4. 25, P<0. 001) and «closing the session» (T1=0. 75, T6=2. 5, P=0. 001) and it mildlydropped on «understanding patients view» (T1=3, T6=2. 33, P=0. 007) and «providing structure» (T1=4. 17, T6=4. 00, P=0. 034). Changesin result of «initiating the session» and «explanation andplanning» dimensions are not statically significant (P=0. 159, P=0. 415respectively). Frequent feedback provided by faculty member can improveresidents’ communication skills. Feedback can affect communication skillseducational programs, and it can be more effective if it is combined with othereducational methods.

Numerous causes arereported for ulnar nerve compression at the wrist, known as Guyon''s tunnelsyndrome. In the present article, a patient with Guyon’s tunnel syndrome duringpregnancy concomitant with an anomaly of ulnar nerve is described. A 29-year-oldIranian woman presented with clinical features of Guyon''s tunnel syndrome (painand paresthesia in the fifth finger of the left hand and atrophy of the firstdorsal interosseus muscle). Symptoms of the patient appeared during the thirdtrimester of pregnancy. Electro diagnostic studies confirmed Guyon''s tunnelsyndrome. Surgical exploration revealed an anomalous arch of the ulnar nervepassing through the flexor carpi ulnaris (FCU) tendon. The anomalous arch ofthe ulnar nerve was released by resection of the segment of FCU tendon passingthrough the ulnar nerve arch. Therefore, in patients with Guyon''s tunnelsyndrome, the ulnar nerve anomaly should be kept in mind as a cause. Moreover,pregnancy may have a provocative effect on Guyon''s tunnel syndrome similar tocarpal tunnel syndrome (CTS).

A twenty-year-oldgirl was referred with tracheal stenosis (TS) which was a consequence ofprolonged intubation after head injury because ofprevious car accident. The patient wasaphasic and had normal respiration. Fiberoptic bronchoscopy showed completetracheal obstruction at second tracheal ring level. Distal trachea was normalthrough tracheostomy tube. Removal ofthe tracheostomy tube and blind reinsertion with a new one was complicated withhypoxia and respiratory distress. Fibrotic bronchoscopy revealed largetracheoesophageal fistula (TEF) below tracheal obstruction. Reinsertion of the tracheostomy tube by fiberoptic bronchoscope was successful. Multidetector CT scan was performed on thesame day with confirmation of TS combined with TEF. Surgery was performed onthe next day. No clinical evidence of TEF was found in back history. Inadequateevaluation of the whole length of the trachea during the first bronchoscopy wasthe reasons for missing TEF. TEF should be considered in patients with TS inspite of no typical symptom such as food aspiration or pulmonary infections.

This studydescribes two cases of cervical sympathetic schwannoma operated at department ofvascular surgery and review the literature to clarify the demographic,diagnostic, and therapeutic features of these rare lesions for the first time.Two 32- and 59-year-old ladies both presenting with a painless cervical masswere referred to our service with the initial diagnosis of carotid body tumor.At the operation, mobile masses which could be easily dissected from thesurrounding arteries and veins, except for the cervical sympathetic trunk wereobserved. Micro-surgical techniques helped us with removing the lesions withsaving the sympathetic trunk in both cases. No permanent deficits were observedpost-operatively in patients. Angiographic studies can provide the onlypre-operative clues to diagnose a sympathetic schwannoma. Total removal of thelesion at the expense of sacrificing the sympathetic nerve is associated withminimal neurologic deficits which are well tolerated by the patient.

Neonatalrespiratory distress is a very common problem in our practice. The causes maybe respiratory, cardiovascular, central, metabolic, haematological andsurgical. The cause of distress due to transient myocardial depression is notvery common in mild asphyxia. We present a case having transient myocardialdepression with severe respiratory distress and features of shock in a mildasphyxiated baby.

Pachyonychia congenital(PC) is a rare autosomal dominant genodermatosis characterized hyperkeratosisaffecting the nails and palmoplantar areas, oral leukokeratosis, and cystic lesions.A 39-year-old woman with PC type 1 (Jadassohn-Lewandowsky syndrome) and B-celllymphoma is described. No similar disorders or parental consanguinity werefound in her family. Typical features of PC developed since her early childhoodand the diagnosis of B-cell lymphoma was established seven years ago, without aclear causal relation between these entities. Despite inherent limitations of asingle case, this report may contribute to PC understanding.