Tehran University Medical Journal

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Background: Rheumatoid arthritis (RA) is a chronic inflammatory condition. The condition can affected many tissues throught out the body, but the joints are usually most severely affected. The high incidence of RA, the conventional treatments and the experimental observation have shown by combination therapy, the disease symptoms of the patients reduce. To compare the efficacy and tolerability of single-agent Hydroxychloroquin (HCQ) with combination therapies composed of (HCQ) and Methotrexate (MTX) and (HCQ), (MTX) and Sulfasalazin (SSZ) in active rheumatoid arthritis patients with additive arthritis.
Methods: One hundred and twenty RA patients with active arthritis (male/female: 30/90) who were treated in rheumatology clinic between 2003 and 2005 were enrolled in this trial. Patients treated with (HCQ) alone(200 mg/day)were include in group (I), patients treated with combination of (HCQ) (200 mg/day)and (MTX) (7.5mg/week)in group (II),and patents treated with combination of (HCQ) (200mg/day),(MTX) (7.5mg/week)and (SSZ)(1 gr/day)in group (III), Forty patients (male/female:10/30) in group (I),(II) and (III)were eligible for statistical analysis at the end of study. Changes in variable were compared by the T-test.
Results: The combination of (MTX), (HCQ)and (SSZ) and the combination of (MTX) and (HCQ) were more effective regarding the clinical and laboratory parameters than (HCQ) alone (P<0.05). Moreover the combination of (MTX), (HCQ) and (SSZ) was more effective than the combination of (MTX) and (HCQ) (P<0.05). Combination therapies seem to be more effective and no more toxic than monotherapy in RA patients with additive arthritis.
Conclusion: Combination therapy with methotrexate, hydroxychloroquin and sulfasalazin is more effective than hydroxychloroquin alone or a combination of methotrexate and hydroxychloroquin in RA. We suggest starting combination therapy for the patients with early RA, when the diagnosis has been established.

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Background: The Fontan operation is the definitive operation for palliation of complex congenital heart disease with single –ventricle physiology. The use of the extra cardiac conduit has recently been gaining popularity. The purpose of this study was to compare the outcomes of extra cardiac conduit Fontan procedure (off-pump technique) and that of traditional technique (lateral tunnel technique) in which cardiopulmonary bypass is routinely used.
Methods: Forty one patients in different age groups underwent extra cardiac conduit Fontan procedure between April 2001 and December 2004. Data were collected from ICU sheets, files and during follow up visits. Under general anesthesia and through median sternotomy, using two temporary decompressing shunts, superior vena cava implanted on right pulmonary artery and a conduit interposed between transected inferior vena cava and main pulmonary artery. Fenestration was done in almost all patients and previous shunts were closed if there were any.
Results: Of our patients, 13 were female and 28 were male. Mean age of the patients was 11.1 years (SD=7.8).In 24.4% of cases Fontan procedure was done as the first palliative surgery and in 75.6% of them there was previous history of palliative procedures. In 6 patients (14.6%) we were constrained to use cardiopulmonary bypass which was predictable or necessary in 50% of cases. There was no reoperation due to post operative bleeding. Two cases suffered from prolonged plural effusion. Our in-hospital mortality was 9.8%. During 2-24 months follow up, we found two cases who were in NYHA functional class II and one case in functional class I.
Conclusion: Extra cardiac conduit Fontan procedure could be used in a safe way. The results of this study were comparable and even in some cases better than that of the traditional technique.

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Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease with several factors that contribute to its manifestation and continuation. One of the factors that initiate RA is emotional stress, which is in direct relationship with the sufficiency or insufficiency of the neuro-endocrine axis. Therefore, any stress that is not resolved in the neuro-endocrine axis might lead to RA and, as the stress continues, it causes the continuation of the disease. The aim of this study is to determine the effect of stress on continuation of RA and to find curative methods and, ultimately, the best method for treatment.

Methods: One hundred rheumatoid arthritic patients (80 females and 20 males), having a final diagnosis of RA based on the guidelines of the American College of Rheumatology and onset of disease within the last 12-36 months, were studied as case and control subjects. Data was collected using interviews and questionnaires that reflected their life events with stress as a serious factor in their disease. The patients were divided into two groups: group A with stable stress and group B with unstable stress. The same treatment method was given to both groups. The results of the treatment were evaluated and compared after two years of follow up. Results: There was significant improvement in the patients in group B with unstable stress over that of the patients in group A with stable stress (P<0.0001). Conclusion: The present study shows that a considerable number of RA patients suffer from serious stress that affects their clinical path and improvement, and is quite visible in the health indexes and continuity of the disease. The results further showed that stress can play an important role in the initiation and continuation of RA. Therefore, by identifying and making efforts to remove the stress factors using anti-anxiety drugs, the disease can be better controlled.

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Background: Dialysis access procedures and complications are important causes of morbidity and hospitalization for chronic hemodialysis patients. Ideally, any patient undergoing hemodialysis should receive an autogenous fistula that can be accessed throughout the patient's life. In patients with primarily unsuitable or secondarily surgically-exhausted veins, a prosthetic graft can be performed. Several recently published studies report the outcome of prosthetic grafts. The conclusions of these studies differ dramatically. The aim of this prospective study was to determine the patency, infection and thrombosis rates using Poly-tetrafluoroethylene (PTFE) in grafts for vascular access in hemodialysis patients.
Methods: During this three-year prospective study, 84 patients underwent placement of vascular access graft at the Vascular Surgery Department of Sina Trauma and Surgery Research Center in Tehran. Demographics, complications, and subsequent treatment were recorded. Primary patency rates were estimated using the Kaplan-Meier method. Logrank tests were used to evaluate the statistical differences in survival distribution.
Results: The mean patient age was 55 years (±12 years). Hypertension, diabetes and smoking were considered to be risk factors for atherosclerosis in 45, 26 and 19 cases, respectively. The patients were followed up for at least 24 months. The primary patency rates were 78%, 63.3% and 54.9% at 6, 12 and 18 months, respectively. There were 39 (46.4%) access failures, which were related to infection in five cases (6%), thrombosis in 30 cases (35.7%) and bleeding in two cases (2.4%). The patency rate in patients without hypertension and with hypertension were 62.2% and 29.7%, respectively (P<0.03). Patency rates for upper extremity and lower extremity grafts were 60% and 26%, respectively (P<0.05).
Conclusion: A PTFE vascular graft seems to be an appropriate vascular access and is a promising alternative when upper extremity arteriovenous fistulas cannot be constructed. Additionally, good care and educating patients can further decrease the rate of complication and morbidity, thereby resulting in a better patency rate.

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Background: Hyperhydrosis, excessive sweating, can profoundly affect the quality of life of the patient, with severe impairment of daily activities, social relationships and occupational activities. The purpose of this study was to evaluate the outcome of thoracoscopic sympathectomy in patients with palmar hyperhydrosis.

Methods: In a clinical trial at Imam Khomeini, Milad and Velenjak Hospitals from 2003 to 2006, 33 patients older than five years of age with palmar hyperhydrosis underwent thoracoscopic sympathectomy of T₂ and T₃ ganglions. The variables regarding operation duration, length of hospital stay and early post-op complications were recorded. In addition, the quality of life of the patients was evaluated using the DLQI questionnaire, while the satisfaction of the patients was evaluated using the visual analogue scale before, immediately after and six months after the operation.

Results: The mean age of the patients was 23 years and 63.6% of our patients were female. The sites of hyperhydrosis were hand, foot and armpit in 72.7% of the patients. In 90.91% of the cases, disease onset occurred during childhood and 78.79% of the patients had a family history of hyperhydrosis. Hyperhydrosis impaired function and had social, interpersonal and emotional effects in 72.7% of the cases. The mean duration of the operation was 40.3 minutes and the mean hospital stay was 1.45 days. The most common early post-op complications were atelectasis (7.57%), short-term pulmonary complications (3.03%) and pleural effusion (3.03%). Compensatory hyperhydrosis occurred in 60% of the cases, while 18.75% experienced gustatory sweating. Palms were reported to be totally dry immediately after and six months after the operation in 81.82% of the cases, while 18.18% reported acceptable levels of perspiration. The mean level of satisfaction immediately after and six months after the procedure was 0.81. All patients felt improvement in all aspects of their lives immediately after and six months after the operation. In terms of quality of life, the mean of DLQI score was significantly lower immediately after and six months after operation (18.78 ± 501 vs. 1.60 ± 0.81 and 1.64 ± 1), indicating that symptoms had less effect on the patients' lives. All patients were willing to re-experience the operation if necessary.

Conclusion: Thoracoscopic sympathectomy is an effective and safe therapeutic modality for palmar hyperhydrosis with a great rate of success and a slight chance of complica-tions. This operation results in a remarkable improvement in various aspects of the patients' lives. Willingness to re-experience the operation indicates the high degree of satisfaction.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Hemorrhoid is among the most common anorectal diseases and patients with high-grade disease conditions need surgical treatment. Many surgical procedures are available to treat the disease. The aim of this study was to compare the operative time and outcomes, (post-operative pain and complications) of LigaSure hemorrhoidectomy with those of the open conventional method.
Methods : This randomized single-blind clinical trial included 57 patients (28 in LigaSure and 29 in the open group). The primary variable was the operative time for the excision of a single hemorrhoidal packet. The other variables were post-operative pain measured by morphine doses administered to control pain, scores of visual analogue scale (VAS) used to measure pain severity, pain during home stay measured by doses of oral ibuprofen and the mean daily VAS scores, early complications including bleeding and urinary retention, longer-term complications and time to return to work.
Results : The demographic data were comparatively the same between the two groups. The average time to excise a single packet of hemorrhoid was significantly shorter in the LigaSure group (8.91 min vs. 17.35 min, P<0.001). Post-operative pain measurements (morphine doses and VAS scores) were lower in the LigaSure group, but the differences were not statistically significant (P=0.055 and 0.077, respectively). Complications of the two procedures were also comparable. Neither of the groups returned to work in a shorter time.
Conclusion: LigaSure hemorrhoidectomy seems to be a safe method and it can reduce the operative time significantly. It may also have a modest effect on post-operative pain.

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Background: Percutaneous coronary intervention (PCI) may been associated with high-er risk of cardiac events during this procedure. The goal of this study was to compare high dose atorvastatin therapy with low dose atorvastatin therapy 24 hours before PCI to a reduction in Peri- percutaneous coronary intervention myocardial infarction.
Methods: One hundred ninety patients with stable angina were enrolled in a randomiz-ed controlled clinical trial study. All patients received low dose atorvastatin. The patients scheduled for elective PCI were randomized to atorvastatin (80 mg/d, n=95) or placebo (n=95) within 24 hours before the procedure. Creatine kinase-MB, troponin I, and high sensitive C- reactive protein levels were measured at baseline and at 6 and 12 hours after the procedure. PCI related myocardial infarction was defined as increasing of Creatine kinase-MB or troponin I three times compared with values before procedure.
Results: Myocardial infarction was detected after coronary intervention in 4.2% of patients in the atorvastatin group and in 13.7% of those in the placebo group (P=0.022). Mean of changed levels of Creatine kinase-MB (0.7±0.5 versus 3.3±1.9 ng/mL, P<0.001), troponin I (0.1±0.2 versus 0.4±0.7 ng/mL, P=0.052) and hs-CRP (0.1±0.5 versus 1±0.9 ng/mL, P<0.001) were significantly lower in the statin than in the placebo group.
Conclusion: Pretreatment with high dose atorvastatin within 24 hours before elective percutaneous coronary intervention significantly reduces procedural myocardial infarct-tion in elective coronary intervention.

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Background: Sacrococcygel region is the most common site for pilonidal sinus and surgery is the most common treatment for it. Numerous operative techniques have been described for management of this disease but a technique with low recurrence and complication rates is the best treatment option. Karydakis has been introduced as a method with less recurrence rate, but it seems that surgeons debate on complications and it is not a common technique in our country. In this article, we will discuss Karydakis procedure and its results after a prospective follow-up in our patients. Methods: This is a prospective single cohort study on the patients with sacrococcygeal pilonidal disease. Cases evaluated in this study included patients underwent Karydakis procedure for their pilonidal sinus from 23 September 2006 to 22 September 2013. Patients were followed-up prospectively after their discharge within the first week, first month and third month for early complications and then annually for recurrence. The length of follow-up ranged from 3 to 77 months (median 36 months). Results: Of 141 patients, 119 (84.4%) were male and mean operating time was 55.52 (35-120) minutes. Mean time to healing wound with no need to dressing was 15.92 (range: 2-120) days and mean time to return to work was 14.44 (range, 1-35) days. Overall rate of early post-operative complications was 21.3% that most of them treated conservatively. Wound breakdown within the caudal part was the most common complication detected in 12.1% of patients and infection was detected in 5.8%. Hematoma, seroma and complete wound breakdown were seen in one patient each. The mean score of patient's satisfaction after one year was 4.91 out of 5. Recurrence was appeared in 1.42% of patients. Conclusion: Karydakis procedure for sacrococcygeal pilonidal disease is associated with low complications, short healing time and return to work, and reasonable recurrence rate.