Tehran University Medical Journal

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This study was conducted on 48 specimens of Rectus abdominis muscles for recognition and definition of passage and ramification of lower intercostal nerves. The main results of this study are as follows: 1- The seventh and eight intercostal nerves penetrated to posterior layer of the Rectus sheath while other intercostal nerves perforated to dorsal layer of internal oblique abdominis aponeurosis. 2- Distance between lateral border of the Rectus abdominis muscle till penetrate point for all nerves were 18±1 mm, but the subcostal nerve was 16±1 mm. 3- Each intercostal nerve was ramified in thickness of muscle and formed many branches that maximum of this was middle longitudinal region and minimum of that was lateral longitudinal region. In addition we did not observe the nerve anastomosis between intercostal nerves. 4- The lower primary branch of the intercostal nerve after piercing of anterior layer of the Rectus sheath was named anterior cutaneous branch and terminated to abdominal skin. 5- All of intercostal nerves at first was placed right angle to muscle fibers but immediately decrease its and was placed parallel to muscle fibers. 6- The entrance, passage and ramification of intercostal nerves in both male and female cadavers were similar.

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The diabetes is an autoimmune disease, in which the role of autoantibodies is of a specific importance. The appearance of these autoantibodies can be the first symptom in the serum of type I diabetic patients, which may appear ten years before onset of the disease. The most important autoantibodies include Glutamic acid decarboxylase autoantibodies (GAD65-Ab). This can be used as a good tool for prediction in screening tests in type I diabetic patients. In the present study with prosedure RIA, we investigated the level of GAD65-Ab in patients with diabetes type I and their close relatives, and compared them with healthy persons. From the type I diabetic patients who have been suffering from the disease for periods of one week to twenty years, 63.3% of them had positive Anti-GAD65. This ratio was 8% in their close trelatives, and 0% in healthy persons. The difference in Anti-GAD65 between the healthy persons and close relative of patients was significant. This test may be employed in diabetes type I, as a screening test, and confirms the results of studies which have been conducted so far outside this country.

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A randomized clinical trial study was undertaken to evaluate the effect of intravenous oxytoxin (50 cases) and intracervical prostaglandin E2 (0.5 mg Tab, 50 cases) on the ripening of the cervix and frequency of successful inductions in patients with low Bishop score (<5). Means of maternal age, gestational age, parity, BS at admission did not show any significant differences between the two groups. Until 6 hrs after beginning treatment, 72% of oxytoxin group and 74% of PGE2 group were achieved active labor and until 12 hrs, 70% and 76% delivered respectively. It was no statistically significant difference. The mean drug administration to delivery time was 7.3±3.1 hrs in oxytoxin group and 7.6±3.1 hrs in PGE2 group (without significant difference). No difference in route of delivery was found between the two groups. Maternal complications were seen in 60% of oxytocin group and 46% of PGE2 group, without significant difference. Between maternal complications, frequency of diarrhea was higher at PGE2 group (P=0.02). Fetal complications were seen 4% in the PGE2 group and 16% in oxytocin group, that was less in the first (RR=0.25 CI 95%: 0.06-0.97).

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Difference aspects of multinomial statistical modelings and its classifications has been studied so far. In these type of problems Y is the qualitative random variable with T possible states which are considered as classifications. The goal is prediction of Y based on a random Vector X ? IR^m. Many methods for analyzing these problems were considered. One of the modern and general method of classification is Classification and Regression Trees (CART). Another method is recursive partitioning techniques which has a strange relationship with nonparametric regression. Classical discriminant analysis is a standard method for analyzing these type of data. Flexible discriminant analysis method which is a combination of nonparametric regression and discriminant analysis and classification using spline that includes least square regression and additive cubic splines. Neural network is an advanced statistical method for analyzing these types of data. In this paper properties of multinomial logistics regression were investigated and this method was used for modeling effective factors in selecting contraceptive methods in Ghom province for married women age 15-49. The response variable has a tetranomial distibution. The levels of this variable are: nothing, pills, traditional and a collection of other contraceptive methods. A collection of significant independent variables were: place, age of women, education, history of pregnancy and family size. Menstruation age and age at marriage were not statistically significant.

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There are many studies about epidural fibrosis after surgical manipulation of the spine. We have studied formation of the post laminectomy epidural fibrosis after application of two materials (Silicone and Teflon) in this report. This expriment is on two groups of rats. Two separated laminectomies were done in each rat, one serving as control while in the other laminectomy spaces Silicone was used in group A and Teflon in group B. Laminectomy spaces were evaluated with gross dissection and histologic studies after 6 weeks. Silicone decreased intermuscular scar, deep scar, dural adhesion and collagen fiber density in epidural space. Teflon decreased dural adhesion and collagen fiber density but did not decrease intermuscular and deep scar formation in epidural space.

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Brucellosis is an endemic disease in Iran with variety of clinical manifestation. Special characteristics of clinical diagnosis and treatment issues may cause some problems in manegement of patients. In this descriptive study 505 patients with Brucellosis retrospectively were evaluated from clinical point of view, Lab exams and therapeutic issues for 10 years (1990 to 1999). From 505 patients, 321 cases were male and 184 were female. 42.7 percent of cases were in age group of 10 to 30 years. Ingestion of un-pasteurized dairy products was detected in (66.7 percent) and 31.86 percent of cases were sheep herders. The most common symptoms and signs were fever (65 percent), sweating (61 percent), arthritis (30.09 percent), sacroilitis (21.5 percent), orchitis (8.2 percent), spondylitis (2-3 percent) and endocarditis (1.18). In this survery blood culture for Brucella melitensis became positive in 48.5 percent and bone marrow in 61 percent. Standard tube agglutination was positive in 96 percent (?1.80). Doxycyclin plus Rifampin was the most common regimen we used (37.8 percent). 4 patients died, but just one of those was directly because of Brucella Endocarditis. In this article we have discussed about some interesting cases as well.

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The use of Frozen-section during surgical procedures, gives the surgeon valuable information and guides him to perform the appropriate surgical procedure. In order to determine the accuracy of Frozen-section in gynecologic surgery, we compared the results of 172 gynecologic Frozen-section diagnosis with their final diagnosis in Mirza Kockak Khan Hospital, from 1378 to 1379. A total of 106 ovarian, 43 uterine, 10 lymph node and 13 other tissue samples were obtained. The Frozen-section diagnosis was compatible with the final diagnosis in 93.6 percent of cases. The sensitivity for non benign lesions was 82.5 percent and the specificity was 96.8 percent. The positive and negative predictive values were 84 percents and 98 percent respectively. 2.3 percent of cases were falsely positive, 1.7 percent falsely negative and 1.2 percent over estimated the degree of malignancy. There was no underestimation and 1.2 percent were uncertain. Frozen-section was found to identify correctly 8 of 8 metastatic ovarian tumors and 1 of 2 germ cell tumors. The accuracy of Frozen-section was 25 percent in ovarian borderline tumors, 60 percent in ovarian mucinous and 80 percent in serous tumors. With the exception of borderline and mucinous ovarian tumors, Frozen-section diagnosis is sufficiently accurate for clinical use. Performing multiple sections is recommended in the Frozen-section diagnosis of mucinous ovarian tumors.

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Pruritus is an unpleasant sensation that provokes the desire to scratch. It has long been recognized as a presenting or concomitant symptom of many systemic diseases. Indeed, generalized pruritus is reported to be associated with underlying diseases in 10-50 percent of cases. This study was conducted to investigate the underlying diseases in pruritic patients without primary skin lesion. Seventy-five patients with at least one-month history of pruritus with no primary skin lesions, presenting to dermatological clinics of Razi Hospital, from April 97 until December 99 were evaluated. The work up procedure consisted of medical history, physical examination, laboratory findings (CBC, ESR, blood chemistry, thyroid function tests, urinalysis, stool exam), chest X-ray and in selected cases, additional specific tests. Fifty-four patients were female, and 21 male the mean age was 45.7y±16.41, and the mean duration of pruritus, 21.8m±21. In 43 patients (75.4 percent), no abnormal finding was detected. Five patients (6.66 percent) had atopy. In the remaining 27 patients (36 percent), the following abnormalities were found: Iron deficiency in 6 patients (8 percent), diabetes mellitus in 6 patients (8 percent), hyperthyroidism in 4 patients (5.33 percent), hypothyroidism in 2 patients (2.66 percent), lymphoma in 3 patients (4 percent), chronic hepatitis, hypocalcaemia, cholelithiasis, psychosis and chronic renal failure each in one patient (1.3 percent). Evaluation of patients with pruritus may be a valuable tool for early detection of underlying systemic diseases.

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Postoperative nausea and vomiting is a common complication that all anesthesiologist are familiar with the problems of its consequences. Although continued research on the recognition of factors affecting the incidence of PONV is being done but they are not sufficient and the need for research along with advances in anesthesiology and newer drugs are considered. In this prospective cohort study 400 children of 3 to 12 age who has been operated for general surgery (other than eye, thorax and upper abdomen) and orthopedic surgery in the Imam Khomeini and Children Medical Center Hospital has been evaluated. Of these, 200 children who had smoking parent and according to definition were passive smokers and the other 200 children had no smoking parents. Both the groups were matched for sex, age, and type of operation. With the analysis of data we noted that the incidence of PONV in both groups was 19.5 and there was no significant difference between the two groups. (Passive smoker 19 percent and non-passive smoker 20 percent). We also noted a relation between the duration and the incidence of PONV. So operation with more than 2 hours had higher incidence of PONV. There was also positive relation between PONV and controlled ventilation. However, there was no significant difference as the sex and type of operation was concerned. In conclusion, children of smoker parents suffer more PONV than children of non-smoker parents if operation takes longer than two hours or the patient is mechanically ventilated during operation.

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The medical septal area (MSA) provides the major cholinergic projection to the hippocampus which is critical for function of the memory. Different brain areas through the MSA modulates septohippocampal functions. This study was designed to determin origins of inputs to this area. For this purpose, stereotaxic injections of one microliter HRP (25 percent, Sigma) by Hamilton syringe to the medical septal area were performed in 8 rats. Following brain tissue fixation, sectioning and enzyme histochemical reaction, the labeled neurons were detected microscopically. Retrogradely labeled perikarya observed ipsilaterally in diagonal band of Broca, lateral septum, hippocampus, subfornical area and ventral pallidum in the telencephalon, lateral preoptic area, lateral hipothalamicarea/tuber cinereum, posterior hypothalamus, submammillothalamic, supramammillary and lateral mammillary nuclei in the diencephalons, ventral tegmental area, interpeduncular nucleus, central grey area and locus coerruleus and also bilaterally in raphe nuclei of the brain stem regions. Based on this results, in addition to learning processes, MSA through its connections with subfornical and lateral hypothalamic area can also support the physiological mechanisms for dipsogenic, electrolytic, and pressor responses in living animals.

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Population growth has been one of the main anxieties of different countries planners so far. Background and purpose growth of population has always had various impacts on society in economical, social, health and even political fields and its cure is controlling population growth. In order to study the efficient factors upon unwanted children, 1527 married women in Tehran have been randomly selected and data from questionnaire was selected. In this study, effective factors such as couple's education level, couple's occupation, number of children, age of marriage, age of last pregnancy, having stillbirth, breast feeding period in last born and effect of sex of infant in family planning upon unwanted children have been studied. Results show that some factors like husband's age, number of children, age of first marriage, age of last pregnancy, husband occupation, having stillbirth, breast feeding period and effect of infant's sex in family planning increase the chance of unwanted children and some criteria like women age, woman's education, fist pregnancy age, woman occupation, decrease the chance of unwanted children. According to logistic regression model, women age is one of the most important effective factors and one year increment in woman's age increase the chance of unwanted child 0.89 more times. Other factors is the number of children that in return for increasing one child to family, the chance of un wanting become 116.8 more times. It seems families don't have enough knowledge about family planning measures and their usage. Breast feeding period in wives who have fed their last children for more than six months, is another important factor which increases the chance of unwanted child to 1.02 more times than woman who have fed their last children for less than six months.

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The main goal of this study is to determine the auditory feedback effects in improvement of speech production process in prelingual totally deaf children who used cochlear implant prosthesis. For this reason, we recorded speech of four prelingual cochlear implant children pre and post of operation. Then we extract some static features of vowels-such as fundamental frequency, formant frequencies, vowel duration and vowel energy-from their stable mid-section and analyze them using a longitudinal prosthesis-on/off analysis. These patients-where are in the range of 7-13 years old-were operated in the cochlear implant clinic of Amiralam hospital. At each session, patients read the sentences once in device-on condition and then after 30 minutes stay in device-off condition. Quantitative results show that at least for the features under study, the patient's reliance on the auditory feedback decreased consistently by time (about 65%-averaged on all three vowels under study and all patients). So we concluded that after a sufficient time of operation, the speech motor patterns of patients will be trained for the correct production of static features of vowels and the relation of patients to auditory feedback for the production of such features considerably decreased by time.

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In recent years off-pump coronary artery bypass surgery (OPCAB) has emerged as preferred method for revascularization of coronary arteries in relatively selected group of patients. Considering patients receiving incomplete revascularization need significantly higher postoperative catheterization and re-intervention (PTCA or CABG), we performed this study to identify safety and feasibility of this technique for total revascularization in nearly all patients requiring coronary artery graft surgery.
Materials and Methods: In this study, 150 consecutive patients underwent OPCAB by one surgeon. Octopus device used for regional wall stabilization. Vascular control achieved by ethibond loops, occluder, and shunts. Situations such as cardiomegaly, poor ventricular function, advanced age, hemodynamic instability, and small coronary arteries were not considered contraindications to OPCAB.
Results: Of 150 OPCAB cases, 146 (97.3 percent) were completely off-pump. The mean number of grafts per patient was 4.1 (range, 2 to 6). Total 595 distal grafts anastomosed to LAD (140) diagonals (140), right coronary artery (145), left circumflex (164). Thirty-day mortality and myocardial infarction were 0.6 percent and 3.3 percent respectively OPCAB patient experienced lesser postoperative bleeding had shorter stay at surgical intensive care unit and extubated earlier. Conduits used were left internal mammary artery, radial artery and greater saphenous vein.
Conclusion: OPCAB is a safe method for complete revascularization in nearly all patients. The OPCAB patients experience less complications, have shorter hospital stay, absolute contraindication for OPCAB other than severe, diffuse coronary artery disease with poor run-off which is better treated by cardiopulmonary bypass.

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"Arterial Thromboembolism" is the most common cause of "Acute Arterial Ischemia" of extremities. In this study, It is attempted to collect retrospectively some documentary information of all "acute arterial thromboembolic occlusions of the limbs".
Materials and Methods: In descriptive retrograde study in Sina General hospital, all related records in this regard were collected from March 1991 to March 1997. To reveal the statistical outcomes and analysis the associations between them as well, the statistical tests like nonparametric ones were employed.
Results: Total number of the cases was 24 with " Acute Thromboembolic Arterial limb Ischemia" (3 in upper and 21 in lower limbs). The results were as follows: Female to male ratio =1/2, "Range of Age": 34-91, "Mode"=8th decade of life, "Mean"-64.48, "Etiology" Cardiac Origin in majority of cases ("A.F" in 57 percent) and Unknown Origin in 1/4 of cases. "Pain" was find in 95 percent, Grade HI ischemia in only 38 percent of patients on presentation and the others in Grade n. The most common "site of embolic occlusion" was "Femoral Ar." (76 percent). "Simultaneous Embolic Events" were fined in 29 percent. "Embolectomy" was performed in 79 percent (84 percent success rate) and "Primary Amputation" in 12.5 percent. "In hospital Mortality Rate" was fined in 24 percent and "Limb Salvage rate" in 68 percent. In conclusion, there were some logic relationship only between "Limb Salvage rate" and "Ischemic Grading" and also "Delayed diagnosis". There was also some significant direct relationship between "Mortality rate" and "Concomitant Embolic events".
Conclusion: This study was an explorative one that paves the way for further complementary investigations. Although there are many recommendations due to upgrading knowledge, attitude and practice of physicians as well as lay people Besides, the upgrading of educational and curative facilities should not be neglected.

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This is a morbidity study about vascular trauma in Sina hospital, from 1974 to 1999. In this study morbidity is defined as amputation, wound infection, and recurrent thrombosis.
Materials and Methods: We reviewed the Patient's records and studied the effects of different factors such as type of trauma, associated injury, absence of capillary filling and presence or absence of distal pulse before and after surgery on morbidity.
Results: Reviewing 100 cases, we found 83 percent of them were thrombosis. The mean age was 32.5 years old. From the patients, 76 percent had penetrating trauma and the reminder had blunt traumas. Type of blunt trauma, associated injury, absence of capillary filling and the status of distal pulse, before and after surgery, time of surgery, muscular response to cautery and duration of hospital stay, all were associated with morbidity (P < 0.05).
Conclusion: In this study it is concluded that prompt diagnosis of vascular injuries, primary resuscitation and transferring the patients to proper centers and appropriate care of complicated cases, will help us to reduce morbidity.

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Background: Transbronchial lung biopsy (TBLB) is an attractive alternative to open lung biopsy as an initial diagnostic procedure for patients with diffuse parenchymal disease or localized densities beyond direct endoscopic vision. TBLB can be carried out safely without fluoroscopy in patients with diffuse lung disease. Since in our bronchoscopic department fluoroscopy is not available, we planned to evaluate the blind (without fluoroscopic guide) TBLB being performed in our department to determine the success rate in obtaining lung tissue, the sensitivity of the procedure and the risk of complications.

Materials and Methods: Sixty-Four TBLB were done in our department during a 6 month period (March-September 1999).

Results: Lung tissue wasn’t detected in two (3.1 percent) samples. Pathological results were helpful in 46 (71.9 percent) cases. No evidence of hemoptysis was found after the procedure. Three (4.68 percent) cases of pneumothorax was detected. Only one of them required chest tube (1.51 percent).

Conclusion: We concluded that blind TBLB was successful in our department with rates of complications comparable to other approved centers.

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Introduction: As spinal cholinergic receptors exhibit an action against somatic pain, this effect could be potentiated by intrathecal injection of cholinesterase inhibitor-neostigmine. This study was designed to evaluate the role of interathecal neostigmine on local back pain relief after single level lumbar disc surgery.

Methods and Materials: In an interventional-expremental study (Imam Khomeini Hospital, Jun. 2000 to sep. 2001), sixty-six patient with unilateral herniated lumbr disc at one lumber space were randomely allocated into two groups including, control (C) group and Neostigmine (N) group. Both groups underwent fenestration employing same anesthetic techniques. At the end of surgery 2 ml normal saline in groups C and 100 micrograms neostigmine methylsulfate (0.2 ml combined with 1.8 ml normal saline) in group N were injected intrathecally postoperative local back pain was measured with 10 cm chart method using Visual Analogue Scale (VAS) at 1, 4, 8 and 12 hours. Total dosage of morphine, as an analgesic rescue, used during the first 24 hours following surgery and observed complications were recorded.

Results: Mean VAS score postoperatively at 1st and 4th hours were 2.24 (Standard Error Mean, SEM=0.36) and 1.82 (SEM=0.28) in group N and 5.36 (SEM=0.39) and 5.61 (SEM=0.37) in group C respectively. Mean morphine used in the first 24 hours was 0.9 (SEM=0.4) in group N and 4.7 (SEM=0.65) mg in group C. All result were found to be statistically different in the two group (P<0.05). There was no neurologic deficit or CSF leakage in both groups postoperatively. Regarding nausea and vomiting, the difference between two groups C (15 percent) and N (24.2 percent) were not significant statistically.

Conclusion: In this study, we have found that injection of 100 micrograms hyperbaric neostigmine intrathecally is a safe and effective method with minimal complications or side effect for pain relief and curtails postoperative opiate demand.

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Background: Transbronchial lung biopsy (TBLB) is an attractive alternative to open lung biopsy as an initial diagnostic procedure for patients with diffuse parenchymal disease or localized densities beyond direct endoscopic vision. TBLB can be carried out safely without fluoroscopy in patients with diffuse lung disease. Since in our bronchoscopic department fluoroscopy is not available, we planned to evaluate the blind (without fluoroscopic guide) TBLB being performed in our department to determine the success rate in obtaining lung tissue, the sensitivity of the procedure and the risk of complications.

Materials and Methods: Sixty-four TBLB were done in our department during a six month period (March-September 1999).

Results: Lung tissue wasn't detected in two (3.1 percent) samples. Pathological results were helpful in 46 (71.9 percent) cases. No evidence of hemoptysis was found after the procedure. Three (4.68 percent) cases of pneumothorax were detected. Only one of them required chest tube (1.51 percent).

Conclusion: We concluded that blind TBLB was successful in our department with rates of complications comparable to other approved centers.

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Introduction: Rheumatoid arthritis (RA) is a chronic and systemic inflammatory disease of unknown etiology. It is characterized by symmetric joint involvement with progressive deformities. This leads to limitation of motion and reduction of activity daily living (ADL). Previous reports showed the beneficial effects of therapeutic exercises in these patients in the remission phase.

Methods and Materials: A clinical trial as a self-control sequential control study was designed to determine the effectiveness of a range of motion (ROM) exercise program in patients with RA, referring to Rheumatology Research Center between 1994-1995. ROM of the selected joints by Goniometer, and ADL by a questionnaire was assessed in all patients in 3 phases: when entering the program, after 6 weeks of observation, and then after another 6 weeks with the therapeutic exercises. The mean difference in these 2 period were compared by student paired t test. The analysis of differences between different subgroups (job, education, etc.) was done by one way variance analysis.

Results: Forty patients completed the program. The mean ADL increased from 0437±0.252 before exercise to 6.69±3.06 after exercise (P<0.001), and the mean scores of ROM increased from 0.278±0.28 to 8±3.57 (P<0.0001), both statistically significant. This was more pronounced in women and in those with ankle joints involvement. The type of disease onset and duration of the disease did not influence the effects of treatment. No increase in disease activity was seen.

Conclusion: This study showed the effectiveness of our ROM exercises in increasing functional capacities of patients with RA in remission phase.

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Background: The role prophylactic antibiotics in otologic surgery continues to be debated and perhaps misused. Prior studies have provided conflicting evidence with benefits obtained from the use of prophylactic antibiotics in surgery for chronic otitis media.

Materials and Methods: The current study was designed to evaluate the role of prophylactic antibiotics in the wound infection and outcome of surgery for chronic ear disease. It was the authors' impression that there was no difference between topical and systemic antibiotics in such surgery. Patients who met the inclusion criteria (n=193) were randomly assigned to a topical treatment group or a control group receiving only intravenous antibiotics for 1 dose intra operatively and 3 dose there after. Patients were followed post-operatively and observed for clinical evidence of infection, graft failur and hearing status.

Results: There was no statistically significant difference between the two groups with regard to the incidence of postoperative infection or graft survival.

Conclusion: The use of prophylactic antibiotics in surgery for chronic otitis media can be recommended as an alternative method.