Tehran University Medical Journal

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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

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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.

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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

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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.

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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.

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Inflammatory bowel diseases are one of the important reasons of the referral to GI practitioners in our country and Ulcerative Colitis is the more frequent type of these disease in Iran. In this study 200 cases of Ulcerative Colitis, which has been referred to Imam Khomeini Hospital during that last 5 year, were studied. Data was collected using the patient's records and face to face interview with them and their relatives. Majority of the patients were female (55 percent). Positive family history was seen in 28 percent of patients, autoimmune disease history in 8 percent, smoking history in 11 percent and smoking cessation history in 13 percent of patients. Most prevalent symptoms in the patients were nocturnal bleeding, rectal bleeding and bloody diarrhea. The most common involved area were recto sigmoid (58 percent) and descending colon (42 percent). Pan colitis was seen in 8 percent. Most people had complications and the most common complications was fissure (14 percent). Recurrence was seen in 83.5 percent of patients. With logistic regression analysis the only variable which showed significant relation with recurrence was male sex. According to the results of this study, it seems that ulcerative colitis clinical and epidemiological pattern in Iran is similar to many other countries, but the higher rate of recurrence and extra intestinal manifestations in patients shows that there is a growing need to reconsider the treatment efficacy in patients and correct the treatment methods.

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Anxiolysis and sedation with oral midazolam are common practice in pediatric anesthesia. Good or excellent results are seen in only 50% to 80% of cases, so we decided to investigate if addition of a low dose of oral ketamine to midazolam (ketamine2.5 mg /kg ^midazolam 0.25 mg/kg )resulted in better premedication compared with oral midazolam 0.5 mg/kg or ketamine 6 mg/kg alone.
Methods and Materials: in a prospective, randomized ,double -blind study we study 105 children (mean age 6 ,range 2-10 yr. ) undergoing non thoracic and non cardiac surgery of more than 30 min duration. The patients were in ASA 1, 2. After oral premedication the child's condition was evaluated by assigning 1-4 point to the quality of anxiolysis, sedation, and separation from parents in the induction room .The groups were similar in sex, age, weight, intervention and duration of anaesthesia.
Results: The score of sedation before transfer to the operation room was significantly better in the ketamine, midazolam combination group than in the ketamine or midazolam group. Success rates for anxiolysis and behavior at separation were grater than 90%with the combination, approximately 80% with midazolam and 70% with ketamine alone .The incidence of salivation, excitation, nausea and vomiting was grater in the ketamine group but were very low in other groups. During recovery there were no difference in sedation or time of possible discharge.
Conclusion: In summery, significantly better anxiolysis and separation were observed with a combination of ketamine and midazolam, even in awake children than with midazolam or ketamine alone. Duration of action and side effects of the combination was similar to those of midazolam.

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Background: Patellofemoral joint disorders are the most common cause of anterior knee pain in patients who referred to orthopedic clinics. Patellar lateralization cause anterior knee pain due to weakness of vastus medialis oblique muscle or tightness of lateral structures like lateral retinaculum or iliotibial band muscle.

Materials and Methods: For evaluation of this abnormality, plane radiography, CT scan and MRI are useful. In plane radiography only one view in a single joint position can be obtained, because of that it is not a good method to detect abnormal tracking during knee range of motion. The purpose of this study was to evaluate patellar tracking by kinematics MRI during five serial degrees of knee range of motion (40, 30, 20, 10, 0 degrees) in 30 patients with patellar lateralization and 10 normal subjects, aged 18-30 years.

Results and Conclusion: tistical analysis showed that in patients group, patella had the most stability in 40 degree of knee flexion and this stability reduced when knee reached to full extension. At this point, patella moved laterally and the most instability was seen during 20 to 0 degree of knee extension.

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Background: One of the most important concerns in orthopedic medicine is the low back. Considering the importance of muscle function in preventing LBT by controlling too much load and stress applied on the spinal joints and ligaments.

Materials and Methods: The aim of this research was to determine the timing and level of activities of lumbopelvic muscles in response to postural perturbations caused by unexpected loading of the upper limbs in standing on three different supporting surfaces (neutral, positive slope, negative slope) in 20 healthy females 18 to 30 years old ( = 23.20 SD = 2.55 ). The electromyographic signals were recorded from the deltoid, gluteus maximus, internal oblique abdominis and lumbar paraspinal muscles of the dominant side of the body to evaluate the onset time, end time, level of muscle activity (RMS) and duration of different muscles in one task and one muscle in different tasks.

Results: The results showed that the agonists (posterior muscles) activated at first to compensate the flexor torque caused by loading and then the antagonists (anterior muscles) switched-on to compensate the reaction forces caused by agonist activities. With regards to continuous activity of internal oblique and its attachments via thoracalumbar fascia to the transverse processes of the lumbar vertebrae, it can be considered as one of the major stabilizer muscles of the trunk .

Conclusion: Finally the results indicated that supporting surface type didn’t have any effect on timing and scaling of muscle activities in different tasks suggesting that probably spinal and trunk priprioceptors are just responsible for triggering postural responses and they don’t have any role in determining timing and scaling.

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Background and Aim: Helicobacter pylori is the etiologic agent of chronic –active gastritis, gastroduodenal ulcers in humans, and a co-factor in the occurrence of gastric cancer and mucosa-associated lymphoid tumors, Adhesion of H.pylori to the gastric mucosa is a critical and also initial step in the pathogenesis of the disease. Bacterial adhesion inhibitory agents provide a novel pharmacologic approach to the management of infectious diseases.    

Materials and Methods: 22 H. pylori strains, isolated from the antral biopsies of 49 patients with dyspepsia, gastritis, gastric ulcer, duodenal ulcer,…were assayed by ELISA (UPR)to investigate the diversity of attachment to 7 mamalian cell lines.

Results: The concentration of H.pylori and cell suspention ,the condition and temperature, can alter the attachment rate.Best bacterial concentration was equal to 1 Mc farland,and for cell suspension was 5*10 cells/ml.90 minutes in 37C incubation period result in maximum attachment. H.pylori can attach to all 7 cell lines, there are no significant differences between 22 H.pylori strains in attachment to cells. The attachment pattern of H.pylori to the cells showed significant reduction respectly from HepII, HeLa, SW742, AGS,HT29/219, HT29 to Caco-2.Maximum attachment were seen to HepII, HeLa and SW742 cells, and among these HepII was the best cells for this purpose.

Conclusion: Our studies suggest that Hep II, HeLa and SW742 cells could serve as a suitable in-vitro model for the study of H.pylori adhesions, attachment, inhibition of attachment and detachment assays and among these Hep II cell is prefer recommended.

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Background: Umbilical cord blood gas analysis is a useful method for assessment of oxygenation and acid-base status in neonates. Severe fetal acidemia is associated with increased perinatal mortality and increased risk of subsequent impaired neurological development. Due to high percentage of C/S in our country and the effect of anesthetic medications on umbilical blood gases which can cause neonatal acidosis and hypoxemia, the study of umbilical cord blood gas in vaginal delivery versus cesarean section is mandatory.

Methods: In this cross-sectional study one hundred samples were taken from Mostafa Khomeini hospital in summer 2004. The samples were taken immediately of umbilical vein after clamping the umbilical cord and analyzed after 10 minutes. Cases were classified in to 3 groups: vaginal delivery (n=40), elective C/S under general anesthesia (n=35) and C/S under spinal anesthesia (n=25). Duration of anesthesia and its effect on blood gas and infants apgar were assessed.

Results: In the first group (vaginal delivery) mean blood gase parameters were pH=7.3064.73, pO2=25.246.87, HCO3=20.562.03, Apgar=8.820.38 and pCO2=41.826.57. In the second group (general anesthesia) mean blood gaze parameters were: pH=7.3044.73, pO2=38.7014.02, pCO2=43.265.87, HCO3=21.1113 and apgar score=8.170.7. In the third group (spinal anesthesia) mean blood gaze parameters were: pH=7.3014.50, pCO2=44.14.99, HCO3=21.382.15, pO2=26.625.5 and apgar=8.600.62. The apgar scores and pO2 demonstrated significant relationship with type of anesthesia. The apgar score was lower and pO2 was higher in C/S under general anesthesia compared with the other two groups. There was significant relationship between duration of anesthesia and umbilical pO With increasing duration of anesthesia, pO2 was reduced. Between the type of delivery and anesthesia duration with PH, pO2, pCO2 and HCO3 were not meaningful relationship (P<0.05).

Conclusion: There was no significant difference between type of delivery and umbilical blood gas parameters. Neonatal apgar score in NVD is higher than the other groups. With increasing duration of general anesthesia in C/S, umbilical po2 is reduced.

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Background: A variable hematological value without clinical sign of sepsis or hematological disorder is often observed in newborns. The purpose of this study was to investigate hematological measurements in umbilical cord vein of newborns delivered spontaneously or by cesarean section.
Methods: We studied 150 pregnant women who delivered term normal infants. The patients were divided into two groups according to the route of delivery: vaginal (n=75) and cesarean section (n=75). Immediately after delivery, umbilical cord blood samples were collected. Any possible relationship between mode of delivery, gestational age, gravidity, parity, sex, weight of the new born infant, and the duration of different phase of labor with the hematological parameters was investigated.
Results: We observed a significant increase in all hematologic parameters including hemoglobin and hematocrit levels and WBC, platelet and RBC counts in newborns delivered spontaneously (p<0.001). The lymphocyte counts were similar in two groups. Male infants and newborns with higher gestational age showed a higher hemoglobin and hematocrit levels. Increased parity and gravidity correlated with a decrease in all hematological values of umbilical vein blood except of lymphocyte count (p<0.001). Prolonged duration of first and second stage was associated with higher mean leukocyte, neutrophil, platelet, hemoglobin and hematocrit values.
Conclusion: The mode of delivery, gestational age, parity, gravidity, sex and weight of newborn, and the duration of first and second stage of labor can influence on hematological parameters of umbilical cord blood.

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Background: There is considerable professional debate over which technique is the best for lifting. The aim of this study is to compare three static lifting styles, the stoop, semi-squat and arm lift, using maximum isometric voluntary contraction (MIVC) as one indicator for recommending a lifting style.
Methods: Thirty healthy women (mean age: 22.37 years) participated in this quasi-experimental study. They performed the tests in static postures by standing on the platform of the Lift TrackTM and pulling the dynamometer of the instrument with maximum effort in three lifting styles: the stoop, semi-squat and arm lift. The subjects warmed-up by practicing the lifts first. The mean MIVC from the two other sets of lifts were used for statistical analysis by repeated measurements and SPSS (ver.10) software.
Results: There were significant differences between the MIVC of the three lifting styles in this study. The largest MIVC was for the semi-squat lift and was the least was for the arm lift (p<0.001). The MIVC of the stoop lift was larger than that of the arm lift (p<0.001).
Conclusion: The largest MIVC for the semi-squat lift suggests that this style is useful for lifting objects from the floor. The differences in biomechanical and muscle pattern activity changes could explain these results. It seems that activation of the quadriceps muscles in the semi-squat lift was a main factor for producing more MIVC, so when this style is recommended for lifting, attention to the power of the quadriceps is important.

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Airway management is one of the most important subjects in medicine. This article reviews the history, assessment of airway prior to anesthesia, techniques and equip-ment of airway management and management of patients with anticipated and unan-ticipated difficult airways. This article covers recent literature on airway appliances and devices and their use in different circumstances. Airway assessment methods especially the recent Iranian method have been reviewed and discussed briefly in this article. On the whole the article covers the etiology of difficult airway and offers guidelines for safe practice of anesthesia in patients in whom airway is anticipated to be difficult.

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Background: Oral clefts are among the most common congenital anomalies. Infants with oral clefts often have other associated congenital defects, especially congenital heart defects. The reported incidences and the types of associated malformations and congenital heart defects vary between different studies. The purpose of this study was to assess the incidence of associated congenital heart defects in children with oral clefts.
Methods: All infants with cleft lip and palate referred to the Children's Medical Center and Bahramy the teaching Hospitals of the Tehran University of Medical Sciences from 1991 to 2005 were prospectively enrolled in this study group. All patients were examined and noted by an academic cleft team contain a pediatrician and a pediatric surgeon, and received cardiac consultation and echocardiography by a pediatric cardiologist. non cardiac associated anomalies, still born and patients without echocardiography were excluded from the study. Data including age, gender, exposure to contagions and high risk elements ,consanguinity and familial history of oral cleft, type of oral cleft, results of cardiac consultation and echocardiography and associated cardiac anomalies were cumulated and analyzed by SSPS version 13.5
Results: Among the 284 infants with oral clefts, 162 were male (57%) and 122 were female (43%). Seventy-nine patients (27.8%) had cleft lip, 84 (29.5%) had cleft palate and 121 (42.6%) had both cleft lip and palate. Of all the patients, 21.1% had congenital heart defects. the most common type Of these congenital heart defects(28.3%) was atrial septal defect.
Conclusions: For patients with cleft lip and palate, we recommend preoperative cardiac consultation, careful examination and routine echocardiography for associated cardiac anomalies, as well as appropriate management and prophylactic antibiotic therapy for those with associated congenital heart anomaly.

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Background: Musculoskeletal disorders (MSDs) are one of the major problems, encountering work force today. Many researches have revealed the disadvantages and inconveniences that such problems have caused. Some kinds of careers are traditional and complex and are more probable to cause disorders. Carpet restoration is one of these jobs causing musculoskeletal disorders in the work force. The nature of this job puts a lot of pressure on the worker’s body. The postures are most of the time problematic and are in need of some ergonomic actions to be taken in order to prevent from diseases and disorders of musculoskeletal system.
Methods: In a cross- sectional survey, 144 male carpet restoration workers enrolled. NORDIC and PLIBEL checklists were used to assess the musculoskeletal stress factors with injury effects. Another checklist was employed to address demographic characteristics of the population under study.
Results: The results showed that 82% of these workers suffered from some forms of musculoskeletal disorders mostly from knee and lower back discomfort. The more they had job experience, the more they suffered from MSDs. Disorders of neck and upper back had significant relationship with the duration of work experience. Also badly designed tools and awkward posture were of main risk factors. PLIBEL checklist successfully showed the main threatening risk factors of all body parts.
Conclusion: The survey revealed that the incidence of MSDs in these workers is high and there are several risk factors affecting their body during work unsuitable design of tools, incorrect work height and bending position of the body during work were the most risk factors, which observed.

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Background: Premedication is widely used in pediatric anesthesia to reduce emotional trauma and ensure smooth induction. The rectal route is one of the most commonly accepted means of drug administration. The aim of our study was to investigate and compare the efficacy of rectally administered midazolam versus that of ketamine as a premedication in pediatric patients.

Methods: We performed a prospective randomized double-blinded clinical trial in 64 children, 1 to 10 years of age, randomly allocated into two groups. The midazolam group received 0.5 mg/kg rectal midazolam and the ketamine group received 5 mg/kg rectal ketamine. The preoperative sedation scores were evaluated on a three-point scale. The anxiolysis and mask acceptance scores were evaluated separately on a four-point scale, with ease of parental separation, based on the presence or lack of crying, evaluated on a two-point scale.

Results: Neither medication showed acceptable sedation (>75%), with no significant difference in sedation score between the two groups (P=0.725). Anxiolysis and mask acceptance using either midazolam or ketamine were acceptable, with  midazolam performing significantly better than ketamine (P=0.00 and P=0.042, respectively). Ease of parental separation was seen in both groups without significant difference (P=0.288) and no major adverse effects, such as apnea, occurred in either group.

Conclusions: Rectal midazolam is more effective than ketamine in anxiolysis and mask acceptance. Although they both can ease separation anxiety in children before surgery, we found neither drug to be acceptable for sedation.

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Background: The typical features of eccentric exercise-induced muscle damage are delayed-onset muscle soreness (DOMS) and prolonged loss of muscle strength. It has been shown that passive warmth is effective in reducing muscle injury. Due to the interaction of different systems in vivo, we used isolated perfused medial gastrocnemius skeletal muscle to study the direct effect of temperature on the eccentric contraction-induced force loss.

Methods: After femoral artery cannulation of a rat, the left medial gastrocnemius muscle was separated and then the entire lower limb was transferred into a prewarmed (35^oC) chamber. With the chamber temperature at 31, 35 and 39^oC before and during eccentric contraction. Isometric force loss was measured after 15 eccentric contractions (N=7-9).

Results: Maximum contraction force reduction has been used as an index for eccentric contraction-induced force loss. In this study eccentric contraction caused a significant reduction in maximum isometric tension (p<0.01), but no significant difference was seen in isometric force loss at 31^oC and 39^oC compared with that at 35^oC.

Conclusions: Our results suggest that temperature changes before or during eccentric contractions have no effect on eccentric contraction-induced force loss.

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Background: Langerhans cell histiocytosis (LCH) is a group of idiopathic disorders characterized by the proliferation of specialized bone marrow-derived Langerhans cells and mature eosinophils. The estimated annual incidence ranges from 0.5-2 cases per 100,000 persons per year. The pathogenesis of LCH is unknown. The prevalence of LCH seems to be higher among whites and males. The most common complaints at presentation are those related to bone lesions. Treatment consists of surgery, chemotherapy and radiotherapy alone or in combination. The age of onset varies according to the variety of LCH. Solitary lesions may occur in bones or skin. Cutaneous lesions present with firm, painless papulonodules or vesicles.

Case report: This six-month-old baby presented with firm papulonodules on her temporal skin, but fortunately her other organs were healthy. She underwent two surgeries, separated by a one-month interval. Due to local recurrence after a short period of time, she underwent a 10-Gy dose of radiation. Her response proved good during follow-up.

Conclusion: Radiotherapy is good for controlling local recurrence in LCH, with few sequelae related to treatment.

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Background: Axillary block is used for inducing anesthesia in outpatient hand and forearm surgeries. Few researches have studied hemodynamic and blockade effects of low doses of Epinephrine. The aim of the present study was to compare the duration of analgesia and hemodynamic changes following the injection of high/low epinephrine doses in such surgeries.

Methods: The present randomized clinical trial study was conducted on healthy individuals (ASA I-II) who were candidates for hand and forearm surgeries. The patients were randomly divided into three groups. The first two groups were allocated to receive lidocaine with low (0.6µg/cc) and high (5µg/cc) doses of epinephrine whereas lidocaine plus normal saline was injected in the third group. The hemodynamic changes (Mean arterial blood pressure and heart rate) and the occurance of any side-effects along with the duration of analgesia and motor block were recorded.

Results: From among the total of 75 patients, 15 cases were excluded due to incomplete blockade or failure needing general anesthesia. The duration of analgesia and the motor block were longer in the high dose epinephrine group, the difference, however, was not statistically significant. Heart rate changes within the groups was significant in the 4^th-7^th and 10^th minutes. Mean arterial blood pressure changes was only significant in the 4^th minute, within the groups.

Conclusions: Administering low doses of epinephrine plus lidocaine as a local anesthetic not only provides acceptable analgesia compared to higher doses of the medication, but also is associated with fewer side effects.