Tehran University Medical Journal

A review of bone metastasis and its treatments, with a special emphasis on local and systemic radiotherapy

Peiman Haddad

Background: Bone is one of the most common sites of metastatic disease in malignancies. Many of the cases are asymptomatic and may be diagnosed in primary or secondary follow-up, but in symptomatic cases pain is the prominent symptom which is mostly exaggerated at nights. The improved survival of cancer patients with bony metastases in recent years, specially in breast and prostate cancer, has given a greater importance to the careful choice of treatments in this setting. This can lead to a better quality of life, lower treatment cost, prevention of disabilities, less delay in primary cancer therapies, and decrease of life-threatening events for the patients. Here we review the metastatic disease of the bone and its treatments, with emphasis on local and systemic radiation therapy. Current literature about bone metastasis and its treatments was reviewed through a search of available databases on internet for papers published in 1995-2013. Special attention was given to the research trials and studies performed by the authors on this setting. Treatment of bone metastases consist of analgesics, radiotherapy, surgery and bisphosphonates. Control of bone metastases is a challenging process, necessitating a multi-disciplinary approach and teamwork between the treating physicians. Radiotherapy is the most useful modality for this purpose in oncology, given both as a local and systemic therapy. We hope that this review would be able to help in choosing the best treatment option for this common palliative situation in Iranian cancer patients.

The effect of oral Matricaria Chamomilla extract and selenium on postpartum depression and plasma oxidant-antioxidant system in mice

Hamid Reza Sadeghipour Roodsari

Background: Postpartum depression (PPD) is a major depressive disorder and one of the most common complications of childbearing. PPD has a serious impact on the quality of life of all family members. Oxidative stress is one of the contributing factors in pathophysiology of major depression. Thus, drugs with potential antioxidant action could be an attractive target for treatment of depressive disorders. Matricaria Chamomilla and Selenium are natural sources of antioxidant. The aim of this study was to evaluate effects of oral administration of Matricaria Chamomilla aqueous extract and Selenium on experimental model of progesterone-induced postpartum depression and plasma oxidant-antioxidant system in mice. Methods: Seventy adult female mice in seven groups were used in this study. All animals received daily injections of progesterone 5 mg/kg intraperitoneally for five days after which progesterone was withdrawn for three days. After modelling postpartum depression with progesterone withdrawal, Matricaria Chamomilla 300 mg/kg and Selenium 0.1 mg/kg and their combination were administered via gavage and imipramine 15 mg/kg was administered intraperitoneally one hour before open field and forced swimming test (FST). In order to investigate the role of oxidant-antioxidant system, PAB and MDA were meatured. Results: All the treatment groups and the standard group spent less immobility time than the control group (P<0.05). Significant changes in the oxidative parameter (PAB and MDA) were not observed in all treatment groups and the standard group compared to the control group. Conclusion: Our study demonstrated the potential antidepressant activity of Matricaria chamomilla and Selenium in the experimental model of progesterone-induced postpartum depression in mice. These elements as supplement compounds could be alternatives for antidepressants in postpartum period. It seems that the antidepresent effects of this compounds do not induced by effects on oxidant-antioxidant system and may exert through any other pathway.

A new grading system “two-tier” in clasification of ovarian serous carcinoma and evaluation of P53 gene expression by immunohistochemical staining

Narges Izadi-Mood

Background: Recently the use of “two tier" grading system in which ovarian serous carcinoma was classified as low-grade or high-grade in comparing to preceding system has improved authority in prognosis and survival. This approach is simplistic, reproducible, and based on biologic evidence. In this study, we reclassified ovarian serous carcinoma by a new two-tier system for grading and then evaluation of P53 expression in these tumors by immunohistochemistry method. Methods: We retrospectively reviewed 32 cases of ovarian serous carcinoma with previous diagnosis of well differentiated (eight cases) and moderate to poorly differentiated serous carcinoma (24 cases) and according "two tier" grading system in low-grade vs. high-grade serous carcinoma reclassified. Subsequntly all cases immunostained by P53 marker. Also clinical data related to survival of patients (with or without recurrence of tumor and death) and paraclinical findings such as presurgical blood serum level of CA125 are gathered. Results: Out of total eight patients with previously diagnosis well diferentiated serous carcinoma and of 24 patients with moderate to poorly differentiated serous carcinoma reclassified as low-grade and high-grade ovarian serous carcinoma respectively and a statistically significant difference was found between two groups. (P<0.005) Also of total 24 cases with high grade serous carcinoma, in 12 cases (54%) P53 immunostaining was detected but in non of all low grade serous carcinoma was seen. All 8 low grade serous carcinoma were alive without recurrence of tumor. In 10 and 12 out of 24 cases with high grade serous carcinoma recurrence of tumor and death were seen respectively. Conclusion: Since the presence of P53 negative expression in all of low-grade serous carcinoma by immunostaining and low-grade serous carcinoma accounts for small pupulation of all ovarian serous carcinoma and also few cases in our study, we did not find significant differences between P53 expression and survival in two low-grade vs high-grade serous carcinoma groups.

Evaluation of recurrent colorectal carcinoma after curative resection

Amir Keshvari

Background: Colorectal carcinoma is considering as a curable disease. Treatment of recurrent cases is hard and sometimes impossible. Evaluation of the rate and affecting factors of recurrence in each hospital would help to decreasing recurrent cases. The aim of this study is evaluation of the rate, clinical and pathologic features, and outcome of recurrent colorectal carcinoma in a referral teaching hospital in Tehran. Methods: Clinical data of 166 curative resections of colorectal carcinoma who were operated between Mehr 1384 and Mehr 1388 (between 23 September 2005 and 23 September 2009) in Imam Khomeini Hospital and were accessible for follow up was collected. Follow up data was collected prospectively up to Farvardin 1391 (19 April 2012). Forty nine recurrences were happened in this period. We compared recurrent and non-recurrent cases for different variables Results: Average age of the patients was 53.5 years, and 47% of them were female. The median time to the diagnosis of recurrent disease was 12 months (range 1 months to 54 months). There were no significant differences between recurrent and non-recurrent patients about age, sex, sub-site of the tumor and sub-type of primary operation. Rate of overall recurrence, local recurrence and distant metastasis were 29.5%, 15.7% and 12.1% respectively. Local recurrence rate was higher in colon cancer (16.44% vs. 15.05%) but distant metastasis rate was higher in rectal cancer (12.9% vs. 10/96%). Rate of curative re-resection was about 25%. Overall survival of the recurrent patients who underwent surgery was better than who underwent chemo or radiotherapy (66.7% vs. 56.8%). Median survival time of recurrent patients after primary surgery was 28 months, and after diagnosis was 12 months (9.28- 14.72,95% CI). Conclusion: In this study the rate of overall recurrence was 29.5%. Local recurrence rate was higher in colon cancer (16.44% vs. 15.05%) but distant metastasis rate was higher in rectal cancer (12.9% vs. 10/96%).

Comparison of two nosocomial infection surveillance in a neonatal ward

Navid Hadavi

Background: Nosocomial infection is one of the major causes of death in neonates. In recent years, the results of nosocomial infection control committee, which carried out, based on a protocol of National Nosocomial Infection Surveillance (NNIS) is not consistent with neonatal review articles. This study was performed to determine the prevalence and incidence of nosocomial infection with an active, prospective method based on definitions and characteristics of Center for Disease Control and prevention (CDC) and comparing it with routine method of NNIS. Methods: This cross-sectional and prospective study was independent from Beasat Hospital nosocomial infection control committee and preformed by daily active visiting of neonatal ward (that is level-II) for six month period. The results of this study were compared with the results of the NNIS committee of nosocomial infection. Collected data were statistically analyzed by SPSS software. Results: From all hospitalized neonates, 369 cases (1292 patients / day) were enrolled in the study. The overall rate of nosocomial infection (frequency) was 2.71% and the overall incidence of nosocomial infection was 7.73 cases per 1,000 patients / day. The most common nosocomial infection in this study was skin and soft tissue infections totally 50%. The incidence of Central Line-Associated Bloodstream Infection (CLA-BSI) was 14.2 per 1000 central catheter/day for the six months of study. Nosocomial infection rate preformed by Beasat Hospital nosocomial infection control committee (based on NNIS) was 0.1 % and incidence of nosocomial infection 0.3 per 1,000 patients/ day at the same 6 month study. Conclusion: It seems that a large part of this considerable differences between the results of this study compared to NNIS based study, is this fact that, for nosocomial infection surveillance in the neonatal field, the presence of a specialist as a performer and leader of the team, is necessary.

Serological study of Helicobacter pylori infection in patients with Polycystic Ovary Syndrome

Farnaz Sohrabvand

Background: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. Chronic infections have been mentioned as one of the different etiologic factors related to PCOS. Due to the high prevalence of Helicobacter pylori infection especially in developing countries, its probable role in the pathogenesis of PCOS and the limited information available in this area, serologic study of H.Pylori infection in patients with PCOS, was performed. Methods: This research was performed as a case control study from Dec 2010 until May 2012 in 82 patients (and their spouses) with polycystic ovary syndrome (case group) and 82 non PCOS patients (control group) with an age range of 20-40 referred to Vali-e-Asr Hospital infertility clinic. Both groups and their husbands filled a questionnaire and were examined by testing their serum H.Pylori IgG and IgA antibody levels. Statistical testing and analysis was performed by t-student and λ2 tests. Results: Mean age of the women and men and also other demographic characteristics except their profession showed no significant difference (P>0.05) in the two groups (PCOS and non PCOS). H.Pylori antibody IgG serum level was positive in 78% and 76.5% and H.Pylori antibody IgA level in 30.5% and 37% of PCOS versus non PCOS patients respectively which showed no statistically significant difference (P>0.05). There was also no significant difference between the H.Pylori antibodies levels in the spouses in the two groups (P>0.05). Conclusion: This study showed no significant difference in serologic examination re-sults in PCOS versus non PCOS patients. The finding of high prevalence of H.Pylori IgG and IgA positive levels in both PCOS and non PCOS patients can be probably re-lated to the high prevalence of H.Pylori infection or exposure in Iranian population and therefore suggest an issue for further investigation.

Efficacy of education with American Society of Health system Pharmacists guidelines on the prevention of stress ulcer

Mohammadamin Valizade Hasanloei

Background: Stress Ulcer Prophylaxis (SUP) is important in patients in Intensive Care Units (ICU). In this study, we evaluated the efficacy of the American Society of Health System Pharmacists (ASHP) guidelines, for stress ulcer prophylaxis. Methods: In this Quasi experimental study, data of patients that admitted to the ICU of Imam Khomeini Hospital of Urmia was recorded for three months. Then our guideline that was selected on the basis of ASHP guidelines were presented to physicians for one month and then patients’ data were collected again. The patients that hospitalized due to acute gastrointestinal bleeding and died in the early hours of admission were excluded. The data were analyzed. Results: This study involved 234 patients, of them 112 patients (91.1%) in the pre- intervention period and 99 patients (89.2%) in the post-intervention period had received acid-suppressive therapy (AST) (P=0.632). Of 77 patients (62.8%) in the pre- intervention period and 88 (79.3%) in the post-intervention period had an indication for SUP according to our ASHP-based guideline (P=0.005). Of the patients without an indication for SUP, 39 of 123 (31.7%) received AST in the pre-intervention period versus 18 of 111 (16.2%) in the post-intervention period (P=0.006). of 112 (91.1%) cases in the pre-intervention period compared with 93 (83.8%) cases of the prescription drug order was incorrect (P=0.092). Gastrointestinal bleeding were in five patients (4.1%) found during the pre-intervention period and 8 (7.2%) cases in the post-intervention period (P=0.295). Conclusion: In this study the majority of cases not been in accordance with the ASHP-based guideline and our education did not affect the quality of stress ulcer prophylaxis. It seems that more attention to the training of physician in the prophylaxis of stress ulcer can be effective in improving the health status of patients and additional costs may be reduced.

The effect of massage therapy on weight gain and calories intake in premature neonates: a brief report

Mamak Shariat

Background: Improvement of growth, nutrition and calories intake in neonates is derived by massage. Methods: This study is a randomized clinical trials settled in Vali-e-Asr Hospital Neonatal Intensive Care Unit (NICU) ward in 2012. The control group consisted of 19 infants who were not massaged on them. 15 infants in the intervention group received massage therapy for 10 days, three times a day by trained massage theurapist. Massage last 15 minutes and was done one hour after feeding. Massages were done in 2-7 days neonates. Weight gain, intake calories and oral feeding were compared between studied groups. Data was registered in SPSS v.18 and was analyzed via compatible statistics tests. Results: There were no significant different anthropometric measures at birth (weight-head circumferences and height) and gestational ages of delivery between two groups. Massages had no side effects on cases. Caloric intake at the end of 10 days (end of intervention) showed significant differences between the two groups (P=0.04). But no differences was shown for weight gain. Cases who received massage reached sooner to oral feeding but this difference was significant at 90% significance level (P=0.08). Conclusion: After 10 days, massage therapy increases oral nutritional intake but to find more accurate details requires further studies to be planned.

A large gastrointestinal stromal tumor of duodenum: a case report

Tayeb Ramim

Background: Gastrointestinal stromal tumors are gastrointestinal tract mesenchymal tumors with gene mutations. The most common site of gastrointestinal stromal tumors is in stomach (40-60%) and small intestine (30-40%), and rare cases about 3-5% of them occur in the duodenum. Case presentation: The patient is a forty six years old man. He complained of frequent colic pain in left upper quadrant of abdomen for two months before admitting to the hospital. The pain resolved spontaneously after a few hours. This situation almost has been repeated every week. The patient had severe repeated melena and faint for two weeks. As soon as the patient was entered the Sina Hospital in 2012, supportive care was started. Then upper gastrointestinal endoscopy was performed for him and the bleeding point was detected. Also abdominal and pelvic computed tomography with oral and intravenous contrast was done. Finally the patient was operated on tumor diagnosis in duodenal area according to classic Whipple procedure. Conclusion: Gastrointestinal bleeding is the most common symptom of gastrointestinal stromal tumors. The bleeding is minimal and chronic. It will be progress to sudden and severe bleeding. Diagnosis is done by upper gastrointestinal endoscopy and biopsy. The large tumors with high mitotic

Dyskeratosis congenita: a case repot

Behfar Pakbaz

Background: Dyskeratosis Congenita (DC) is a rare inherited disease with an incidence of approximately one case per million population. The disease is characterized by a classic triad: nail changes, color reticulated skin and oral leukoplakia. In these patients, premature death is often associated with bone marrow failure, infections, pulmonary complications, or malignancy. Three patterns of inheritance for dyskeratosis congenita have been reports, X-linked recessive trait, autosomal dominant and recessive trait. The present study is a case report of an adoloscent patient with dyskeratosis congenita. Case presentation: The patient is a 16 year old boy living in Arak without history of any illness was referred with fever, chills, malaise and admitted to Vali-e-Asr Hospital with initial diagnosis of sepsis. The patient was treated with broad-spectrum antibiotics. In tests, showed pancytopenia. Bone marrow biopsy was performed. Blood and urine culture were negative, rheumatologic lab test and other tests were normal. Ultrsonography of abdomen and pelvis showed splenomegaly. In physical examination, diffuse hypopigmented lesions on the trunk and extermities, nails dystrophy and oral mucosal leukoplakia were observed. Skin biopsy was consistent with DC. Conclusion: The skin and oral mucosal lesions have an impact role in the diagnosis of systemic disease. Early diagnosis and treatment of patients with DC are important in improving clinical outcomes.