Tehran University Medical Journal

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Early diagnosis, treatment, investigation and follow up of children with urinary tract infection (UTI) are needed to minimize renal scarring. The aims of this study were 1) to evaluate the ability of DMSA scintigraphy, ultrasound and biological parameters in detecting renal parenchymal involvement in children with acute pyelonephritis (APN) 2) to assess the relation between renal parenchymal changes and creatinine clearance 3) to determine the incidence of renal scarring after APN.
Materials and Methods: We prospectively studied 54 children (median age 4.02± 3.41 range 1 month to 12 years) with first time symptomaticUTI. All patients had DMSA scan and ultrasonography within 5 days of admission. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), white blood cell (WBC), was measured at the time of infection, and voiding cystourethrography was performed in all children within 10 days. When scintigraphy showed renal parenchymal changes, repeat DMSA scan was done at least 3 months after initial infection.
Results: Changes on the DMSA scan were found in 93/108 (85.5 percent) renal units in 54 children during acute pyelonephritis. Among 42 children who had underwent repeat scintigraphy , renal scars were found in 9 of 16 (56.25 percent ) renal units in 8 infants under 1 year ,23 of 32 (71.87 percent) in 16 children aged 1-5 years, and 33 of 36(91 percent ) in 18 patients older than 5 years. Ultrasonography showed renal changes in 20 of 108 (18.5 percent) kidneys. Reflux was seen in 21 of 108 (19.44 percent ) renal units. The sensitivity of ESR, CRP, WBC, and ultrasonography was 78.5 percent , 64.5 percent , 69.9 percent , 18.5 percent respectively, and the specificity of them was 40 percent, 33.3 percent, 13.3 percent,
80 percent respectively. There was a positive correlation between renal parenchymal involvement and creatinine clearance level (p<0.001).
We found no difference between groups with or without scars with respect to levels of ESR, CRP, and WBC.
Conclusion: The present study suggest that DMSA scan may be a more reliable method of investigation than ultrasonography and biological parameters for identifying children at risk of permanent renal lesion. Additionally we found positive correlation between renal parenchymal change and creatinine clearance level. In order to detect persistent changes, it is suggested that DMSA scintigraphy should be performed at least three months after UTI.

 

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Background: Migraine is a chronic hereditary and relapsing headache. With regard to the prevalence of this ancient disease and its economic complications in country, in this study , nocturnal serum melatonin of migraine patients and control subjects have been evaluated and compared by ELISA kit.

Materials and Methods: Fifty migraine patients (mostly women) were compared to a control group (mostly men) matched according to age. Results: Statistical analysis revealed a decrease in nocturnal serum melatonin levels for migraine patients (32.9 28.4) compared to the control one (75.6 56.8). With using of t-test by ELISA kit showed significant difference (p=0.0064).

Conclusion: With regard to this, the pineal gland has the main role in the synchronization of the organism with the environmental conditions and migrainous headaches.

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Background: Chang in the serum K+ level may increase perioperative morbidity and mortality in kidney transplant recipients. Thus this research was done with the aim of evaluated of K+ change in kidney transplant recipients. Hence the following study was carried to evaluate the fluctuation of potassium ion in the kidney transplant recipient patients.

Materials and Methods: In a simple randomized clinical trial the serum K+ level was assessed in 40 kidney transplant candidates as following interval, pretransplantation, during renal art, anastomosis, after diuresis and post transplantation period. After hydration with 5 ml/kg normal saline all patient were undergone general anesthesia identically. They were premedicated fentanyl (2µg/kg), induction was performed by thiopental sodium (5 mg/kg). Tracheal intubation was facifitated with atracurium (0.6 mg/kg). Anesthesia was maintained with N2O + O2 50%, halothane 0.1% and fentonyl 1 µg/kg every 30 min.

Results: The least mean K+ level was during anastomosis (ie. 3.5±0.24 mmol/L) and showed a decrease in the serum K+ level compared to preoperative period (mean 4.4±0.48 mmol) (P< 0.001). The maximum serum K+ level detected preoperatively and postoperatively were 5 (mmol/ L) and 4.7 (mmol/L) respectively.

Conclusion: Despite the above results we inferred that range of serum K+ level was maintained within normal. Therefore with suitable pereoprative assessment hyperkalemia is a rare occurrence in transplant recipients.

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Background: Chang in the serum K+ level may increase perioperative morbidity and mortality in kidney transplant recipients. Thus this research was done with the aim of evaluated of K+ change in kidney transplant recipients. Hence the following study was carried to evaluate the fluctuation of potassium ion in the kidney transplant recipient patients.

Materials and Methods: In a simple randomized clinical trial the serum K+ level was assessed in 40 kidney transplant candidates as following interval, pretransplantation, during renal art, anastomosis, after diuresis and post transplantation period. After hydration with 5 ml/kg normal saline all patient were undergone general anesthesia identically. They were premedicated fentanyl (2µg/kg), induction was performed by thiopental sodium (5 mg/kg). Tracheal intubation was facifitated with atracurium (0.6 mg/kg). Anesthesia was maintained with N2O + O2 50%, halothane 0.1% and fentonyl 1 µg/kg every 30 min.

Results: The least mean K+ level was during anastomosis (ie. 3.5±0.24 mmol/L) and showed a decrease in the serum K+ level compared to preoperative period (mean 4.4±0.48 mmol) (P< 0.001). The maximum serum K+ level detected preoperatively and postoperatively were 5 (mmol/ L) and 4.7 (mmol/L) respectively.

Conclusion: Despite the above results we inferred that range of serum K+ level was maintained within normal. Therefore with suitable pereoprative assessment hyperkalemia is a rare occurrence in transplant recipients.

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Background: Despite several years of intensive investigation, relatively few studies have been made of children with lupus nephritis. The prognosis of children with lupus nephritis is poor for those with diffuse proliferative glomerulonephritis and active interstitial inflammation. As newer treatment modalities become available for patients with severe lupus nephritis, it become increasingly important to identify patients at risk for renal failure. The aim of this study was to evaluate the clinical course, histopathology, serologic features and prognostic significance of some parameters, to identify the risk factors for renal failure and mortality in children with lupus nephritis.

Materials and Methods: Retrospectively 30 children under 16 years of age with lupus nephritis from 1989 to 1999 were studied. All patients received renal biopsy and follow-up biopsies were performed in 3 children. Lupus nephritis was classified by the World Health Organization (WHO) criteria. The clinical and serologic parameters at the time of renal biopsy were recorded.

Results: All children underwent renal biopsy within 1 year of disease onset. There were 1 (3.3%) patients with class II, 5 (16.7%) with class III, 21 (%70) with class IV, and 3 (%10) with class V nephritis based on initial biopsy according to the WHO classification. The mean follow-up time was 60 months. Follow-up biopsies were histologically stationary in 2 patients and progressive in one. The overall renal and patient 5- year survival rates were 46.66% (14/30) and 93.33 %( 2/30) respectively. They were 47.61% (10/21) and 95.21 %( 20/21), respectively, of patients with class IV proliferative glomerulonephritis. Children with renal pathology (class V in the WHO classification system) at initial biopsy, were at high risk for renal failure 66.66% (2/3) or morality %33.33 (1/3) despite aggressive treatment. The results revealed that those with persistent hypertension, anemia, and decreased creatinine clearance rate, nephrotic proteinuria, at initial biopsy were more prone to develop renal failure (P<0.01).

Conclusion: The prognosis of children with class IV nephritis in our study was better than reported in other series in recent years. However, those with class V disease, persistent hypertension, anemia, low creatinine clearance and nephrotic proteinuria at the time of diagnosis are at increased risk for renal failure. The improved results may be due to initial histological classification, better supportive care and selective use of aggressive therapy such as methylprednisolone pulse therapy and intravenous cyclophosphamide for those with high risk factors.

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Background: Hyperglycemia is a metabolic response to surgical stress. In this study, patients’ blood glucose changes were measured before, during and after elective eye surgeries under general anesthesia, with two methods: glucometer and glucose oxidase enzyme lab assay. Probable influencing factors and the correlation rate of these two methods were evaluated.

Methods: This analytic cross – sectional original study was performed on 230 American Society of Anesthesiologists (ASA) Class 1or 2 non–diabetic patients. All the patients underwent a similar general anesthesia and their blood glucose levels were measured simultaneously with two cited methods on three occasions.

Results: In all cases, post-surgery blood glucose in comparison to pre-surgery levels increased significantly in both methods irrespective of independent variables of the study. Considering these independent variables, increase in blood glucose levels was significant in most of the patients. The mean increase in blood glucose post-surgery in comparison to pre–surgery, measured with lab assay, had significant statistical correlation with the type of eye surgery but not with other variables like age, gender and duration of surgery. Correlation of the two methods were also partially significant statistically.

Conclusion: Considering the results of this study and the fact that blood glucose changes under general anesthesia is usually unrecognized clinically, we recommend blood glucose measurement in non–diabetic patients during long surgeries. It is advantageous to use Accu–chek (Sensor model) glucometer for this purpose.

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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.

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Background: Drug Utilization Evaluation (DUE) studies are performed to define, determine, and finally improve the quality of drug usage. These types of studies are especially valuable for drugs with a narrow therapeutic index or specific indication, or for expensive medications. In Iran, vancomycin is only available by prescription for methicillin-resistant staphylococcal and enterococcal infections. It is obvious that extensive and irrational use of this drug can increase bacterial resistance to this antibiotic. The goal of this study was to assess vancomycin utilization.
Methods: In a descriptive cross-sectional study performed during the fall and winter of 2004, this vancomycin DUE was done in the Infectious Disease Department of Imam Khomeini Hospital in Tehran. All of the patients receiving vancomycin were enrolled in this study. The Centers for Disease Control (CDC) and American Society of Hospital Pharmacists (ASHP) protocols have been used to perform this study.
Results: Of the 565 inpatients at this hospital, 39 subjects (7%) received vancomycin. Vancomycin utilization among these patients was compatible with CDC and ASHP protocols in only 28% and 35% of the patients, respectively.
Conculusion: Vancomycin is predominantly administered empirically, rather than being based on the antibiogram. This may be due to the routine protocol of the ward or the physician doubting the reliability of the antibiogram.

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Background: Failed endotracheal intubation is one of the principal causes of morbidity and mortality in anesthetized patients. If the anesthetist can anticipate which patients may be more difficult to intubate, can reduce the risks of anesthesia greatly and be more prepared for any difficulties that may occur. The aim of this study was to investigate the inability of patients to protrude the lower jaw in predicting difficult intubation.
Methods: In this prospective study, we enrolled 300 patients, above 16 years of age or older, who were scheduled for elective surgery. For all of the patients, before each operation, a single anesthesiologist measured the temporomandibular mobility, which was defined as the difference between the distances, from the lower incisors to the upper incisors in a neutral position and at maximum mandibular protrusion. At the time of intubation, another anesthesiologist, blinded to the preoperative airway assessment test, performed a laryngoscopy in which the laryngoscopic view of the larynx was determined according to the Cormack and Lehane scoring system. Difficult intubation was defined as laryngoscopic views of grade III and IV.
Results: Twenty-one patients were identified as having difficult intubation. Only one patient could not be intubated. The forward movement of the mandible was significantly greater in patients with easy intubation compared to those with difficult intubation (6.42±1.95 mm vs. 3.58±1.26 mm respectively, P<0.001). The use of a cut-off point of less than 5 mm for prediction of difficult intubation showed a sensitivity of 92.86% and a specificity of 70.43%.
Conclusion: The forward movement of the mandible is significantly greater in patients with easy intubation compared those with difficult intubation Although infrequent difficulties may arise, most patients that do not have indicators of difficult intubation will be easy to intubate under anesthesia.

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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: Several randomized controlled trials have demonstrated the safety and efficacy of drug eluting stents (DES) in selected groups of patients with less complicated diabetes. We conducted this study to determine how an unselected group of diabetic patients in Iran fare following DES implantation.

Methods: Data were collected on 147 consecutive diabetic patients who underwent percutaneous coronary intervention (PCI) with the implantation of at least one DES at the Tehran Heart Center from June 2003 to September 2005. Clinical follow-up was performed by timely scheduled visits at one, four and nine months following DES implantation. Nine months of follow-up was completed for 94.5% of the patients. The primary endpoint was the occurrence of major adverse cardiac events (MACE), which include cardiac death, myocardial infarction and target vessel revascularization (TVR). In-hospital complications were the secondary endpoint.

Results: A total of 158 coronary artery lesions were treated with DES in 147 diabetic patients (mean age = 56.4±8.92 years, 57.1% were men). During the nine-month follow-up, MACE occurred in 3.4% of patients, with a myocardial infarction rate of 1.4% and TVR rate of 1.4%. Considering one patient who underwent TVR due to acute stent thrombosis following angioplasty (during hospitalization) the total number of TVR reached 3 (2%). Only one patient (0.7%) died of cardiac death, which occurred after the procedure and before discharge. In-hospital complications occurred in six patients (4.1%) five patients suffered from myocardial infarction.

Conclusions: PCI with DES seems to be safe and effective in diabetic patients. However, more studies with larger study populations and longer follow-up are required to confirm this issue.

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Background: The major responsibility of an anesthesiologist is to provide adequate respiration for the patient. The most vital element in providing functional respiration is the airway. No anesthetic is safe unless diligent efforts are devoted to maintaining an intact functional airway. Difficult intubation had been classified into four grades, according to the view obtainable at laryngoscopy by Cormack and Lehane in 1984. This grading system has been in use to evaluate and manage those patients with difficult airway by anesthesiologists. In clinical state, grades III and IV are quite rare, so the need for a modified Cormack and Lehane grading system was felt. The use of a modified Cormack-Lehane scoring system of laryngoscopic views during direct laryngoscopy, was previously examined in the Western population. Koh and his co-workers had examined this modified Cormack and Lehane grading system in Asian population in a study in Singapore General Hospital. The aim of this study was to investigate this scoring system in Iranian patients.

Methods: In a cross sectional study, a modified version of the Cormack and Lehane grading system was evaluated in 300 patients requiring tracheal intubation. In the modified system, grade II (only part of the glottis is visible) was divided into IIa (part of the cords is visible) and IIb (only the arytenoids or the very posterior origin of the cords are visible). Difficult intubation was defined as requiring more than one laryngoscopy or the use of special equipments.

Results: Sixty eight patients (22.7%) were scored as grade IIa and 32 (7.7%) as grade IIb. The prevalence of difficult intubation in grade IIb was significantly higher than patients in group IIa (47.8% vs. 2.9% respectively, Fisher's exact test, p= 0.001)

Conclusion: The modified grading system provides more information than the original Cormack and Lehane system.

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Background: Based on the reports, high frequency of special alleles of HLA class II genes might be associated with susceptibility to or protective from a particular cancer. These alleles might vary depending on the geographical region. Here we investigate the association between alleles of HLA class II genes and breast cancer in Iranian women.
Methods: 100 patients with pathologically proved breast cancer who referred to Cancer Institute, Tehran University of Medical Sciences in Tehran, Iran, were divided to two groups based on ages (40 years old and less/ or more than 40 years old) and were randomly selected and compared with a group of 80 healthy blood donor subjects. HLA class II alleles were determined by amplification of DNA with polymerase chain reaction (PCR) method followed by HLA-typing using sequence-specific primer (SSP) for each allele.
Results: The most frequent alleles in the DR and DQ regions in group 1 (40 years old and less) in comparison with control group were HLA-DQA1*0301 (p=0.002) and HLA-DQB1*0302 (p>0.05). In contrast HLA-DQA1*0505 (p=0.004) had significantly lower frequency in this group compared with control group. Patients of group two (more than 40 years old) had a higher frequencies of HLA-DQA1*0301 (p=0.001) and HLA-DRB1*1303 (p=0.02) and a lower frequency of HLA-DQA1*0101 (p=0.002) compared to healthy control.
Conclusion: These findings provide information of a positive and negative association between certain alleles of HLA class II and breast cancer in our population and also might support that the pattern of inheritance in the early and late onset of breast cancer differ substantially.

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Background: Molecular DNA markers are one of the most important tools in molecular biology labs. The size of DNA molecules is determined by comparing them with known bands of markers during gel electrophoresis. There are many different protocols to produce these kinds of molecular markers. In this study we have suggested an efficient strategy to produce molecular weight markers in industrial proportions. Methods: To achieve the desired sizes of DNA fragments, a combination of two previously known methods, restriction enzyme digestion and polymerase chain reaction (PCR), were used. The enzymatic digestion process was based on designing and constructing plasmids which equaled in size with the desired length of DNA fragments and produced the desired DNA fragment upon linearization. In the PCR method, the desired length of DNA fragments were cloned in multiple cloning sites of pTZ57R plasmid and in a PCR reaction, the new constructed plasmid was used as a template to produce the final fragment. Results: Upon application of this strategy, 2000 and 3000 bp DNA fragments were produced by enzymatic digestion of plasmids of the same size. Moreover, 100 to 1500 bp fragments were produced during PCR using only a set of forward and reverse primers at the flanking region of pTZ57R multiple cloning site. Conclusion: The highest advantage of this cost-benefit approach is to produce different types of molecular weight markers by using an effective and short protocol

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Background: Patients who require surgery on the lower extremities are considered to be a high risk group from the point of anesthesia. This study was performed to compare sitting and lateral positions in spinal anesthesia method with hyperbaric bupivacaine 0.5% for hemodynamic status and analgesic period in patients under vascular surgery of the lower limbs in Imam-Khomeini Hospital Complex affiliated to Tehran University of Medical Sciences in 2009.

Methods: In this study 40 patients were divided into two groups of 20 to undergo spinal anesthesia with 3 ml of hyperbaric bupivacaine 0.5% injected into the subarachnoid space in sitting or lateral positions. The anesthesia was performed at T10 level and the hemodynamic status and analgesic periods were compared in the two groups.

Results: The changes in mean arterial blood pressure and systolic and diastolic blood pressures were different between the two groups (P<0.05). Except in the first and thirtieth minutes, the changes in heart rate (HR) were significantly different throughout the study between the two groups (P<0.04) and they were higher in sitting position. The duration of analgesia was significantly longer in lateral position (P<0.04) and the use of fluid was significantly larger in the sitting group (P<0.05).

Conclusion: According to the obtained results, the changes in hemodynamic variables were significantly lower in the group in lateral versus sitting position in patients undergoing spinal anesthesia with bupivacaine for vascular surgery of the lower limb.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Previous studies were suggestive of a good prognosis in patients with acute coronary syndrome (ACS) and absence of any critical stenosis in coronary angiography but recent limited reports have revealed that patients with non-obstructive acute coronary syndrome are at a higher risk of future clinical coronary events.

Methods : A concurrent prospective cohort study was designed and 146 male patients with ACS and non-obstructive coronary artery disease were regarded as the unexposed group, while 191 female patients with non-obstructive coronary artery disease were regarded as the exposed group. Coronary events were recorded within one year of follow-up. Prognostic factors were evaluated at baseline by using a standardized protocol.
Results : Of the 337 patients with ACS, 191 (56.6%) were female. Coronary events in female patients after one year of follow-up were: ST EMI 3 (1.6%), unstable angina pectoris 22 (11.5%), Q-wave MI 1 (0.5%) and no syncope. In male patients the outcomes were: ST EMI 4 (2.7%), unstable angina pectoris 29 (19.9%), Q-wave MI 1 (0.7%), and syncope 1 (0.7%). Multivariate adjusted relationships revealed that physical inactivity (P=0.035), dyslipidemia (P=0.001), low ankle brachial index (P=0.024) and age between 40-50 years (P=0.004) were significantly associated with coronary events in women. In male patients, body mass index of 30-39.99 (P=0.011) was associated with a higher rate of ST-segment elevated MI.
Conclusion: Prognostically, coronary events and clinical endpoints were significantly different between men and women with acute coronary syndrome. Persistence of symptoms over one year seems to relate to the development and progression of coronary atherosclerosis.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: The techniques used in assisted reproductive technologies have progressed considerably, but many embryos do not implant after transfer upon the use of these techniques. One of the causes of infertility is repeated implantation failure due to decreased endometrial receptivity. Furthermore, in clinical conditions such as endometriosis and myoma, implantation decreases after embryo transfer. In this case-control study the expression patterns of HOXA-10 and BTEB1 mRNAs were evaluated at the time of implantation in patients with myoma and endometriosis.
Methods : In this study performed in Hamadan University of Medical Sciences during 1389, the cases included 16 patients with endometriosis and myoma (8 in each group) and the control group consisted of 8 fertile women. Endometrial sampling was performed at mid-secretory phase. Later, the expression patterns of HOXA-10 and BTEB1 mRNAs were evaluated using a semi-quantitative RT-PCR method.
Results : The optimal PCR cycles determined were 30, 32 and 26 for HOXA10, BTEB1 and β-actin, respectively. Endometrial HOXA-10 and BTEB1 mRNA expression levels (normalized to ß-actin expression) at the time of implantation were significantly decreased in the endometrium of infertile patients with endometriosis compared with that of healthy fertile controls (P<0.05). A similar pattern was seen in patients with myomas for both HOXA10 and BTEB1 genes, (P<0.05).
Conclusion: It seems that lower expression of HOXA-10 and BTEB1 mRNAs in the implantation window of endometrium that increase normally, could account for some aspects of infertility in patients with endometriosis and myoma.

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Background: Hypercholesterolemia is considered a major risk factor for pancreatitis, atherosclerosis and coronary heart disease. Cholesteryl ester transfer protein gene polymorphisms are known to be associated with changes in lipid levels. We investigated the association between a polymorphism in the CETP gene (D442G) with plasma lipid levels and CETP activity in patients with hypercholesterolemia.

Methods: This case/control study that be done in Hamadan university of medical sciences (from October 2008 to September 2009), included 102 patients with hypercholesterolemia and 200 healthy individuals. Polymerase chain reaction and restriction fragment length polymorphisms were used to determine genotypic distribution and allelic frequencies of polymorphisms. The plasma CETP activity was measured by a kit in a fluorescence spectrometer. Lipid concentrations were measured by routine biochemical and enzymatic assays.

Results: Plasma cholesteryl ester transfer protein activity was significantly higher in the cases than the controls (P<0.05). The genotypic and allelic frequencies for this polymorphism were not statistically different between the patients with hypercholesterolemia and the controls (in controls: DD 96%, DG 4%, GG 0% and in cases: DD 86%, DG 10%, GG 4%), (P>0.05). Plasma HDL-C, LDL-C and TC were higher in both groups with GG and DG genotypes than with DD genotype, whereas serum CETP activity was lower in GG genotype compared with other genotypes (GD or DD), (P<0.05).

Conclusion: The results showed that D442G polymorphism of CETP gene was associated with changes in lipid profile and plasma CETP activity in the selected population and it might have a role in contributing to a genetic risk for developing coronary artery disease.

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Background: Inadequate ventilation, esophageal intubation and difficult intubation are the most common adverse respiratory outcomes in patient undergoing anesthesia .The aim of this study was to compare Mallampati test in supine and sitting positions in traditional approach and during phonation for predicting difficult laryngoscopy and intubation.
Methods: In this study performed in Imam Khomeini Hospital in Tehran, Iran, Mallampati test was performed on 661 patients who met the inclusion criteria for the study. The test was done in supine and sitting positions with and without phonation by a rater who was blind to Mallampati test. Subsequently, laryngoscopy view and difficult intubation were evaluated in the four aforesaid positions by Mallampati test for predicting difficult laryngoscopy and intubation. For each situations, sensitivity, specificity, positive and negative predictive values and accuracy were calculated.
Results: Overall, 28 (4.2%) patients had difficult laryngoscopy and 9 (1.4%) patients had difficult intubation. The highest sensitivity for Mallampati test in predicting difficult laryngoscopy and intubation was in supine and sitting positions without phonation, and the highest specificity was seen in sitting position with phonation. Negative predictive values were more than 95% in all different positions for Mallampati tests and the highest positive predictive value was seen in supine position with phonation.
Conclusion: According to our findings, the highest correlation between Mallampati test and different positions in predicting difficult laryngoscopy and intubation was seen in supine position with phonation. Phonation improved Mallampati score in supine rather than sitting position.

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Background: Dyskeratosis Congenita (DC) is a rare inherited disease with an incidence of approximately one case per million population. The disease is characterized by a classic triad: nail changes, color reticulated skin and oral leukoplakia. In these patients, premature death is often associated with bone marrow failure, infections, pulmonary complications, or malignancy. Three patterns of inheritance for dyskeratosis congenita have been reports, X-linked recessive trait, autosomal dominant and recessive trait. The present study is a case report of an adoloscent patient with dyskeratosis congenita. Case presentation: The patient is a 16 year old boy living in Arak without history of any illness was referred with fever, chills, malaise and admitted to Vali-e-Asr Hospital with initial diagnosis of sepsis. The patient was treated with broad-spectrum antibiotics. In tests, showed pancytopenia. Bone marrow biopsy was performed. Blood and urine culture were negative, rheumatologic lab test and other tests were normal. Ultrsonography of abdomen and pelvis showed splenomegaly. In physical examination, diffuse hypopigmented lesions on the trunk and extermities, nails dystrophy and oral mucosal leukoplakia were observed. Skin biopsy was consistent with DC. Conclusion: The skin and oral mucosal lesions have an impact role in the diagnosis of systemic disease. Early diagnosis and treatment of patients with DC are important in improving clinical outcomes.