Journal of Research in Medical Sciences
Volume:18 Issue: 7, Jul 2013

We investigated the difference of clinical practice pattern between end‑stage chronic obstructive pulmonary disease (COPD) patients with and without palliative care at the end of life in Taiwan. A total of 91 COPD patients who died in an acute care hospital were enrolled from one community teaching hospital in northern Taiwan between September 1, 2007 and December 31, 2009. The patients were divided into palliative (n = 17) and non‑palliative care (n = 74) groups. Demographics and medical care data obtained through retrospective review of medical records were analyzed to determine significant between‑group differences.There were no between‑group differences in intensive care unit (ICU) utilization, duration of ICU stay, duration of ventilator usage, invasive diagnostic procedures, invasive treatments, medications, and total medical cost. Patients in the palliative group had longer hospital stays (median 26 days vs. 11 days, P < 0.01) and higher rate of do‑not‑resuscitate orders (100% vs. 51%, P < 0.001), but lower rates of ICU mortality (73% vs. 41%, P = 0.026), invasive ventilation (57% vs. 29%, P = 0.04), cardiopulmonary resuscitation (12% vs. 51%, P < 0.001), and daily medical cost (250 US dollars vs. 444 US dollars, P < 0.001). Palliative care was underutilized and referral was delayed for COPD patients. COPD patients are polysymptomatic approaching the end of life and this characteristic should be taken into account in providing appropriate end‑of‑life care in the same way as for cancer patients. Palliative care for COPD patients is urgently needed in Taiwanand should be promoted

In this case report, we present a 30‑year-old man who developed pityriasis rubra pilaris (PRP) following exposure to Dolomite. The diagnosis of PRP was confirmed histologically and the patient was successfully treated with acitretin and cyclosporine.

Anaplastic thyroid cancer (ATC) is a rare disease with an incidence of less than three cases per million of habitants in western countries. ATC accounts for 1‑10% of all tumors derived from the thyroid gland. Classic chemotherapy approach based on platinum and anthracyclines regimens have been considered standard for the last decades. Novel multitarget agents have shown promising responses; however, no positive randomized clinical trials are available up to now. To our knowledge, the case we are presenting here is the first reported case showing clinical and visual activity using sunitinib as a salvage treatment in an ATC patient who was not fit to receive systemic chemotherapy treatment.

The purpose of this study is to determine sensitivity and specificity of body mass index (BMI) based on Center for Disease Control 2000 (CDC) percentiles compared to fat mass index (FMI) as an indicator of being really obese in children. Obesity was compared based on these two indexes among children under study. This cross-sectional study was conducted on 410 primary school girls aged 8-10 years, in the city of Esfahan. Weight and height were measured and BMI was calculated based on weight divided by height squared. Fat mass was measured by body composition analyzer (BCA) and FMI was calculated by dividing fat mass by height squared. FMI at or above the 90th percentile and FMI less than 90th percentile of reference data were considered as criterion for defining real obesity and normal adiposity, respectively. Receiver operating characteristic (ROC) curve was used to assess the performance of BMI in detecting obesity on the basis of FMI. Furthermore, the rate of agreement between two indices was calculated using Kappa coefficient P number. Mean and standard deviation of FMI and BMI in all children were 6 ± 2.1 (kg/m2) and 19.4 ± 3 (kg/m2), respectively. The area under the ROC curve for obesity was 0.75. The cutoff point, sensitivity, and specificity of BMI to classify children as obese compared to FMI were 21.2 kg/m2, 79%, and 73%, respectively. In this cutoff point for BMI (21.2 kg/m2), the agreement rate between BMI and FMI for determining obesity status was 0.5 (P < 0.001). Our results indicated 79% of children who were recognized as obese based on FMI, were also classified as obese according to BMI. Twenty-seven percent of children, who were non-obese, were identified as obese based on BMI. It appears that FMI compared to BMI is more accurate in determining obesity, but further studies are required.

The aim of this study was to compare the postoperative pain scores and morphine requirements between spinal anesthesia (SA) with hyperbaric bupivacaine 0.5% and general anesthesia (GA) with 1 minimal alveolar concentration (MAC)of isoflurane in 50% N2O and O2 after elective lower abdominal surgery. In this randomized clinical trial, 68 patients with American Society of Anesthesiologists (ASA) I or II undergoing lower abdominal surgery were randomly assigned to have elective lower abdominal surgery under SA (n = 34) or GA (n = 34). The SA group received 3 cc of 0.5% hyperbaric bupivacaine (15 mg), at L3–L4 interspace intrathecally and also 2 mic/kg fentanyl and 0.15 mg/kg morphine intravenously for intraoperative analgesia. In the GA group, induction of anesthesia was carried out with Na thiopental 6 mg/kg body weight, fentanyl 2 mic/kg body weight, morphine 0.15 mg/kg, and atracurium 0.6 mg/kg body weight, and then, trachea was intubated. The primary outcome was postoperative pain scores at rest and under stress on a visual analog scale and the secondary outcome was morphine requirement by the patients. Outcome measures were recorded at 2, 4, 6, 12, and 24 h postoperatively. The duration of postanesthesia care unit (PACU) and hospital stay were recorded. Intraoperative parameters, postoperative pain scores, complications, recovery time, and the duration of hospital stay at follow up were compared between the two groups. Patients in SA group had significantly lower scores of a postoperative pain at rest (3.4 ± 1.6 and 4.1 ± 1.2 at 2 and 4 h postoperatively vs. 5.2 ± 1.5 and 5.8 ± 0.9 in the GA group with p < 0.05), but there were no significant differences between both groups for scores of postoperative pain at 6, 12, and 24 h. The amount of morphine requirement in 6 h postoperatively was significantly lower in the SA group (10.2 ± 4.3 mg vs. 15.6 ± 5.6 mg in the GA group with p < 0.05), but there were not significant differences between the two groups after 6 h postoperatively. The duration of PACU stay was shorter for the GA group than the SA group (75 ±6 vs. 126 ± 12 min, p < 0.001), but there was no significant differences between the duration of hospital stay between the two groups (1.8 ± 0.6 vs. 2.1 ± 0.8 days). Although in patients undergoing elective lower abdominal surgery with SA may have lower pain scores and also lower morphine requirement in the first 6 h postoperatively, but after that there were no significant differences between SA and GA regarding postoperative pain scores and analgesic requirements and so more attention should be given to their postoperation pain relief.

Reforms in inpatient care are critical for the enhancement of the efficiency of health systems. It still remains the main costly sector of the health system, accounting for more than 60% of all expenditures. Inappropriate and ineffective use of the hospital infrastructure is also a big issue. We aimed to analyze statistical data on health indices and dynamics of the hospital stock in Kazakhstan in comparison with those of developed countries. Study design is comparative quantitative analysis of inpatient care indicators. We used information and analytical methods, content analysis, mathematical treatment, and comparative analysis of statistical data on health system and dynamics of hospital stock in Kazakhstan and some other countries of the world [Organization for Economic Cooperation and Development (OECD), USA, Canada, Russia, China, Japan, and Korea] over the period 2001–2011. Despite substantial and continuous reductions over the past 10 years, hospitalization rates in Kazakhstan still remain high compared to some developed countries, including those of the OECD. In fact, the hospital stay length for all patients in Kazakhstan in 2011 is around 9.9 days, hospitalization ratio per 100 people is 16.3, and hospital beds capacity is 100 per 10,000 inhabitants. The decreased level of beds may adversely affect both medical organization and health system operations. Alternatives to the existing inpatient care are now being explored. The introduction of the unified national healthcare system allows shifting the primary focus on primary care organizations, which can decrease the demand on inpatient care as a result of improving the health status of people at the primary care level.

The aim of this study was to create a diagnostic model using the artificial neural networks (ANNs) to predict malignancy in multinodular goiter patients with an indeterminate cytology. Out of 623 patients, 411 evaluated for multinodular goiter between July 2004 and March 2010 had a fine‑needle aspiration biopsy. All patients underwent total thyroidectomy. The interpretation was consistent with an indeterminate lesion in 116 (18.6%) patients. Patient’s medical records including age, sex, dominant nodule size, pre‑operative serum thyroid‑stimulating hormone level, thyroid hormone therapy and final pathologic diagnosis were collected retrospectively The mean age of the patients was 44.6 years (range, 17–78 years). About 104 (89.7%) were female and 12 (10.3%) were male patients. Final pathology revealed 24 malignant diseases (20.7%) and 92 (79.3%) benign diseases. After the completion of training, the ANN model was able to predict diagnosis of malignancy with a high degree of accuracy. The AUC of ANNs was 0.824. The ANNs technique is a useful aid in diagnosing malignancy and may help reduce unnecessary thyroidectomies in multinodular goiter patients with an indeterminate cytology. Further studies are needed to construct the optimal diagnostic model and to apply it in the clinical practice.

There is a broad variation in reported frequencies of seizure in multiple sclerosis (MS). In this study, the seizure and its characteristics analyzed among a large group of patients with MS. We reviewed the medical records of all definite MS patients referred to the MS Clinic of Kashani hospital, Isfahan, Iran, between 2007 and 2011. Altogether, 34 cases with seizure activity identified among the 920 definite MS subjects (3.69%). Five excluded due to the other probable etiologies rather than MS. In the remained 29 patients (3.15%), the type of seizure was mostly generalized (79.3%); interictal electroencephalography showed an abnormal pattern in 84.6%, brain magnetic resonance imaging revealed subcortical white mater lesions in 84.6% of patients. The mean duration of MS onsets was 8.17 years and the mean interval between MS onset and the first seizure occurrence was 3.7 years. In general, response to antiepileptic treatment was excellent. Seizures can occur at any stage during the course of MS, but it is more common during the early stages.

Cardiovascular diseases, cardiovascular risk factors, and mortality due to these situations are more frequently encountered in schizophrenic patients when compared with the general population. The mean platelet volume (MPV) is a surrogate biomarker of the platelet activity and an useful prognostic test in cardiometabolic diseases. The aim of this study was to investigate what influenced MPV levels in patients with schizophrenia. We evaluated hospital records of 60 hospitalized schizophrenia patients. Thirty age‑ and sex‑matched healthy control subjects were also included as a control group. MPV levels were significantly higher in patients who were on atypical antipsychotic drugs than in patients who were not using any drug (9.2 ± 0.8 vs. 8.6 ± 0.8 fL, P = 0.016) and also higher than control group (9.2 ± 0.8 vs. 8.1 ± 0.9 fL, P < 0.001). Furthermore, patients who were not using antipsychotics had higher MPV than control group (8.6 ± 0.8 vs. 8.1 ± 0.9 fL, P = 0.036). Atypical antipsychotic use [Odds ratio OR) = 6.152, 95% confidence interval (CI,) P = 0.003)] and platelet distribution width (OR = 0.989, 95% CI, P = 0.032) were associated with high MPV levels in univariate analysis. In multivariate logistic regression model, only atypical antipsychotics use (OR=6.152, 95% CI, P = 0.003) was found to be independent predictor of high MPV levels after adjustment of other potential confounders (age, gender, presence of hypertension, diabetes mellitus, hyperlipidemia, and smoking). MPV seems to be influenced not only by schizophrenia itself but also by atypical antipsychotic drugs. It might be concluded that schizophrenic patients are under increased risk for cardiometabolic diseases and risk factors and this risk is higher in patients on atypical antipsychotic treatment.

In this randomized, double‑blinded study, we investigated the preemptive effects of propofol, remifentanil or ketamine on post‑operative pain scores and analgesic requirements in elective lower abdominal surgeries under general anesthesia during the first 24 h of post‑operative period. Seventy five patients, American Society of Anesthesiologists physical status I or II candidate for elective lower abdominal surgery under general anesthesia were randomized to three groups (25 each). According to their allocated group, patients received either propofol 0.25 mg/kg, remifentanil 0.25 mic/kg or ketamine 0.3 mg/kg as preemptive analgesia immediately after the induction of general anesthesia. Post-operative pain scores with a numerical rating scale (visual analogue scale 0-10) were assessed and analgesic requirements and side-effects were compared through analysis using the SPSS version 18 in the post-operative period; post-anesthesia care unit 2, 6, 12 and 24 h. Patients’ demographics were similar in all groups. The pain scores were significantly lower in remifentanil group immediately after recovery and also at 2 and 6 h post-operatively, but it reversed at 12 and 24 h after recovery comparing with propofol and ketamine. However, the mean of administered morphine in the first 24 h was significantly lower in propofol group (18.97 ± 6.6) comparing with remifentanil group (21.96 ± 6.55) and ketamine group (24.26 ± 5.84) (P value, 0.01). Prophylactic preemptive single dose of intravenous (IV) 0.25 mg/kg propofol significantly decreased post-operative analgesia requirements comparing with IV 0.3 mg/kg ketamine or 0.25 µg/kg remifentanil.

There have been few studies to examine the effect of magnesium (Mg) supplementation on liver enzymes. The aim of this study was to evaluate the effect of Mg supplementation and weight loss on liver enzymes, lipid profile, and fasting blood sugar in patients with nonalcoholic fatty liver disease (NAFLD). This study was a double-blind, placebo-controlled, randomized clinical trial. Ultrasonography was used to diagnose fatty liver in patients with alanine aminotransferase (ALT) ³ 40 U/L and without other hepatic diseases. A total of 68 participants (18-56 years) with NAFLD were randomly divided into two groups to receive either Mg supplement (350 mg elemental Mg per day) or placebo for 90 days. At baseline and at the end of the intervention serum ALT, aspartate aminotransferase (AST), alkaline phosphatase (ALP), total cholesterol (TCHO), high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), blood sugar and serum insulin, and Mg levels were measured in fasting state. Low-density lipoprotein cholesterol (LDL-C) and insulin resistance (IR) were calculated using Friedewald formula and homeostasis model assessment of insulin resistance (HOMA-IR), respectively. All participants received lifestyle recommendations including low calorie diet and physical activity. Significant decreases within the intervention and placebo groups were observed in ALT (75.64 ± 49.45 to 41.82 ± 19.40 U/L, P = 0.000; 68.50 ± 26.96 to 40.17 ± 19.40 U/L, P = 0.000 in Mg and placebo groups, respectively). Similar significant decreases were observed in AST and fasting serum insulin within the study groups. The decrease in weight was also significant in both groups (91.05 ± 13.77 to 87.60 ± 14.37 kg and 94.59 ± 16.85 to 91.45 ± 16.39 kg in Mg and placebo groups, respectively). LDL-C and TCHO were decreased significantly in placebo group but not in the intervention group. Serum Mg was increased significantly in the intervention group. No statistically significant differences were observed between the two study groups at baseline and after intervention. According to the findings of this study, Mg supplement does not affect liver enzymes but weight loss may have an important role in improving fatty liver disease.

Androgen deprivation is the basis of treatment for advanced stages of prostate cancer. Cardiovascular disease may be a risk factor for mortality in prostate cancer. Therefore, we decided to evaluate the effect of androgen-deprivation therapy (ADT) on cardiovascular risk factors in patients with prostate cancer. In a cross-sectional study on 2011, 35 patients suffering from metastatic prostate cancer as candidates for ADT were enrolled. Serum levels of fasting blood sugar (FBS), triglyceride (TG), and total cholesterol (TC) were measured at the beginning and after the 5th month of ADT. The mean level of TG increased significantly from 130.82 ± 41.57 mg/dl to 150.05 ± 48.29 mg/dl (P < 0.012). Also, serum level of TC increased from 197.62 ± 40.71 mg/dl to 212.54 ± 38.25 mg/dl, which is statistically significant (P < 0.001). A non-significant increase in serum level of FBS from 96.74 ± 14.04 mg/dl to 99.17 ± 15.23 mg/dl was also seen (P = 0.27). ADT in prostate cancer may lead to an increase in TG and TC levels. In the patients with a high risk of cardiovascular disease patient’s lipid profile should be considered during ADT.

Ketamine, a non-competitive NMDA (N-Methyl-d-Aspartate) receptor antagonist, is recognized as an intraoperative anesthetic agent. Increasing interest in the use of low-dose ketamine for postoperative analgesia has developed in part because of its NMDA-antagonistic properties, which may be important in attenuating central sensitization and opioid tolerance. Despite of many trial evaluations which have been done on the effect of low-dose ketamine in postoperative pain, the role of ketamine, as a component of perioperative analgesia, remains unclear. We evaluated the analgesic effect of low-dose ketamine during anesthesia induction in painful ophthalmic surgery. After institutional approval and written informed consent, 88 patients undergoing retinal detachment, strabismus, and keratoplasty surgery aged 18–80 years old were randomly divided intoequal case and control groups. Anesthesia was induced with sodium thiopental, fentanyl, atracurium, and liducaine, and maintained with N2O, O2, and propofol. Ketamine 0.5 mg/kg was administered intravenously to patients in the case group during anesthetic induction. Mean blood pressure and pulse rate were listed in questionnaire every 5 minutes. The consumption of anesthetic, perioperative additional analgesic, extubation time, postoperative pain and nausea scores (based on Visual Analog Scale), vomiting frequency, and the recovery time were recorded. There were no differences in the recovery time (17.3±3.4 in the case group vs. 16.3±3 in the control group, P<0.05), postoperative pain scores (5±1 in the case group vs. 5.6±2 in the control group, P<0.05), the consumption of anesthetic (9376.9±1245.8 in the case group vs. 9012.9±1620 in the control group, P<0.05), the analgesic requirements (1000 in the case group vs. 940.9±135.6 in the control group, P<0.05), and perioperative additional analgesic (63.4±26.5 in the case group vs. 69.4±25.6 in the control group, P<0.05) between two groups. The extubation time in the case group (13.59±4.83) was significantly shorter than in the control group (15.9±3.6) (P-value=0.01). This study demonstrates that a low dose administration of ketamine during anesthesia induction in retinal detachment, strabismus, and keratoplasty surgery improves the extubation time but have no effect on postoperative pain, nausea and vomiting, and perioperative additional analgesic requirements.

The aim of this study is to evaluate the outcome of an innovative, minimally invasive sling technique with autologous tissue in women with concomitant incontinence and anterior vaginal wall prolapse (AVWP). Fifty-six women with stress urinary incontinence (SUI) or mixed urinary incontinence and AVWP were randomly assigned into two groups: in Group A (26 patients), anterior colporrhaphy (Kelly placation) and sling placement using a strip of anterior vaginal wall were performed, and in Group B (30 patients), transvaginal mesh correction of AVWP and tension-free vaginal tape (TVT) insertion (retropubic – craniocaudal route) using polypropylene mesh were carried out. The patients were followed-up for over 18 months and were assessed objectively using a 48 h frequency-volume chart, a 48 h pad test and a standardized stress test. Related surgical complications and outcomes were recorded and compared. Surgical cure rates for Group A and Group B at the first (3 days) and last (18 months) post-operative visits were 62% and 84%; and 54%, and 72%, respectively (P = 0.09 and 0.31). Complications occurred in 9 patients (44%) of Group B, but only 3 patients (12%) in Group A. Vaginal sling surgery using an anterior vaginal wall strip can improve SUI and in comparison with propylene mesh is associated with lower complication rates. Although, the surgical success rate of this technique is lower than T-Sling, larger studies with selected patients will help assess the suitable patients for this pelvic reconstructive surgery.

Drug‑drug interactions (DDIs) are one of the commonest causes of medication error in developed countries, particularly in the elderly due to poly‑therapy, with a prevalence of 20‑40%. In particular, poly‑therapy increases the complexity of therapeutic management and thereby the risk of clinically important DDIs, which can both induce the development of adverse drug reactions or reduce the clinical efficacy. DDIs can be classify into two main groups: pharmacokinetic and pharmacodynamic. In this review, using Medline, PubMed, Embase, Cochrane library and Reference lists we searched articles published until June 30 2012, and we described the mechanism of pharmacokinetic DDIs focusing the interest on their clinical implications.

Previous studies have inspected the associations between Adiponectin (ADIPOQ) 276G/T polymorphisms and atherosclerosis, but the results are inconclusive. The aim of this study was to explore the relationship between polymorphism +276 G > T (rs1501299) in ADIPOQ and atherosclerosis. A widespread search was directed to identify all studies on the association of ADIPOQ 276G/T polymorphism with atherosclerosis risk. The fixed effect pooled measures according to odds ratio (OR) and 95% confidence interval (CI) were calculated in the meta-analysis. Heterogeneity among studies was evaluated using Q test and the I2. Publication bias was estimated using modified Egger’s linear regression test and Fuunel plot. Nine studies regarding the associations between the ADIPOQ 276G/T polymorphism and atherosclerosis risk were enrolled in this meta-analysis, including 1959 cases and 3739 controls. The 276G/T polymorphism was not significantly associated with atherosclerosis, yielding pooled ORs of 0.925 (95% CI: 0.728-1.178) and 0.921 (95% CI: 0.804-1.054), for TT versus GG, and TG versus GG, respectively. Significant between-study heterogeneity was not found in our meta-analysis. Furthermore there was no evidence of publication bias in the meta-analysis. The present meta-analysis showed that there is no association between ADIPOQ 276G/T polymorphism and atherosclerosis. High quality studies are still needed to add for more investigation of the association between ADIPOQ 276G/T polymorphisms and atherosclerosis.

It may be difficult to differentiate between the first demyelinating attack and the neurological manifestations of connective tissue diseases. A total of 79 patients with optic neuritis were compared with 79 healthy controls. Their blood samples were tested for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), antiβ2-Glycoprotein I antibody (IgG, IgM), anticardiolipin antibody (IgM, IgG), lupus anticoagulant, anti-double strand DNA (anri-ds DNA), antinuclear antibody (ANA), anti-myeloperoxidae (p-ANCA), and anti-Proteinase 3 (C-ANCA). In clinically isolated syndrome group β2-Glycoprotein (IgM) and lupus anti-coagulant were positive in 1.3% of patients whereas ANA was positive in 1.3% and anti-β2-Glycoprotein I (IgM) was positive in 2.5% of control group. No rheumatologic disease was found in objects with positive tests. This study shows no specific difference between two groups.