Tehran University Medical Journal

---

The diffractive multifocal IOL provides simultaneous bifocal imaging by utilizing both diffractive and refractive optics. In both distant and near vision, there is a clear highly focused image on the retina. The second image is highly defocused, providing only faint background illumination. A small amount of the light goes to the higher orders of diffraction which are not perceptible by eyes. The bright spot produced by a zone plate is so intense that the plate acts much like a converging lens. There are also fainter images corresponding to focal lengths f/3, f/5, f/7, ...

---

In this work, we tried to know something more about the embryotoxicity effects of the doses of 50, 200, 400 mg/kg/day of ranitidine of (H2 antihistaminic agent) by intraperitoneal administration on mice. The studies were performed on albino mice kept under specific conditions and a constant dark-light cycle at 24+1C and 55+5% relative humidity. Generally, the animals were acclimatized for four weeks before mating. Two female mice at 12-14 weeks of age were placed overnight with a male of proven fertility. The day on which a vaginal plug was found, was taken as day one of pregnancy. Also the vaginal smear was prepared for further proof. Treatment of pregnant females was started from day 7 and continued up to the 15th day of gestation and then on day 18 they were necropsied for routine teratological observations. The live fetuses were weighed and inspected for gross external abnormalities under a dissecting microscope. Resorption plus dead fetuses less than 6mm of length were designated early death and dead fetuses of more than 6mm of length were consequently called late death. The statistical study was done by student t-test. One-third of the fetuses were fixed in bouin's fluid to detect visceral malformations by the rasor- section technique. There was no significant difference in the frequency of late death between the control groups and the groups given ranitidine. Differences were observed in the number of implantation sites except for 400 mg/kg/day. Data pooled from all experimental groups clearly show that pig tail, deformed cranium, low body weight and skeleton, unshaped external ear and jaw and polydactyly are the most common external abnormalities. Results of this study show the hazards o the ranitidine used during early pregnancy.

---

A case with bilateral spontaneous pneumothorax was presented. Etiology, mechanism, and treatment were discussed on the review of literature. Spontaneous Pneumothorax is a clinical entity resulting from a sudden non traumatic rupture of the lung. Biach reported in 1880 that 78% of 916 patients with spontaneous pneumothorax had tuberculosis. Kjergaard emphasized 1932 the primary importance of subpleural bleb disease. Currently the clinical spectrum of spontaneous pneumothorax seems to have entered a third era with the recognition of the interstitial lung disease and AIDS as a significant etiology. Standard treatment is including: observation, thoracocentesis, tube thoracostomy. Chemical pleurodesis, bullectomy or wedge resection of lung with pleural abrasion and occasionally pleurectomy. Little information has been reported regarding the efficacy of such treatment in spontaneous pneumothorax secondary to non bleb disease

---

Helicobacter pylori, as a causing agent of peptic ulcer in adults, is also encountered in children although in a lower incidence. Endoscopic biopsy studies of gastrointestinal mucosa in 110 children with clinical signs of peptic ulcer (continuous vomiting, chronic abdominal pain, hematemesis and melena) in Amir-Kabir Children's Hospital in Tehran showed positive helicobacter pylori findings in Giemsa or Hematoxylin-Eosin stained specimens. Doudenal ulcer with 81.1% was the most frequent lesions involved, the next more frequent lesions being gastric ulcer (805), dudenitis (75%) and gastritis (51.7%)

---

Carpal tunnel syndrome (CTS) is considered by researchers because of its high prevalence, and several studies have been done to find the causes and factors which increase the chance for the syndrome. These studies have shown relationships between this syndrome with some physical parameters like wrist dimensions, weight and systemic conditions. There is no investigation on risk factors in CTS in our country. So the main goal of this research is to find and introduce predisposing factors for carpal tunnel syndrome. Methods: Seventy patients and 33 controls 22 to 70 years old were studied. Standard methods for median and ulnar nerve studies were used and questionnaires included physical measurements, history of diseases and personal information were completed for each person. Results: Patients had higher wrist ratio (mean difference, 0.0267, P<0.001), weight (mean difference: 6.098, P<0.001) and body mass index (mean difference: 3.376, P<0.001). Regression analysis showed strong positive relation between wrist ratio and median latencies. The strongest correlation was found between wrist ratio and median minus ulnar distal sensory latencies (Y2=0.4014, P<0.0001). No relation was found between weight and body mass index with median latencies. Seventy-nine percent of patients and 48.5% of controls had wrist ratio of 0.7 or greater (P<0.05). Seventy-two percent of patients with repetetive hand activities and 78% with associated conditions had wrist ratio of 0.7 or greater. Seventy-six percent had wrist ratio less than 0.7. No relationship was found between obesity, diabetes, thyroid disorders, rheumatoid arthritis, taking oral contraceptive, hysterectomy, oophorectomy, menopause and repetetive hand activities with involvement of carpal tunnel syndrome. Discussion: Wrist dimensions seem to be an important predictor for carpal tunnel syndrome also in patients with associated conditions. If individuals with squarer wrists are involved in special conditions, they may show symptoms of the syndrom. Carpal tunnel syndrome is caused by many factors but wrist dimensions seem to be a predisposing factor and provides an explanation for bilateral involvement or familial occurrence of it.

---

Sixty-nine children with phenylketonuria (PKU) under coverage of Tehran Genetic Research and
Consultation Center, fed Lofenalac and Phenylfree were studied. The 24-hour dietary recall method was used
to determine food intake and blood samples were analyzed for iron parameters. The results showed that over
7% of the children had a low intake of energy, protein and iron. In addition, hemoglobin and hematocrit were
lower than normal in 3.1% of the children, while in 24.2% of them there was decreased serum transferrin
saturation percent. There was a statistically significant relationship between lenght of diet therapy and iron
parameters. The findings show that inadequate nutrient intakes may, over time, cause appearance of anemia signs in the children with PKU dependent on special formulations

---

Cesarean section (CS) is a relatively safe procedure, performed for different maiernal and fetal indications. Despite complications of general anesthesia, post-operative infections, and thromboembolic events, CS is being performed with increasing frequency. In this study, we have examined the indications and complications of CS's performed in Arash Hospital from December 1993 to November 1994. Of the total 3480 cases of chiidbrilh, 900 (24.45%) were performed by CS, most and last frequently in December/January and November/December respectively. However, Ute ratio of CS cases to all cases was equal throughout the year. The most common indication of CS was failure to progress in labor (38.54%), and the other causes were repeat CS (21.77%), meconium excretion (11.97%), malpresenlation (8.55%) and fetal distress (5.58%). The indication of CS varies with meternal age. Between 41-45 years, the most common indications were prior CS (42.5%), and request for concommitant tubal ligation (12.5%), whereas in the younger age groups, the most common indication was failure to progress in labor. In primiparous cases, 44.55% of the CS's were performed due to failure to progress in labor, while the latter was the indication of CS in only 14.5% of the multiparous women. Complications were observed in only 4.54% of CS cases

---

Between 270 patients complaining of symptoms of vaginitis, bacterial vaginosis was diagnosed in 68 women (%25) based on at least three of four criteria: 1. Homogenous vaginal discharge 2. Positive amine test 3. pH more than 4.5 4. Clue cell in wet smear. The results were compared to 55 normal controls.
Clue cell with more than %20 of epithelial cells was seen in %87 of cases and %5.5 of controls. A pH more than 4.5 showed the greatest sensitivity (%100) and the smallest specificity (%47). The most frequent complaints included increased discharge, bad odor, and sensing bad odor after coitus.

---

Perinatal mortality rate is an import health index. In this study, we have attempted to determine the causes and rate of perinatal mortality, in 18885 randomly selected newborns, in all the obstetrics and delivery centers of Tehran, during one year (1994-1995). The mortality rate was approximately 21/1.000. Cesarean section was performed in 42.2%, and vaginal delivery in 57.8% of cases. Prematurity was observed in 11.3% and 8.4% weighted less than 2500 gr (low birth weight : LBW). Perinatal mortality was significantly more frequent in the presence of prematurity (p = 0,000), LBW (p = 0.000), mothers who were older than 35 y (as compared to the 20-29 y age group p = 0.01), high parity (> 5 p = 0.00001), and high gravida (> 5 p = 0.04), low educational level (less than high school diploma p = 004), twin or multiple pregnancies (p = 0.000), congenital malformations (p = 0.000), low Apgar score (< 4 in 1 and 5 p = 0.000), and in the absence of perinatal care (p - 0.000 002)

---

Helicobacter pylori (H.Pylori) is the most common human infection in the world. This agent has a strong role in pathogenesis of chronic gastritis and peptic ulcer. Therefore introducing of simple and cost effective tests are important for diagnosis of H.Pylori infections. ELISA has been considered as an alternative test compare with biopsy, histological staining, culture and urease test in diagnosis of H.Pylori infection. In this investigation, 111 patients referred to GI endoscopy department of Imam Khomeini Hospitals for U.G.I problems which were evaluated for H.Pylori infection. Culture and histological staining (GIMSA and H & E) were used as a gold standard test compare with ELISA-IgG and urease test. Sensitivity and specificity for ELISA were 90%, 93% respectively. This report suggests that ELISA is a cost effect and valid test in diagnosis of H.Pylori infection

---

Febrile seizure is the most frequent type of seizure in childhood occurring in 2-4% of children under the age of 5. Although pathogenesis of seizure following fever is not well understood, multiple risk factors are known to contribute to its precipitation. One of the possible risk factors which had not been mentioned yet in reference texts and still is in the research phase is a serum sodium level below the normal limits which specially plays a role in the recurrence of febrile seizure. In this descriptive retrospective study records of 400 in-patients cases of primary episodes of febrile seizure in Bahrami children hospital in the years of 1996-1997 were reviewed. 214 (53.5%) cases had serum sodium levels of <135 m.mol/L. The mean serum sodium level for all the cases was 135.28±4.65 m.mol/L which is considerly less than the serum sodium level of 140±0.8 m.mol/L seen in healthy children. There was no significant difference in serum sodium levels different sex and age groups in this patient population

---

Acute appendicitis is the most common condidition, requiring emergency operation in children. Late appendicitis is still a major sours of morbidity and potential mortality. The charts of all pediatric appendectomy patients (150 cases) treated between 1367-1373 (Iranian calender) in Amir Kabir Medical Center were reviewed. Mean hospital stay was 4.7 days. Mean ages of patients was 8.5 years. Male to female ratio was 1.2/1. Most common symptom was abdominal pain (100%) and deep tenderness in right lower quadrant in 94.6%. Mean temprature was 37.2 and leucocytosis (more than 10000) were in the 76.3%. 14 patients had perforated appendicitis and most common pathology was acut supporative appendicitis. Accuracy of diagnosis was 96.6% and post operative pelvic abccess was 2%. Mortality occurred in one case (0.6%)

---

Fever among elderly patients frequently marks the presence of serious illness. All such patients should be strongly considered for hospital admission, particularly when certain clinical features are present. In prospective case series study in Emam Khomeini hospital during 6-month period (March Through October 1991). All patients presenting to infectious wards who were 65 years or older who had fever (oral temperature 37.8°C or more) were studied. There were 101 patients (63 men and 43 women) with 65 to 92 years old (mean 73). The most important predisposing factor were, hypertension and heart disease in 20 patients, diabetes in 15 patients and pulmonary disease in 5 patients. Final diagnosis among 101 patients were: pneumonia 25 (24.8%), UTI 14 (13.9%) sepsis 12 (11.9%), cellulitis 16 (15.8%), IUO 4 (4.9%), malignancy 6 (5.9%) meningitis 8 (7.9%), gastroenteritis 4 (4.4%) brecullosis 7 (6.9%) and others 5 (5%). Outcome of them were complete recovery 41 (40.6%), relative recovery 42 (41.6%) and death 18 (17.8%)

---

Association of EBV with the tumor cells of HD has been proven by a variety of the methods, using serologic and immunohistochemical techniques and in the recent years with molecular biologic techniques which can detect EBV genome in tumor biopsies. In this regard we prompted to perform a case control study on 25 childhood HD cases with respected to their antibodies gainst EBNA and EBV-IgM antibodies in Imam Khomeini Hospital in Tehran. In our study the ratio of positive titers was significantly higher among HD patients compared with age and sex-matched healthy controls.

---

A retrospective study was conducted to investigate about breast cancer in Tehran from 1985 to 1995. All breast pathological records at five General District and Teaching Hospitals (18 general surgical wards) were reviewed and data were extracted. Overall, 3085 records were found (7291 female and 294 male). The final diagnosis was made for 2436 female records including 903 breast cancer (37.1%), 1430 benign breast disease (58.7%), 45 breast skin disease (1.8%) and 58 normal pathological report (2.4%). The dominant group age for breast cancer in women was age group of 40-49 years. The most frequent pathological stage was stage III. Breast cancer was also seen in 2.3 percent of women of 25 year old or younger. The diagnosis was also made for 278 men showing 32 breast cancer (11.5%), 23 benign breast disease (86%), 3 breast skin disease (1.1%) and 4 normal pathological report (1.4%). The results suggest that 3.5 percent of the overall breast cancer were men's, all having over 40 years of age with 60 years or older as the most frequent age. The most frequent pathological stage was stage III. The findings have some implications for public health professionals in terms of breast cancer screening in Iran.

---

In a historical cohort study we evaluated the effects of spontaneous abortion on subsequent pregnancy outcome. 1693 pregnant women were classifield in three groups: 1100: without any prior pregnancy, group 1 550: with history of one spontaneous abortion (G2A1), group 2 43: with two or more prior spontaneous abortions and no other prior pregnancies, group 3. We collected data through interview, patient's records and physical examination. We matched the patients according to their age subgroups, history of chronic disease, drug administration and radiation during current pregnancy and familial marriage. Then we compared adverse outcome of present pregnancy in group 1 and 2 with the women without prior pregnancy. We analysed the data with Chi-square and Fisher's exact methods. In this study we concluded that history of one spontaneous abortion had no effect on subsequent pregnancy except on prolonged ROM (P<0.000), but history of two or more abortions significantly affects occurrence of stillbirth (RR=29, P=0.003) and placenta previa (RR=8.5, P=0.03). These findings suggest that pregnant women with history of two or more spontaneous abortion need special prenatal care.

---

The object of this study was to find a suitable staining method for P.carinii. This parasite is not easily stained and clinical signs are not specific for the diagnosis of P.carinii pneumonia and therefore optimal laboratory methods for observing the organism are extremely valuable. In all 17 new conventional and modified staining techniques were used on lung impression smears and tissue section of sprague Dawley Rat treated with cortisone. Of these methods modified methylene blue 1 & 2, modified cresy violet 1, 2, 3, 4 modified Gram, modified Giemsa 2 and modified Griedley techniques have not previously been reported. After comparing readability of the slides, ease of performances, rapidity, availability and sensitivity of these 17 techniques for the diagnosis of P.carinii pneumonia, modified toluidine blue 01 & 2, modified methylene blue 1 & 2 and modified cresyl violet 3, 4 are suggested as the methods of choice for the rapid diagnosis of P.carinii pneumonia.

---

Different aspects of the effect of trauma on the health status of populations have been studied annually 35 millions deaths, 3.5 millions disabilities and a sum of 500 billions $ cost. Evaluating different modes of prevention, a comprehensive study was carried out in the US during the 7th and 8th decades, introducing the TRISS method for the purpose of comparing the outcomes of trauma cases among multiple centers. This study has been carried out during 1996-97 in there hospitals of Tehran. After entering the hospital, all trauma cases were traced by trained interviewers until leaving the hospital. Based on the TRISS model, probability of survival was calculated for each patient and compared with the results of the MTOS study. Among 4863 cases evaluated, 300 (6.2%) deaths were observed, which is significantly more than the expected number (222 deaths, 2.7%) calculated under TRISS model. This difference may indicate a difference in the quality of trauma care.

---

Hepatomegaly, decrease in the liver paranchymal echo and increase in the gallbladder wall thickness has been shown in acute viral hepatitis. The present study was done to determine sonographic changes in acute viral hepatitis. We performed liver and bile ducts sonography and specific tests on 42 patients (mean age: 31.5 and 61% male) with acute viral hepatitis. Gallbladder wall thickness was seen in 45.2% and hepatomegaly in 33.3% of patients and liver paranchymal echo was decreased in 19.3%. Age, sex, type of hepatitis, cholecystitis like symptoms, aspartate aminotransfrase, alanine aminotransfrase, alkaline phosphatase and bilirubin did not significantly corralate with these changes. Only raised prothrombin time was strongly correlated to the thickening of the gallbladder and decrease in the liver paranchymal echo and cholesistic like symptoms we can postulate that thickening of the gallbladder and decrease in the liver paranchymal echo is not dependent on the severity and speed of the paranchymal necrosis (as considered with ALT and AST) but they depend on the liver function disturbance (as considered with PT) because the thickening of the gall bladder is present in 45% of the patients and 10% of the normal population have gallbladder stones, one should not perform the diagnosis of acute cholecystitis, only on the basis of sonographic report without attention to the clinical and laboratory data.

---

Cardiopulmonary resuscitation (CPR) is one of the most important skills that every body must know it in medical services. In educational hospitals, the (Newly-arrived residents are in first cell for management of victims, specially in emergency rooms and at nights. Their knowledge and ability for successful CPR have a direct relation with prevalence of total mortality and morbidity. This research has assessed the knowledge and attitude of the new residents about CPR, and for answering to this question: "Is the CPR workshops necessary for all of the new residents in the beginning of their courses". All of the 506 new residents were examined simultaneously in 2 separate years with a questionnaire consist of 50 questions about their CPR secence and skills and 8 questions about their attitude in CPR. These informations were analyzed by SPSS and EPI6 softwares. The mean correct answers were 55%±11.8. The best results were about arrythmias (68.6%) and airway management (63.6%) and the worst were about IV access (43.1%) and pediatric CPR (31.5%). These findings were similar in 2 sequential years. Their knowledge had significant relation with sex (P=0.002), their original university (P=0.031), their residency course (P=0.024) and their residency reception scores (P<0.001). Males and knowledge more than females. The max scores were from Kerman (62%) and Beheshti universities (60.5%) and the min score were from Hamadan (48%) and Kashan universities (37%). The orthopedic (62.5%) and urologic residents (61.6%) had the most knowledge and the gynecology residents (53.8%) had the least. The knowledge had no relation with the time of graduation. About their attitude in CPR: Their knowledge was moderate (65.8%), their abilities was moderate (58%) and their education about CPR in MD course had been low (51.5%). Their references for education had been individual studies (74.6%), CPR workshop had not been condected in the most universities (92.7%). knowledge about CPR is low (55.8%) and must be 100%. In advanced centers, continuous educations in CPR is essential. Residents with low scores have accepted in courses that have more CPR situations. Difference in knowledge of residents from different universities, show the different educations. Primary knowledge was low and after years, this is lower. Attitude of residents show the low knowledge, low ability, low education in MD, courses.