Tehran University Medical Journal

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The study was conducted to determine the clinical pattern and etiology of cerebral venous thrombosis in Iran. Records of all adult patients admitted with a clinical diagnosis and MRI of cerebral venous thrombosis from 1993 through 1999 in three major hospitals of Tehran, Iran were reviewed. Fifty patients (39 women, 11 men) aged 14 to 56 years were identified. Headache the most frequent and often the earliest symptom, was encountered in 82 percent and papilledema, the most frequent sign in 56 percent of cases. Infection was the cause of cerebral venous thrombosis in 26 percent of our cases. Other causes included oral contraceptive (32 percent), vasculitis (6 percent), Behcet's disease (4 percent), postpartum state (4 percent), myeloproliferative disease (2 percent), ulcerative colitis (2 percent), antithrombin III deficiency (2 percent) and diabetic ketoacidosis (2 percent). Oral contraceptive was recognized as the most common etiology. Infection is an important cause whereas procoagulation disorders are uncommon.

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Testicular germ-cell tumors are the most common malignancy among men aged 20-40 years, and 60 percent of them are seminomas. These tumors are now an important socio-economic problem, considering their growing incidence. Thus we undertook to evaluate the results of curative irradiation in our testicular seminoma patients and compare them to literature results considering the use of cobalt-60 systems in our department (in contrast to the use of linear accelerators). All testicular seminoma cases referred after orchiectomy to Radiation-Oncology Department of Tehran Cancer Institute and treated curatively during the 12-years period of 1987-1998 were reviewed. These included 147 patients. The results showed a mean age of 34.5 years. Eighty-six patients (58.5 percent) were in stage I, 57 (38.8 percent) in stage II and 4 (2.7 percent) in stage III. With a mean follow-up time of 53.5 months (range 2-158 months) after radiotherapy, there were 12 (9 percent) local relapses and 8 (6.5 percent) distant metastases among the 122 patients who came back for follow-up. The 10-years overall survival was 97.9 percent and disease-free survival 79.7 percent (life-tables). Mean overall and disease-free survival time was 155 and 133 months respectively, with a median survival time of more than 158 months (Kaplan-Meier). The only significant prognostic factor was stage of the disease (P=0.01), though lactate dehydrogenase (LDH) was significant only in multi-factorial analysis (P=0.02). In conclusion, our survival figures were all favorably comparable to literature results, considering the higher ratio of stage II in our patients. We recommend training of young men for testicular self-examination and a greater attention to LDH measurement, and hope for installation of linear accelerators in our department to further improve the treatment results with less side effects.

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Introduction: Clinical manifestations of primary hyper-para-thyroidism (pHPT) had been dramatically changed during last 25 years. Evaluation of changes in clinical findings was the aim of this study.

Materials and methods: In a retrospective, descriptive case series, patients' records of all 47 pHPT (44 females, 3 males) from 1988 till 1998 were studied. Patients’ clinical presentations, signs and symptoms, laboratory and radiologic findings were reviewed and the results were compared with 34 patients' studied during 1978-1987. Serum Ca>10.5 mg/dl with increased or high normal PTH were the diagnostic criteria of pHPT.

Results: Patients’ age range was 11-70 and mean ±SD was 38±16 years, with a female to male ratio of 14:1. 57 percent of the patients had bone pain and muscle weakness, 12 percent were asymptomatic, 10 percent had pathologic fractures, 8 percent had renal stones, 8 percent had symptoms of hypercalcemia, and 2 percent had giant cell lesion. The mean±SD of serum calcium was 11.48±1.16 mg/dl, phosphorus was 2.4±0.6 mg/dl and 24-h urinary Ca was 294±197 mg. Serum PTH was increased from 1.5 to 500 folds. The frequency of single adenoma in right inferior, left inferior, and left superior gland were 43 percent, 30 percent, and 13 percent respectively.

Conclusion: In the study 12 percent of patients were asymptomatic whereas there was no asymptomatic case in the previous study. Prevalence of severe bone disease and the interval between onset of symptoms and diagnosis was also reduced. According to this study detection of pHPT in asymptomatic phase remarkably increased.

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Background: A plan for management of infected arterial pseudoaneurysm has evolved from our experience with forty two cases of such aneurysms treated between 1378 and 1382.
Methods: Clinical data of 42 patients with femoral pseudoaneurysm resulting from addictive drug injection who presented in emergency department of Sina Hospital between 1378 and 1383 were retrospectively reviewed.
Results: All patients were men with the mean age of 36.9 years. Twenty eight patients were referred from other medical centers. The mean time of delay in presentation was 17.3 days. The mean duration of drug injection was 14 months. Primary repair and emergent vascular bypass were performed in 3(7.1%) and 2(4.8%) patients, respectively. 5(11.9%) patients undergone delayed revascularization. Thirty two (76.2%) patients returned to their normal lifestyle without any vascular bypass. One patient required amputation and one patient died due to sepsis and acute renal insufficiency.
Conclusion: Management of infected femoral pseudoaneurysms is simple ligation of the external iliac or femoral artery. When Doppler is not available “Operation Room and postoperative Direct Observation” is recommended in such patients to avoid unnecessary revascularization surgery.

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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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Background: Trauma is the most common cause of mortality in the first four decades of life. In our country, cardiovascular diseases and trauma are leading causes of mortality, respectively. By gathering information on trauma mortalities, we can learn more about causes, and that knowledge can lead to prevention.
Methods: This is a prospective descriptive study in Tehran during 12 months period (Sep 1999- Sep 2000). Two hundred and forty five trauma deaths in six hospitals were evaluated. The data was collected through a questionnaire, designed in Sina Trauma and Surgery Research Center (STSRC) used for the study. The questionnaires were completed by trained physicians visiting trauma patients in emergency room and wards round the clock. Data obtained included patient demographics, level of prehospital care, medical and operative procedures performed in emergency rooms (ER) and wards (according to ICD-10 coding), Glasgow Coma Scale (GCS) and vital signs at time of presentation to emergency rooms, Injury Severity Score (ISS), length of hospital stay and outcome of patients.
Results: Twenty and forty five (3%) of 8000 trauma patients was died. Mean age was 40.7 (±23.5) years old and 208 (84.9%) patients were male. The highest mortality rate was seen in the age group of 25 to 30 years. Road Traffic Accident was the main cause of death followed by falling with 174(71%) and 41(16.85), respectively. Among victims of road traffic accident, pedestrians and motorcyclists were prominent with 119 and 28 cases respectively. The majority of cases were dead due to head injuries (69%) and abdominal trauma was the second cause with 19 (7.8%) cases.
Conclusions: Based on our findings the mechanism of injury have the positive effect on trauma outcome .Traffic accidents and assault is preventable and must be attended.

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Background: Human respiratory syncytial virus (HRSV) is the most important viral agent of acute lower respiratory tract disease in infants and young children worldwide. This virus is responsible for 50% brochiolitis and 25% pneumonia in infants. There are limited data of molecular epidemiology of HRSV from developing countries. This is the report on the molecular epidemiology of human respiratory syncytial virus in Iran. Methods: In this study, RT-PCR for second hypervariable region of the HRSV G glycoprotein was performed on 72 throat swabs collected from children less than 5 years of age with acute respiratory symptoms in 1386. Results: Of the 72 throat swabs collected from children with acute respiratory symptoms, 14 (19.44%) were positive for HRSV. Phylogenetic analysis revealed that all HRSV-positive samples clustered in three genotypes of subgroup A: 12 strains (85/71%) in genotype GA2, 1 strain (7/1%) in genotype GA1, and 1 strain (7/1%) in genotype GA5. In this study we couldn’t identify any genotype of subgroup B. Conclusion: Our results revealed that multiple genotypes of subgroup A were co- circulated during 1386 in children less than 5 years of age in Iran. Also this study revealed that genotype GA2 was predominant genotype in isolates were obtained from several cities (Tehran, Isfahan, Karaj, Qazvin, Bandar Abbas, Shahreza), so we speculate that this genotype may be predominant during 1386 in Iran. This study supported that RT-PCR for second variable region of G protein is an effective method for further studies of HRSV genotype designation in Iran.

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Background: Cancer and obesity are two major public health concerns. More than 12 million cases of cancer are reported annually. Many reports confirmed obesity as a risk factor for cancer. The molecular relationship between obesity and breast cancer has not been clear yet. The purpose of this study was to investigate priorities of effective genes in the molecular relationship between obesity and breast cancer. Methods: In this study, computer simulation method was used for prioritizing the genes that involved in the molecular links between obesity and breast cancer in laboratory of systems biology and bioinformatics (LBB), Tehran University, Tehran, Iran, from March to July 2014. In this study, ENDEAVOUR software was used for prioritizing the genes and integrating multiple data sources was used for data analysis. Training genes were selected from effective genes in obesity and/or breast cancer. Two groups of candidate genes were selected. The first group was included the existential genes in 5 common region chromosomes (between obesity and breast cancer) and the second group was included the results of genes microarray data analysis of research Creighton, et al (In 2012 on patients with breast cancer). The microarray data were analyzed with GER2 software (R online software on GEO website). Finally, both training and candidate genes were entered in ENDEAVOUR software package. Results: The candidate genes were prioritized to four style and five genes in ten of the first priorities were repeated twice. In other word, the outcome of prioritizing of 72 genes (Product of microarray data analysis) and genes of 5 common chromosome regions (Between obesity and breast cancer) showed, 5 genes (TNFRSF10B, F2, IGFALS, NTRK3 and HSP90B1) were the priorities in the molecular connection between obesity and breast cancer. Conclusion: There are some common genes between breast cancer and obesity. So, molecular relationship is confirmed. In this study the possible effect of gene F2 polymorphism in making breast cancer associated with obesity risk factor was confirmed, the fact that past studies have not been reported.

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Background: Coagulase-negative staphylococci (CoNS) were considered as contaminats previously, but, during the past decade considered as one of the most common photogenic bacteria in hospital. Resistance to beta-lactams especially methicillin in staphylococcus species is being worrying in hospitals. Rapid identification of mechanisms of resistance and confirmation of their resistance to methicillin is a basic principle for antibiotic treatment. The aim of this study was to determine antibiotic resistance, frequency of mecA gene, and determination of SCCmec types in CoNS isolates from teaching hospitals in Iran.

Methods: The descriptive cross-sectional study was carried out one hundred clinical samples isolated from patients with an average age of 7-69 years at teaching hospitals in Hamadan City, Iran, from September 2014 to February 2015. After confirmation of isolates by microbiological standard biochemical tests, antimicrobial susceptibility testing was performed by disk agar diffusion (DAD) method. After extraction of isolated genomicm, mecA gene was detected. Then, the types of SCCmec were performed by PCR.

Results: In this study, 387 clinical samples were collected which among 100 CoNS isolated, Staphylococcus epidermidis was the most prevalent species with frequency 55 (55%), followed by S. haemolyticus 40(40%) and S. saprophyticus 5(5%). The highest antibiotic susceptibility was to rifampin 96(96%) and the lowest resistance was detected for trimethoprim/sulfamethoxazole (TMP/SMX) 47(47%). None of the strains were resistant to vancomycin. Resistance to methicillin was detected in 50% of CoNS isolates. Typing of SCCmec was performed by The polymerase chain reaction (PCR). Frequency types of SCCmec was type III with frequency 13(13%), type V 11(11%), type II 6(6%), type IV 4 (4%), type I 3(3%) respectively. Thirteen isolated was not typable in this study.

Conclusion: The result of this study showed that a large percentage of coagulase-negative staphylococci are resistance to methicillin, and the prevalence of SCCmec type was type III, which encodes the largest number of resistance genes. This information could be use in epidemiological study for preventing of infectious control in hospital and health centers.

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Background: Systemic sclerosis is an autoimmune disease affecting connective tissues, (including epidermal, subepidermal, microvasculature, etc.), leading to various extent of end-organ damage. The leading cause of mortality among these patients is lung involvement. The cardiovascular events happen more frequently in patients suffering systemic scleroderma, comparing to healthy population. This study was designed to clear the correlation between development of coronary calcification (as an indicator of atherosclerosis) and lung disease in these patients.
Methods: All patients with definite diagnosis of systemic sclerosis, who referred to Shahid Modarres Hospital between March 2011and March 2014, entered to the study. Patients suffering hypertension, hyperlipidemia and who had a past or current history of smoking were excluded from the study. Atherosclerosis was determined by coronary calcium score (based on Agatston score) and the severity and extent of lung disease was assessed by wells scoring system and Warrick scoring system (based on lung CT scan without contrast). The spearman correlation analysis was done on the data by SPSS software, version 20 (IBM SPSS, Armonk, NY, USA). All the patients had informed consent and no additive charge was delivered.

Results: The study population consisted of 25 patients with systemic sclerosis. 21 patients were female and the 4 other ones were male. The mean age was 67±4 years old. The mean Wells score in patients was 13±2.59, the mean Warrick severity score was 6.54±6.16 and the mean Warrick extent score was 14.42±14.59. No correlation was observed between presence of calcification in coronary arteries (Wells score r2=0.63  P=0.77, severity score r2=0.27, P=0.2, extent score r2=0.11, P=0.6), aorta annulus (Wells score r2=0.04, P=0.83, severity score r2=0.06, P=0.77, extent score r2=0.06,  P=0.76) and thoracic aorta (Wells score r2=0.05, P=0.83, severity score r2=0.03, P=0.9, extent score r2=0.03, P=0.9) with the severity and extent of lung involvement. Conclusion: It seems that the presence of coronary atherosclerosis or calcifications in aorta annulus and thoracic aorta (assessed by Agatston calcium score) has no significant correlation with the severity and extent of lung disease (assessed by Wells and Warrick score) in patients with systemic sclerosis.

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Results: In the present study, the mean age in the two groups was similar (about 50-60 years). The distribution of sex, diabetes, weight, height and blood pressure was homogeneous in both groups. There was a statistically significant difference in the incidence of thrombosis and pain between the two groups. The results of this study showed that in the snuffbox angiography group, the number of uncomplicated cases was significantly more than the radial angiography group and in the snuffbox angiography group, the number of postoperative pain and thrombosis cases was significantly lower. The length of hospital stay in the Snuffbox group was shorter than the radial group, but there was no statistically significant difference. Conclusion: Snuffbox angiography has fewer complications compared to the usual transradial method, so it can be used as a safe method for angiography.

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