Tehran University Medical Journal

Psychiatric disorders and pregnancy

SH Akhoondzadeh

Psychiatric disorders are common in women during their childbearing years. Special considerations are needed when psychotic disorders present during pregnancy. Early identification and treatment of psychiatric disorders in pregnancy can prevent morbidity in pregnancy and in postpartum with the concomitant risks to mother and baby. Nevertheless, diagnosis of psychiatric illnesses during pregnancy is made more difficult by the overlap between symptoms of the disorders and symptoms of pregnancy. In majority of cases both psychotherapy and pharmacotherapy should be considered. However, psychiatric disorders in pregnancy are often under treated because of concerns about potential harmful effects of medication. This paper reviews findings about the presentation and course of major psychiatric disorders during pregnancy.

Renal oxidative stress status and histology in gentamicin nephrotoxicity: The effects of antioxidant vitamins

R. Ghaznavi

Background: In recent publications, several mechanisms have been implicated in gentamicin (GM) nephrotoxicity. Reactive oxygen species have been proposed as one of the causative factors of the drug renal side effects. This study was designed to evaluate the protective effects of the antioxidant vitamins against GM-mediated nephropathy in insitu isolated rat kidneys.

Methods: Male Sprague-Dawley rats were randomly assigned to one of the following groups of seven rats: Group 1 (control) was tyrode perfused kidneys. Group 2 (GM), 200µg/ml gentamicin was added to the perfusate. Group 3 (GM + Vit C), the same as group 2 but vitamin C (200 mg/L) was added to the drinking water for 3 days and 100 mg/L to the perfusate. Group 4 (GM + Vit E), the same as group 2 but vitamin E (100 mg/100 g BW, ip) was injected 12 h before experiments. Group 5 (GM + Vit C + Vit E) the same as group 2 but Vit E and C were co-administered (same as Group 3 & 4). Urinary N-acetyle-B-D-glucosaminidas (NAG) and renal cortex superoxide dismutase (SOD) levels were measured and tissue histological evaluations were performed.

Results: Gentamicin caused a significant nephrotoxicity demonstrated by increase in urinary NAG. Decline in SOD contents were observed comparing to controls. Vit C or Vit E inhibited the gentamicin-induced increased releases of NAG into urine but did not show a significant effect on the SOD levels.

Conclusion: Co-administration of VitC&E significantly prevented the GM nephrotoxicity demonstrating by preservation of SOD levels and prevention of increase in urinary enzyme activities. Histological studies of renal tissues provided additional evidences for protective effects of antioxidant vitamins. We concluded that moderate doses of Vit C & E have protective effects in gentamicin nephrotoxicity and co-administration of these vitamins have additional beneficial effects.

The effect of anti-human plasminogen monoclonal antibodies on Glu-plasminogen activation by plasminogen activators

M. Akrami

Background: Human plasminogen is a plasma glycoprotein synthesized mainly in the liver. Conversion of plasminogen to plasmin by plasminogen activators is a key event in the fibrinolytic system. In this study, we investigated the effects of two anti-human plasminogen monoclonal antibodies, A1D12 and MC2B8 on Glu-plasminogen activation in presence of u-PA, t-PA and streptokinase.

Methods: Producing of Hybridoma antibodies was performed by fusion of spleen cells from BALB/C mice immunized with Glu-plasminogen and NS1 myeloma cells. Antibody binding to Human Glu-plasminogen was assessed using an ELISA assay. Activation of plasminogen was determined by measuring plasmin generation using the chromogenic substrate S-2251 and the effect of monoclonal antibodies, A1D12 and MC2B8 on plasminogen activation in solution was then evaluated. Initial rates and kinetic parameters of plasminogen activation in the presence of monoclonal antibodies were calculated. The effect of the monoclonal antibody MC2B8 on the rate of plasmin hydrolysis was measured. The effect of F(ab&apos)2 fragment of A1D12 on u-PA catalyzed-plasminogen activation also compared with the effect of the whole antibody in this reaction.

Results: ELISA assay showed that the antibodies reacted well with antigens. A1D12 increased the maximum velocity (Vmax) of plasminogen activation by each of the three plasminogen activators and MC2B8 decreased it. In all activation reactions, the KM value of plasminogen activation did not significantly change in the presence of antibody A1D12 whereas antibody MC2B8 increased the KM value of plasminogen activation by u-PA, fibrin monomer dependent t-PA and streptokinase. Monoclonal antibody MC2B8 had no significant effect on plasmin hydrolysis rate of synthetic substrate S-2251. Activation rate of plasminogen by u-PA in the lower concentration of F (ab)2 fragment of A1D12 was identical to activation in the presence of the whole antibody.

Conclusion: The binding of the A1D12 F(ab) region to Glu-plasminogen increases the catalytic efficiency of plasminogen activation by plasminogen activators. Therefore, it may be useful to apply clinically A1D12 for the therapy of thromboembolic events such as myocardial infarction by humanizing the F(ab) fragment of the A1D12 antibody. Inhibition pattern of antibody MC2B8 obey the mixed type of enzyme inhibition by binding the antibody probably at, or near, the cleavage site of Glu-plasminogen.

How addicts think about addiction and community problems?

A. Pash Meysamie

Background: addiction and drug abuse have many risk factors in community and individual attitude also causes much diversity in community perception and attitude toward addiction.

Methods: in this study we assessed attitude toward an addict in 42 addict men and asked about problems in their community and recreational behaviors. They were residents of a rural area in Babol city. In the control group we assessed the same parameters in 268 non addicts in the same area. All of the addicts have been using opium more than many times a week at least for recent 6 months. Data collected via a semi structured questionnaire through conversation.

Results: There was a significant difference between addicts’ attitude toward toward addiction compare to non-addicts’. Both addicts and non-addicts indicated that the first three community problems in their area were unemployment, lack of recreational facilities and addiction, in respective order. Answering questions about recreational activities, both groups indicated that there were no recreational facilities in the community.

Conclusion: In planning a preventive approach, there is a major role for attitude toward addiction in any community. The conflict seen in this study between addicts’ attitudes toward an addicted person and addiction as a community problem has it’s interesting feature. Recreation and physical and cultural facilities need to pay more attention as indicated by our study participants. This seems to have an important impact in prevention of many community problems as well as addiction.

A survey on Candida colonization prevalence in patients with gastritis, duodenitis and peptic ulcer

S.J Hashemi

Background: Prolonged antiacid and antibiotic usage in gasterointestinal diseases may predispose candidial colonization in GI tract. In order to isolate and diagnose of candida infections in patients with gastritis, duodenitis, gastric ulcer and duodenal ulcer, this study have been planned.

Methods: We studied 300 biopsy specimens of patients referred to hospital, 51.7% of the patients were male and the others were female. The isolated fungi were identified by direct examination and culture of specimens.

Results: Forthy four cases of yeasts were isolated in this investigation. Isolated yeasts have been identified as follows: 26 cases of C.albicance , I case C.tropicalis, 2 cases of C.krusei, and finally 1 case of unknown yeast.

Conclusion: All the patients had a positive history of long lasting antacid taking for gastric ulser or gastritis. Candidiasis must be investigated in patients with gastritis, duodenitis and gastric ulcer, who are refractory to classic therapies and also in patients who have the chronic disease .

Diffusion-weighted and conventional MRI in detection of Multiple Sclerosis lesions in brain: a comparative study

Z Miyabi

Background: Multiple sclerosis (MS) is a chronic disease that begins most commonly in young adults and is characterized pathologically by multiple areas of central nervous system (CNS) white matter inflammation, demyelination, and glial scarring. The most valuable aid for diagnosis is magnetic resonance imaging (MRI). New type of MRI has been developed on the basis of molecular diffusion which capable of detecting acute and active lesions. Early diagnosis and treatment is possible to stop or slow down progression of disease. The aim of this study is to compare the findings of conventional and diffusion- weighted (DW) MRI in detection cerebral lesions of MS.

Methods: Thirty patients with clinically definite MS and 30 healthy volunteers were studied in a descriptive-prospective survey over a twelve-month period of time. Conventional and DW MRI were used in both groups. Total number, morphology, location and the mean size of the intra-cerebral plaques of MS were compared between group. The sensitivity and the specificity of both imaging methods in detecting these plaques were determined.

Results: Thirty patients with MS with the mean age of 32.76±8.79 years and 30 healthy individuals with the mean age of 32.75± 9.23 years were enrolled. Plaque within the brain was significantly higher by the conventional method (P< 0.05). Ovoid lesions were greater in number in the conventional method group. More lesions were detected by the conventional method in the areas of periventricle, centrum semiovale and corpus callosum. Regarding the size of plaque, the minimum measurement was significantly lower in the conventional method group. The sensitivity of both methods was 100%. The specificity of conventional and DW MRI was 86.6% and 96.6%, respectively.

Conclusion: In our study the sensitivity of both methods was the same but the specificity of DW MRI was higher. DW MRI may detect lesions which are not detectable by the routine methods.

Serum inhibin levels in polycystic ovary syndrome: a case control study

M. Lankarani

Background: Polycystic ovary syndrome(PCOS) is the most common endocrinopathy in women and the most common causes of anovulatory infertility.Inadequate follicule stimulating hormone is hypothesized to be a proximate cause of anovulation.Inhibins are glycoprotein hormone produced by the granulosa and theca cells of the ovary that selectivly inhibits FSH production and or release from the pituitary. The possible role of inhibin in the etiology of polycystic ovary syndrome (PCOS) is controversial. This study was designed to investigate levels of serum inhibin in women with PCOS.

Methods: In a case-control setting 41 women with PCOS from the endocrine and gynecology and obstetrics clinic of Shariati Hospital and 44 women with normal cycles (control group) aged 15-40 year-old were evaluated. In all patients with PCOS and control women appropriate medical history was taken and physical examination was done.Serum inhibin levels were compared in two groups. Statistical analysis was performed using the Mann -Whitney U test

Results: Mean age of cases and controls was 23.6±5.3 and 23.1 ±3.9 years, respectively. Mean body mass index (BMI) in cases and controls were 25.07±5.45 and 21.33± 2.46 Kg/m2, respectively. There was no statistically significant difference in mean age between the two groups (p > 0.05) but mean BMI was significantly different between the two groups (p < 0.001). Mean serum levels of inhibin in cases and controls were 1.62±1.23 and 2.26±2.26 U/ml, respectively which was not significantly different between the two groups (p: 0.168).

Conclusion: There was no significant difference in serum inhibin levels between patients with PCOS and healthy women. We concluded that basal inhibin levels cannot be used for routine screening in women with PCOS. Further study is needed to determine the role of inhibin in these patients with assay of its two subunits (Inhibin A and B).

Knife conization: Indications, complications and cytopathologic study

F. Ghaemmaghami

Background: Cervical cancer is one of the most common cancers in women.Conization of the cervix is one of the best diagnostic and therapeutic modality in preinvasive lesion of the cervix.

Methods: In this retrospective study we have evaluated the indications,complications, cytopathologic results, diagnostic and therapeutic value of 44 patients who underwent cervical conization.

Results: Age of the study group ranged from 18 to 75 (mean=43.18, SD=±11.4), and their parity ranged from 0 to 10 (mean 4-5, SD=±2-3). Ten cases (22.7%) were menopauses. The main indication was inability to visualize the entire T.zone (19 cases/43.2%) that was more prevalent in menopauses (50%/5cases in menopauses and 41.2% /14 cases in premenopauses). Bleeding occurred in 2 cases (4.5%) and urinary infection in 1 case (2.3%). The most common histologic result after conization was mild dysplasia in 23 cases (52.3%). The most common colposcopic biopsy result was moderate dysplasia in 16 cases (36.4%).The most common pap smear result was HSIL in 16 cases (36.4%). Two cases (4.5%) had invasive cancer in colposcopic- biopsy: one of them had ASCUS in the pap and another one had HSIL. Four cases (9.1%) had invasive cancer in histologic report: one of which had ASCUS on the pap and the others had HSIL.

Conclusion: Pap smear in screening of cervical cancer are not reliable and colposcopy is more acceptable in LSIL and ASCUS. Gynecologists should develop the skill to perform an accurate knife conization because the classical indications for conization continue to be valid and it has a low complication rate.

Evaluation of primary cutaneous malignant melanoma according to Breslow and Clarke pathological indices

Z. Safaii Naraghi

Background: Malignant melanoma is one of the fatal cutaneous neoplasms which are curable by early diagnosis. This neoplasm is diagnosed by the biopsy of the suspected lesion. It is essential to classify the tumor based on its histology, thickness, phase of growth, level of invasion, mitotic rate, presence of regression, inflammatory infiltration and ulceration. These descriptions yield some knowledge about the progression of disease and suggest an estimate of the status of the screening system for early diagnosis.

Methods: This is a cross-sectional retrospective descriptive study. Pathological slides with diagnosis of malignant melanoma from 1377 to 1379 that present in the pathology department were assessed according to mentioned pathological indices and the 10-year survival calculated in this regard.

Results: We assessed 47 cases with mean age of 57.38 (SD=5.85) and the gender distribution was 51.1% male and 42.2% female. More than 42% of cases were in Clarke level I, 2.1% Clarke level II, 6.4% Clarke level III, 40.4% Clarke level IV and 8.5% Clarke level V. Fifty three percent of patients were breslow thickness equal to or less than 0.75 millimeter(mm) , 8.5% between 0.76 to 1.69 mm , 27.7% between 1.7 to 3.6 mm and 10.6% greater than 3.61 mm. Mean breslow thickness show no significant difference between males and females but there is a significant relation between thickness and age of the patients. Mean 10-year survivals of patients were 75% and were greater in females than males. We found a linear relation between patient age and breslow thickness that is calculated by the following equation: Log Breslow thickness (mm) = - 0.625 + 0.016×age (year)

Conclusion: Complete recording of clinical and pathological data of patients with malignant melanoma make a proper stream to reach a surveillance system.

Clinical characteristics of Pulmonary Tuberculosis in patients with HIV/AIDS: a Case-Control Study

A Hadadi

Background: Pulmonary TB is still the most common form of the tuberculosis in HIV infected patients with different presentations according to the degree of immunosuppression. The aim of this study was to investigate the impact of HIV infection on the clinical, laboratory and radiological presentation of tuberculosis.

Methods: We compared 80 HIV negative pulmonary TB patients with 40 HIV positive pulmonary TB patients during 1999-2005 in a teaching hospital of Tehran University of Medical Sciences, Iran.

Results: Tuberculosis was more common in men in both groups. The mean age of HIV positive patients was lower than HIV negatives (35.95+/-10.4 versus 46.95+/-20.39, P =0.002). Weight loss and chronic cough were significantly more frequent in HIV negative patients (76.3% vs. 45% p<0.001 and 93.8% vs. 80%, P<0.05 respectively), whereas fatigue were more prominent in HIV positives (45% vs. 21.3%, P< 0.001). Cavitations and infiltrations were reported in the CXR of HIV/TB patients less than HIV negative patients (OR=0.21, 95% CI: 0.05-0.97, P= 0.01 and OR=0.27%, 95% CI: 0.09-0.75%, P =0.02 respectively). Primary involvement pattern was observed more than secondary involvement in HIV/TB group (OR=3.95, 95% CI: 1.73-9.03, P =0.001). The laboratory findings in HIV/TB patients were as follows: more negative PPD skin (75% vs. 50%) tests, higher ESR (86.5% vs. 63.7%), lower mean Hb (10.6 vs. 12.4) and lower mean leukocyte (6545 vs. 9195) and lymphocyte count (1281 vs. 1838). In all of the above mentioned findings the differences between two groups were significant. Fourthy Seven% of patients had Lymphocyte count less than 1200 which means they were in AIDS stage.

Conclusion: Immune system suppression in HIV can alter the clinical, laboratory and radiological features of tuberculosis. It is crucial to consider tuberculosis in differential diagnosis of every HIV patients with respiratory symptoms.

Ebstein-Barr virus antibodies titer before and after radiotherapy in patients with nasopharyngeal carcinoma, Cancer Institute, Imam Khomeini Hospital, 2003 – 2004

F. Amoozegar Hashemi

Background: High titer of IgA and IgG are found in the presence of EBV genome in epithelial cells of nasopharyngeal carcinoma. In this survey we evaluated the accuracy of EBV antibodies titers in screening and follow up the patients.

Methods: Thirty nasopharyngeal carcinoma patients were followed from 2003 to 2004. Serum EBV antibody levels were measured before and after ( 3 months ) radiotherapy or combined radiotherapy and chemotherapy.

Results: More than 77% of patients were seropositive before treatment .The antibodies decreased significantly, 3 months after treatment (p<0.05).

Conclusion: This investigation shows the efficiency of serologic methods for screening of high risk people and follow up of patients after treatment, but more complementary studies is needed

Upper Lip Bite Test with Thyromental, Sternomental and Interincisor distance in predicting difficult intubation.: a comparative study

Z. Hosain-Khan

Background: Difficult intubation (DI), often unexpected, remains a primary concern for anesthesiologists. The purpose of this study was to compare the sensitivity and specificity of ULBT with sternomental, thyromental and interincisor distances in predicting difficult intubation.

Methods: In a prospective study, 380 patients undergoing general anesthesia were included. In all patients sternomental, thyromental and inter-incisor distances and the ULBT score were evaluated preoperatively. The Cormack grade was determined after the induction of anesthesia and grade 3 or 4 was considered as difficult intubation. The best points with highest accuracy were determined by ROC curve. Sensitivity and specificity of these tests in predicting difficult intubation were calculated and evaluated.

Results: In 19 (5%) patients, intubation was difficult. ULBT class III, inter-incisor distance less than 4.5 cm, thyromental distance less than 6.5 cm, sternomental distance less than 13 cm were considered as difficult intubation and there were significant differences between them and laryngeal view (P<0.05, McNemar) but there was no difference between laryngeal view in both sex. The sensitivity and specificity of ULBT is significantly higher than thyromental and sternomental and Inter-incisor distances (the specificity were respectively 91.96% vs. 64.77%, 70% and 82.27% and accuracy were respectively 91.05% vs. 76.58%, 71.32%, 81.84% and 59.53%)

Conclusion: We conclude that the specificity and accuracy of ULBT is significantly higher than inter-incisor, thyromental and sternomental distances and is more accurate in airway assessment.

Laryngotracheal Injury following Prolonged Endotracheal Intubation

J. Mehdizadeh

Background: Prolonged endotracheal intubation is a growing method for supporting ventilation in patients who require intensive care. Despite considerable advancement in endotracheal intubation, this method still has some complications the most important is laryngo-tracheal injuries.

Methods: Over a 2-year period, this retrospective study was conducted on 57 patients with history of prolonged intubation who were referred to the ENT Department of Amir Alam Hospital. For each patient, a complete evaluation including history, physical examination, and direct laryngoscopy and bronchoscopy was done under general anesthesia.

Results: Fifty-seven patients (44 male mean age, 23.014.7 years) were studied. Mean intubation period was 15.88 days. The most common presenting symptom was dyspnea (62%). Head trauma was responsible for most cases of intubation (72.4%). The most common types of tracheal and laryngeal lesions were tracheal (56.9%) and subglottic (55.2%) stenosis, respectively. Mean length of tracheal stenosis was 0.810.83 cm. There was a statistically significant relationship between length of tracheal stenosis and intubation period (P=0.0001) but no relation was observed between tracheal stenosis and age, sex, and etiology of intubation (All P=NS). Among the glottic lesions, inter- arytenoids adhesion was the most common lesion (25.9%). No statistically significant relation was found between glottic and subglottic lesions and age, sex and intubation period (all P=NS). Length of stenosis and intubation period was significantly greater in tracheal/ subglottic lesions than those in glottic/ supraglottic lesions (all P=NS).

Conclusion: After prolonged endotracheal intubation, laryngo-tracheal lesions had no relation with patient’s age, sex, and cause of intubation.There was direct relation between length of tracheal stenosis and intubation period. Glottic lesions were more commonly observed in head trauma patients. Lesion length and intubation period were greater in tracheal and subglottic lesions.