Tehran University Medical Journal

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Background: The increasing use of β-lactam antibiotics in clinics for the treatment of different bacterial infections since early 1980s has led to increased rates of resistant bacteria isolated from patients. One of the problems in the treatment of nosocomial infections is related to resistant bacteria such as Enterobacter cloacae due to cross resistance through extended-spectrum beta-lactamase production. The aim of this study was to determine the prevalence of extended-spectrum beta-lactamase producing E. cloacae from different clinical specimens collected from hospitalized patients.

Methods: In the present study, 101 E. cloacae confirmed by standard specific microbiologic tests were collected from different specimens in Milad and Motahri hospitals in Tehran, Iran during February 2010 and September 2011. Antibiotic susceptibility tests were conducted according to the process recommended by the Clinical and Laboratory Standards Institute for 13 antibiotics of choice. Extended-spectrum beta-lactamase producing strains were screened for by combined disk method as a phenotypic diagnostic test.

Results: From a total of 101 E. cloacae, 33 (33%) were shown to produce extended-spectrum beta-lactamase by phenotypic tests 5% of the bacteria were resistant to imipenem too.

Conclusion: This study clearly showed the high prevalence of resistance to broad-spectrum beta-lactam antibiotics in the isolated E. cloacae among which 5% were multi drug resistant. All the isolated E. cloacae were susceptible to Colistin. These results can be alarming for physicians treating resistant E. cloacae infections, especially extended-spectrum beta-lactamase producing species.

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Background: Abacavir is an anti-retroviral medication used to treat HIV infected/AIDS patients and its efficacy has been proven in randomized clinical trials. The most significant adverse reaction associated with abacavir is the acute hypersensitivity phenomenon which manifests in many forms and in severe cases could result in death. Hypersensitivity reaction to abacavir has been closely linked to the presence of HLA-B*57:01 allele. Avoidance of abacavir initiation in allele-positive patients is the most effective strategy in preventing possible severe hypersensitivity reactions. Previous epidemiologic studies have made great strides toward delineating HLA-B*57:01 allele frequency in different regions of the World and the available results indicate significant discrepancy between geographical regions. Despite these efforts, no study to date has determined the allele frequency among Iranian HIV-positive patients. The aim of the present study was to determine the proportion of allele-positive patients among a group of Iranian HIV-infected patients. Methods: Between September 2012 and February 2013, 122 HIV-positive patients were selected among patients referred to Imam Khomeini Hospital’s Consultation cen-ter for high risk behaviors using the convenience sampling method. Sampling scheme was designed in a manner to include equal number of infected patients with and without clinical Acquired Immunodeficiency Syndrome (AIDS). Patient data was collected using available records and a blood sample for DNA analysis was also obtained. Presence of HLA-B*57:01 allele was determined using the Polymerase Chain Reaction- Sequence Specific Method (PCR-SSP). Results: Seventy three patients (59.8%) were male. Co-infection with hepatitis B and C was observed in 1.7% and 40.7% of the patients, respectively. History of addiction and anti-retroviral therapy was positive in 50.0% and 60.7% of the patients, respectively. Overall, three patients were allele-positive which corresponds to a frequency of 2.46% (95% CI: 0.005-7.30). No association between presence of allele and investigated vari-ables were identified. Conclusion: Frequency of HLA-B*57:01 allele among a group of Iranian HIV-infected patients is estimated to be 2.5%. This rate is comparable to those reported in other Middle-Eastern countries, yet is relatively lower than reports generated from South-Eastern Asia, Europe, and the United States. Future studies with larger sample sizes are needed to corroborate these findings.

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Background: Maternal mortality is one of the most important indicators of women health standard in developing countries. This study aimed to determine the prevalence of risk factors and etiology of maternal mortality in a geographic region of Iran. Methods: This descriptive- analytic cross sectional study included all pregnant women who died during pregnancy and six weeks after delivery due to pregnancy related fac-tor. The study was done in Sistan region in the north of Sistan and Baluchestan Prov-ince of Iran from April 2002 to March 2014. The immigrant women were excluded. Data were collected using 3 parts questionnaire. The validity and reliability of ques-tioner were approved by experts in this field. Data were analyzed using the statistical software SPSS version 18, Chi-square test and ANOVA analysis were performed. Results: The total number of deliveries during this time period was 60496. The total number of maternal mortality was 57 patients which means 94.2 out of 100.000 live births. Most of the dead mothers had more than 35 years old (46.9%), gestational age was more than 22 weeks (77.2%), gravidity more than 4 (21.1%), pregnancy interval lower than two years (46.9%) and 75.4% of death was in post-partum. The main cause of mortality was post-partum hemorrhage (19.3%). Conclusion: Based on our findings, some factors including multiparity, pregnancy his-tory more than 4 times, short interval between pregnancies lower than 2 years and ma-ternal age more than 35 years were some risk factors for maternal death. Maternal mortality in the postpartum period was more than pre-delivery period. Bleeding was the main cause of maternal mortality. Therefore monitoring of vital signs in the post-partum period and the proper management of bleeding are very important. It is sug-gested that risk assessment should be done for pregnant women in delivery ward for detecting high risk pregnant women. Suitable management for these women especially for patients with postpartum hemorrhage plays an important role to decrease the ma-ternal mortality.

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Background: Rupture of uterus is a catastrophic complication associated with significant maternal and fetal morbidity and mortality. The prevalence of an unscarred uterine rupture is very rare. Although the most important complication of dilatation and curettage is perforation of uterus, dilatation and curettage is not introduced as an important cause of uterine rupture. Case presentation: Here we present a case of uterine rupture in a pregnant woman that was admitted in Tehran General Women Hospital, in December 2014, with reducing fetal movement in her 41th weeks of pregnancy. She did not have any risk factors for rupture of uterus including cephalo-pelvic disproportion and polyhydramnios, also there was no history of uterine surgery such as myomectomy and uterine abnormality repair. A term dead male neonate was delivered by cesarean section due to arrest of descending in stage 2 of labor. The baby weighed 3400 gr and had anomaly in ears, larynx, uvula and soft palate. Its chromosomal study depicted both trisomy and monosomy for chromosome 13 and 21. Mother had a history of illegal curettage and trauma to the uterus in her first pregnancy two years ago. She did not say to us this history and abortion during admission. After cesarean section we saw that in the left side of the posterior wall of uterus was ruptured and baby was died. At surgical exploration, moderate hemoperitoneum was evident. Fetus was already dead at the time of extraction. Total estimated blood loss was 100 ml, the patient was transfused with two units of packed cell. The woman was discharged on the fifth postoperative day in good condition. Conclusion: Effective contraception and safe curettage can reduce maternal mortality and morbidity. Also special attention to a history of curettage to predict uterine rupture is critical.

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Background: One of the main reasons of hemorrhagic fevers is Ebola. The high rate of mortality and lack of definite treatment have been caused this infection to be a serious problem in the world. Ebola, especially in the early stages, when causes symptoms such as fever, anorexia and nausea, can be confused with malaria infection and conversely, severe malaria with Ebola. Plasmodium falciparum is an important cause of severe malaria that more than other types of plasmodium confused with Ebola. Case presentation: The patient is a 54-year-old man who had gone to Sudan about 8 months ago. The patient reported that fever, chills and headache had been started one week before traveling from Sudan to Iran and hematuria was added to his symptoms in third week of illness in Iran. He was referred to the emergency department with probable diagnosis of Ebola. Plasmodium falciparum gametocytes were revealed in his peripheral blood smear. Finally, he was treated with Coartem (artemether/lumefantrine) for malaria and after clinical improvement discharged to home with good condition. Conclusion: Ebola should be suspected in every patient with fever and a history of traveling to endemic areas. Considering the fact that in most areas where Ebola is endemic also malaria is common, lack of clinical suspicion to malaria causes that clinicians mistake malaria with Ebola. Necessary laboratory tests to rule out important differential diagnoses in patients with suspected Ebola virus contains: Peripheral blood smear for malarial parasite and blood culture and blood cell counts to investigate typhoid fever and other bacterial infections. Therefore, malaria should be considered as an important differential diagnosis in every patient suspected with Ebola.

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Background: There are many genetic and non-hereditary risk factors that are known to causes venous thromboembolic (VTE) disorders, Cardiovascular diseases and types of cancer. One of these is the Prothrombin G20210A mutation. Prothrombin mutation (guanine to adenine G→A) at nucleotide position 20210, which is present in the 3′ untranslated region of the prothrombin gene. Prothrombin G20210A mutation is present outside the coding region for prothrombin, and hence it does not affect the actual structure of the prothrombin molecule and it does not affect its function as a strong clotting factor when activated into thrombin. However, several studies have shown that, G20210A heterozygosity was associated with a threefold increased risk for VTE. Moreover, the association of PTH G20210A polymorphisms with cancer has been reported. The present study was designed to determine the frequency of PTH G20210A polymorphism in Southern Iran. Methods: In this cross-sectional study, 140 healthy women were from Southern Iran recruited among participants in Namazi Hospital, Shiraz, Iran, from March 2013 to February 2014. A total of 5 ml of peripheral blood was taken from individuals then Genomic DNA was extracted using blood DNA kit (Ron’s Blood and Cell DNA Mini Kit, BioRon, Germany). The amplification refractory mutation system- polymerase chain reaction (ARMS-PCR) method was used for the detection of PTH G20210A single nucleotide polymorphism in each subject. Results: The frequencies of the GG and GA genotypes were as 97.9%, 2.1% respectively. The frequency of G allele was and the frequency of A allele was 1.1%. Conclusion: Results of the present study might be important in understanding the distribution of PTH G20210A polymorphism in the Southern Iran. Minor allele frequency in this population is higher than in the Iranian and European population but similar to the prevalence in the Western Iran, Iranian Jews, American, Irish, Tunisian and Bahraini population.

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Background: To examine the association among pelvic girdle pain (PGP), urinary incontinence (UI) and pelvic floor muscle (PFM) function in pregnant women in second and third trimester.

Methods: 300 pregnant women who admitted for standard pregnancy care were enrolled in the study. Urinary incontinency was measured via the international consultation on incontinence questionnaire short form. Pelvic girdle pain was diagnosed according to existing guidelines. Vaginal examination assessed pelvic muscles contract- relax patterns and muscle strength. The software stata version 13 (Stata Corp., TX, USA) was used for data analysis.

Results: Overall 300 women (150 with PGP and 150 without PGP) were included in final analyses. There was not significant differences between the demographic data including, body mass index before pregnancy, maternal age, mode of delivery. Prevalence of urinary incontinence in women with pelvic girdle pain was 41.5 percent (CI 95%: 32.01- 51.48) while the prevalence of urinary incontinence in women without pain was 21.9 percent (CI 95%: 14.99-30.03). Using logistic regression, the relationship between urinary incontinence and pelvic girdle pain was significant. (CI 95%: 1.07-3.31, P=0.02). Multivariate logistic regression analysis was used to evaluate the relationship between PGP and pelvic floor muscle function and results showed that pelvic floor muscle strength in women with PGP was significantly lower than women without PGP. (CI 95%: 0.24-0.68, OR= 0.4, P<0.001). The duration of the contraction of the pelvic floor muscles in patients with PGP was significantly shorter than women without PGP. (CI 95%: 0.21-0.60, OR =0.35, P<0.001).

Conclusion: There was a significant association between pelvic girdle pain and urinary incontinence during the second and third trimesters of pregnancy and also the pelvic floor muscle strength and duration of the contraction of the pelvic floor muscles in women with pelvic girdle pain was significantly lower than those without PGP.

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Background: Chorionic villus sampling refers to a procedure in which small samples of placenta are obtained for prenatal genetic diagnosis, generally in the first trimester of pregnancy in 11 weeks till 13 weeks+6 days. This procedure provides prenatal diagnosis in pregnancy. Amniocentesis is a technique for windrowing amniotic fluid from the uterine cavity using a needle via a trans abdominal approach. Amniocentesis and chorionic villus sampling are invasive prenatal procedure. Their complications are fetal loss vaginal bleeding, rupture of membrane chorioamnionitis and limb reduction. There are some probable predictors of fetal loss after chorionic villus sampling and amniocentesis including maternal age, gestational age, number of needle insertion, previous miscarriage, and placental location. The aim of this study was to compare procedure related complications of amniocentesis and chorionic villus sampling in a tertiary referral hospital in Iran.

Methods: This retrospective cohort study was done in pregnant women who were high risk in genetic screening tests. The pregnancy outcome of women who underwent amniocenthesis and chorionic villus sampling was assessed in Yas Women General Hospital (Mirza Kuchak Khan), Tehran, Iran, from 2001 to 2011. Group one, pregnant women who underwent amniocentesis, was compared with group two, pregnant women that underwent chorionic villus sampling. The statistical analyses were performed with SPSSv.20 using a significant level of α<0.05.

Results: There were no significant differences between the two groups in procedure related fetal loss before 24th weeks of pregnancy (1.1% in chorionic villus sampling group versus 0.6% in amniocentesis group, P=0.318). A significant relationship between the number of needle insertion in the chorionic villus sampling group and fetal loss before 24th weeks of pregnancy was seen P<0.028. There were no significant differences between the two groups in the occurrence of vaginal bleeding, rupture of membrane, pre-term birth, placenta location, low birth weight and very low birth weight. The risk of chorioamnionitis was higher in chorionic villus sampling group (P=0.019). No significant difference was observed between the liquid and bloody amniotic fluid and pregnancy complications.

Conclusion: There was no significant difference between the procedure related complications of amniocentesis and chorionic villus sampling.

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Background: There are evidences that suggest the impact of stress on pregnancy outcome. Prolong antenatal depression and anxiety may cause lots of adverse pregnancy outcomes such as abortion, still birth, low birth weight and preterm labor. The aim of this pre-posttest randomized control trial study was to determine the role of stress management training in the first trimester on stress reduction in pregnant women referring to General Yas Women Hospital related to Tehran University of Medical Sciences in Tehran, Iran, from May 2014 to January 2016.

Methods: Anxiety status of 75 pregnant women in the first trimester was assessed by standard anxiety questioner using Hamilton anxiety rating score. Scores 18-25, 25-35 and >35 were considered for mild, moderate and severe anxiety, respectively. According to the level of anxiety, women with moderate and severe anxiety as the interventional group were arranged for participation in stress management workshops, applying mindfulness technique including: body scan, setting meditation and passing thought technique in 5 an hour sessions. For this experimental group were made available CD training for practicing lessons during the week. All groups didn’t need to medical treatment according to the psychiatrist interview. In the ending of therapy, clinical groups were assessed by anxiety scale again. Women with mild anxiety as the control group received only regular prenatal care without any psychological interventions. The validity and reliability of questioner were approved by experts in this field. This research was supported by Tehran University of Medical Sciences and Health Services grant and also the study approved by ethics committee of Tehran University of Medical Sciences. Data were analyzed using the statistical software SPSS version 18, and Student’s t-test analyses were performed.

Results: The level of anxiety and stress was decreased significantly between women in clinical groups, 27.5 to 14.1 for moderated level stress (P= 0.001) and 40.1 to 16.6 for high level of stress (P= 0.0001) respectively.

Conclusion: First trimester of pregnancy is a crucial stage of fetal growth and development. Based on our findings, stress management training in this period has beneficial effects on stress reduction and enhances maternal health status.

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Background: Different treatment used for resolving menopausal problems. Some studies assayed effectiveness of citalopram but it had some side effects and other studies about medicinal plants in Iran, including Melissa (combination of officinalis and foeniculum vulgare) showed improvement insomnia and anxiety. This study decided to assay effectiveness of this drug and comparison with placebo and citalopram in treatment of sleep disturbance of menopausal women.

Methods: Sixty postmenopausal women suffering from sleep disturbances that referred to Yas hospital between 2011-2013 were recruited to this double blind controlled study with 8 weeks’ follow-up period. They were randomized in three groups of twenty patients each, group A: received Melissa 600 mg that made by traditional medical school, group B: received citalopram 20 mg from Arya company that increased to 30 mg after one week and group C: received placebo. The patients were evaluated by Pittsburgh Sleep Quality Index (PSQI) questionnaire before and after treatment, also we checked the side effects of every drugs. Study was dissertation of one of the author with code 22263. This research has been supported by Tehran University of Medical Sciences and Health Services Grant. This study was registered at Iranian Registry of Clinical Trials with code of IRCT2013072714174N1. Results: Pittsburgh sleep quality index improved significantly in all groups, there was significant differences between Melissa group and two other group, but there wasn’t significance difference between citalopram and placebo group, there was a trend in favor of Melissa versus citalopram and placebo. All of seven field of PSQI improved significantly in all groups that showed improvement of sleep quality in all field of sleep disturbance. Conclusion: Melissa (compound of officinalis and foeniculum vulgare) may be recommended for the treatment of sleep disturbances in postmenopausal women. Although further investigation with more cases is needed to find long-term results and compare with hormone therapy.

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Results: Totally 960 pregnant women (760 controls and 200 cases) participated in the study. The mean age of the subjects was 31.07±0.17 years old with a minimum age of 17 and a maximum age of 45. The averge age of case group women was 33.57±0.40 years and this was 30.41±0.18 years in control group. This study indicated that maternal age (P<0.001) and the number of pregnancies in the case group are significantly (P<0.001) higher than the control group. Also, having a history of miscarriage (P<0.001), having a history of infertility (P<0.001), and having hypothyroidism (P=0.030) are significantly more common in the case group. The frequency of intrauterine growth failure (P=0.003) and neonatal hospitalization (P<0.001) were also significantly higher in the case group. Conclusion: Despite recent advances in the prenatal field, the accuracy of screening tests may still vary depending on maternal age and other existing characteristics. Hence, it seems considering the mother's background characteristics are important just the same as the screening test results.

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Results: Twenty-seven patients in each group have completed the study. The mean age of the control group and test group was 48.2+4.8, 47.8+5.7 and 47.2+4.9 years respectively (P=0.91). Two groups were comparable regarding nystagmus severity. All patients had at least two attacks During the last six months. The mean of serum 25 OHD was 33.81 in the control group and 11.41 in the test group that was statistically significant (P=0.001 for all) and the severity of torsional nystagmus in three axes of horizontal, vertical and oblique in the control group was 4.98, 9.06, 5.40 respectively and 3.32, 8.86, 6.93 in the test group that was statistically significant as compared with the control group (P=0.001). Conclusion: Findings of this study indicate a relationship between vitamin D deficiency and recurrence of nystagmus in BPPV patients

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