Tehran University Medical Journal

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Background: Laparoscopic techniques for the placement of peritoneal dialysis catheters are becoming increasingly popular. Recently, with the improvements in laparoscopic surgery, various methods for the insertion of peritoneal dialysis catheters have been reported, indicating that the laparoscopic insertion is preferred over the open and percutaneous techniques. The aim of this study was to introduce and assess a simplified laparoscopic method for the insertion of peritoneal dialysis catheters in continuous ambulatory peritoneal dialysis (CAPD) patients.
Methods: We enrolled 79 consecutive end-stage renal patients (46 men and 33 women) with a mean age of 50 years (range: 19-83 years) in this study. During the surgery, a 5-mm trocar was placed in the left upper quadrant for the optics and another 5-mm trocar was placed to the left of the umbilicus. Using the second trocar, a tunnel was formed 2 cm left of the umbilical plane for the insertion of a Tenckhoff catheter. Under direct vision, the catheter was advanced into the abdomen. The catheter was tested for patency. Catheters of all subjects were capped for two weeks before dialysis initiation.
Results: The mean duration of the operation was 15 minutes. Ten patients died during the follow-up period, all due to other medical problems, and six patients underwent renal transplantation however, no deaths or complications were observed during surgery. Early onset complications were seen in 12 patients (15.1%). The most frequent late-onset medical and mechanical complications were peritonitis (6.3%) and hernia (3.7%). During a follow-up period of four years, removal of the catheter was required in two patients as a result of peritonitis.
Conclusion: We obtained a low complication rate and a high catheter survival rate with this laparoscopic insertion of the Tenckhoff catheter. We believe future experience will encourage the use of this safe, simple and quick procedure.

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Background: Alkaloids are a group of nitrogenous compounds with potential effects on the physiological behavior of human and animals. Some of these compounds are considered important drugs in modern medicine, such as atropine and morphine. Plants are considered the most important source of alkaloids. Therefore, investigating the presence of alkaloids in different plants is very important. Usually, alkaloids in plants are identified by methods such as those of Dragendorf, Wagner and Meyer, among others, which require milligrams of alkaloids for identification. In the present study, a fast and sensitive procedure for detecting of alkaloids in plants is presented.
Methods: Twelve dried plants samples were investigated for the presence alkaloids. After extracting the total alkaloid into methanol using a Soxhlet extractor, a few milligrams of the extract was transferred to a separatory funnel, buffered to pH 4.7, the bromocresol green (BCG) solution (10-4 M) was added, mixed and extracted with CHCl3 until a yellow color was observed in the CHCl3 layer, indicating the presence of the alkaloid. The crude extracts were also investigated by the standard methods of Dragendorf, Wagner and Meyer for the presence of alkaloids.
Results: Investigation of the 12 plant samples for the presence of alkaloids by the standard reagents of Dragendorf, Wagner, and Meyer showed that only Camelia sinensis (flowers), Echium amoenum Fisch & Mey (flowers), and Stachys (aerial parts) are devoid of alkaloids, with all other samples positive for alkaloids. By the BCG procedure, similar results were obtained, except for the E. amoenum flower, which was positive. The minimum detectable limit for alkaloids by the BCG method is the equivalent of approximately 40μg atropine.
Conclusions: According to previous reports, only one of these plants does not contain alkaloids. All studied plants positive for alkaloids by standard reagents were positive by the BCG procedure. Stachys was negative for alkaloids by both the standard reagents and the BCG method, in agreement with previous reports. However, black tea, reported to contain xanthine alkaloids, was negative for alkaloids by both the standard reagents and the BCG method. Therefore, the BCG method is not suitable for the detection of xanthine alkaloids. Nevertheless, the microgram detectable limit for alkaloids indicates that the BCG method is very sensitive.

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Background: Hypopharyngeal cancer usually presents with cervical mass, hoarseness, radiated otalgia, and dysphagea in the advanced stages. Radical surgery followed by radiotherapy plays an important role in the treatment of patients with hypopharyngeal cancer. However, there is no general consensus as to which is the best method of reconstruction after surgical resection. The aim of this study was to evaluate the complications of pectoralis major myocutaneous flap (PMMF) and gastric pull-up (GPU) techniques to reconstruct a circumferential defect after laryngopharyngoeso- phagectomy.

Methods: We retrospectively reviewed the records of 64 patients who underwent radical surgery and reconstruction with either PMMF or GPU technique. Demographic characteristics, tumor location, proximal margin involvement, history of radiotherapy, presence of lymphadenopathy, cervical dissection, and postoperative complications such as fistula, anastomotic site stenosis, swallowing dysfunction, and stoma stenosis were compared between the two groups. Postoperative complications of the reconstruction methods were compared.

Results: A total of 64 patients, 43(67%) in GPU group and 21(33%) in PMMF group, were studied. The groups did not differ in demographic characteristics. The locations of the tumoral lesions were in larynx (n=7), proximal esophagus (n=5), posterior cricoid (n=5), pyriformis sinus (n=7), posterior wall (n=7), and miscellaneous (n=41). Six patients (6.3%) had proximal margin involvement, 19 patients (29.9%) had history of radiotherapy, 26 cases (40.6%) had lymphadenopathy, and 49 cases (76.5%) had cervical dissection. There was no significant difference between the two groups regarding stenosis or swallowing dysfunction rates, but fistula was seen lower following GPU compared with PMMF (p<0.001).

Conclusions: The GPU technique results in similar functional stenosis or swallowing dysfunction rates, but lower fistula compared with PMMF reconstruction.

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Background: Early diagnosis of renal parenchymal involvement in children with acute pyelonephritis (APN) using isotope scan and early treatment may decrease or prevent development of renal parenchymal lesions. We designed this study to assess the diagnostic value of certain biologic parameters in children with first- episode of acute pyelonephritis (APN) documented by 99m Tc-dimercaptosuccinic acid (DMSA) scintigraphy.
Methods: We compared the laboratory findings of leukocyte count, erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) levels with the results of the DMSA scans obtained within three days of admission. One hundred-two children (93 girls and 9 boys aged 1 month–12 years (mean 2.85±2.92 years) were enrolled in the study. Of these patients, 203 renal units, were investigated using scintigraphy. Voiding cystourethrography (VCUG) was performed in 98 children (195 renal unit) when urine culture became negative.
Results: In all children one or both of kidneys had parenchymal involvement on scintigraphy. Changes on the DMSA scan were found in 178(88%) renal units during the acute phase. The extent of changes in DMSA scan were mild in 113/178(55.7%) renal units, moderate in 40/178(19.7%) and severe in 25/178(12.3%). When inflammatory markers were correlated with the development of the severe renal lesions, as assessed with DMSA scan, a highly significant correlation with both ESR (p=0.007) and leukocyte counts (p=0.02) were found.
conclusions: We conclude that the incidence of renal parenchymal involvement in Iranian children with APN is very high. Although increased ESR and leucocytosis may be valuable markers for determination of severe renal parenchymal involvement, but these parameters and also CRP, were inadequate in distinguishing mild to moderate renal parenchymal involvement.

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Background: Central venous catheter (CVC) related infections are important complications of cathter application. This study assessed the usefulness of mupirocin in prevention and control of these infections.
Methods: In this randomized clinical trial, consecutive surgical patients requiring central venous catheter (for more than 2 days) in Amir-Alam Hospital from 2006-2008 were enrolled. Patients were divided in two groups in “case group” patients received topical mupirocin 2% every 48 hours at the time of insertion of catheter and dressing change and for “control group” mupirocin was not used. All of the patients received chlorhexidine and enoxoparin as complementary treatments. Two groups were comparable in regard of age, sex and risk factors.
Results: One hundred eighteen patients enrolled in the study (57 in case and 61 in control group) completed the study. 84 catheters in case group and 88 catheters in control group were inserted. The catheters in 90% of patients were inserted in jugular vein. At the end of study 29(16.8%) patients (16 in control versus 13 in case group) had catheter colonization (p=NS). Catheter related bloodstream infection was observed in 16(9.3%) patients (6 in case versus 10 in control group) (p=NS).Catheter related local infection was seen in 2(1.1%) patients of control versus none of mupirocin group. (p=NS).
Conclusions: Mupirocin was not effective to control and prevention of bacterial colonization and catheter related infection.

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Background: Increased rate of oxidative stress have important role in diabetic nephropathy. Oxidative stress induces the synthesis of antioxidant enzymes. One of them, Extracellular- SOD (EC–SOD) is a major anti-oxidative enzyme and the only one that neutralizes superoxide ion, a precursor of reactive oxygen species (ROS). The aim of this study was to evaluate the correlation between diabetes- associated oxidative stress and antioxidative defense in macroalbuminuric type 2 diabetic patients.

Methods: One hundred and thirty three patients (74 women, 59 men) with type 2 diabetes were studied during 1385-86. According to level of urinary protein, two groups of patients normoalbuminuric (urinary protein excertion below 30mg/24h) and macroalbuminuric (urinary protein excretion more than 300mg/24) were recognized. In each group serum level of oxidized- LDL and EC-SOD were measured.

Results: The mean age of patients and the mean duration of diabetes was 59.09±8.26 years and 137.92±65.91 months, respectively. The plasma oxidized-LDL level and extracellular- superoxide dimutase level were significantly higher in macroalbuminuric than normoalbuminuric group (88.57±33.36 versus 78.24±27.59u/l, p=0.039 for oxidized-LDL and 87.60±21.18 versus 76.25±16.25mu/l, p<0.001 for EC-SOD). Oxidized- LDL was significantly correlated to EC-SOD in macroalbuminuric patients (r=0.425, p<0.0001). Oxidized-LDL and EC-SOD does not correlate to Fasting Plasma Glucose and HbA1c in each two groups.
Conclusion: The significantly elevated plasma oxidized-LDL in patients with macroalbuminuria suggests that, oxidized-LDL may play an important role in the progression of diabetic nephropathy. Besides severity of oxidative stress in macroalbuminuic patients, increase level of EC-SOD enzyme could be a compensatory mechanism to prevent tissue damage.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Multiple myeloma is a plasma cell dyscrasia characterized by proliferation of plasma cells in bone marrow associated with the production of monoclonal immunoglobulins. In recent years, the use of arsenic trioxide, formerly approved for treatment of acute promyelocytic leukemia has been considered for refractory myeloma treatment. This study was designed and carried out to evaluate the efficacy and possible side effects of ATO on patients with refractory multiple myeloma.

Methods: This study carried out on myeloma patients whose diseases were at least refractory to two standard treatment regimens conducted in Ghazi Tabatabaei Hospital in Tabriz- Iran. Arsenic trioxide was administered as an intravenous infusion at a dose of 0.25 mg/kg/d for 5 d/week during the first two consecutive weeks of each 4-week cycle with two week rest. Patients who completed one 4-weak cycle were evaluated for response to treatment.

Results: Twelve patients with refractory disease to conventional treatment regimens received arsenic trioxide. The response to the treatment assessed based on the amount of serum proteins electrophoresis of the 10 patients. Stable disease observed in four patients (33%), progressive disease in five patients (41.6%), complete response in one (3.8%) and the remaning two patients could not be assessed for response (because of increased liver enzymes after the first week). One patient completed six cycles. Some adverse events such as: increase liver enzymes and serum creatinine, neutropenia, pruritus, nausea, vomiting, lower extremities edema, and noninfectious diarrhea were observed.

Conclusions: The use of arsenic trioxide is promising in treatment of refractory multiple myeloma.

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Background: The current standard of adjuvant management for gastric cancer after curative resection based on the results of intergroup 0116 is concurrent chemoradiation. Current guidelines for designing these challenging fields still include two-dimensional simulation with simple AP-PA parallel opposed design. However, the implementation of radiotherapy (RT) remains a concern. Our objective was to compare three-dimensional (3D) techniques to the more commonly used AP-PA technique.
Methods: A total of 24 patients with stages II-IV adenocarcinoma of the stomach were treated with adjuvant postoperative chemoradiation with simple AP-PA technique, using Cobalt-60. Total radiation dose was 50.4Gy. Landmark-based fields were simulated to assess PTV coverage. For each patient, three additional radiotherapy treatment plans were generated using three-dimensional (3D) technique. The four treatment plans were then compared for target volume coverage and dose to normal tissues (liver, spinal cord, kidneys) using dose volume histogram (DVH) analysis.
Results: The three-dimensional planning techniques provided 10% superior PTV coverage compared to conventional AP-PA fields (p<0.001). Comparative DVHs for the right kidney, left kidney and spinal cord demonstrate lower radiation doses using the 3D planning techniques (p<0.0001), the liver dose is higher (p=0.03), but is still well below liver tolerance.
Conclusion: Despite the department protocol using conventional planning, 3D radiotherapy provides 10% superior PTV coverage. It is associated with reduced radiation doses to the kidneys and spinal cord compared to AP-PA techniques with the potential to reduce treatment toxicity.

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Background: Many chemotherapeutic regimens used in the treatment of cancer generate free radicals that may be a part of their beneficial effects. The aim of this study was to assess the oxidative status in patients undergoing chemotherapy for acute myeloid leukemia (AML).

Methods: Thirty-eight patients with AML (17 female and 21 male patients) with a mean age 34.05±12.49 years were included in the study. All the patients received cytarabine and daunorubicin as their standard induction therapy. Serum levels of malondialdehyde (MDA), total antioxidant capacity (TAC), and also the erythrocyte superoxide dismutase and glutathione peroxidase activities were measured before and 14 days after chemotherapy.

Results: Plasma malondialdehyde concentrations increased significantly (from a former 2.68±0.89 nmol/ml to 3.14±1.29 nmol/ml) 14 days post chemotherapy (p=0.04). Moreover, the total plasma antioxidant capacity changed from 1.09±0.15 mmol/L to 1.02±0.14 mmol/L (p=0.005). Erythrocyte superoxide dismutase and glutathione peroxidase activity decreased over time from 1157.24±543.61 U/gHb to 984.01±419.09 U/gHb (p=0.04) and 46.96±13.70 U/gHb to 41.40±6.44 U/gHb (p=0.02), respectively.

Conclusion: In this study, an increase in malondialdehyde levels and a decrease in the levels of antioxidant enzymes and total antioxidant capacity were observed. It seems that chemotherapy by cytarabine and daunorubicin generates enormous amounts of free radicals in patients undergoing the treatment for AML. Use of antioxidant supplementation during chemotherapy i is discouraged as it may interfere with the generation of free radicals that may be a part of the therapeutic efficacy of these drugs.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Osteoma is a bony slow growing benign tumor in one of the sinuses. It is usually asymptomatic but clinical symptoms will occur by its overgrowth, occupation of sinus space and obstruction of ostia.
Methods : This descriptive, cross-sectional, retrospective study was done by accessing the medical records of 17 patients with paranasal sinuses osteomas admitted in Tehran Amir Alam Hospital during 1999-2008.
Results : The mean age of the participants was 33.9 years and 12 (70.6%) were male and 5 (29.4%) were female. No positive family histories existed for the lesions. The mean time interval between the onset of symptom and attending the hospital was 4.4 years.
Frontal followed by ethmoid sinus osteomas were more common in comparison to other sinuses. The most reported symptoms in frontal sinus osteomas were upper eyelid inflation and headache and proptosis, nasal congestions and diplopia in ethmoid sinus osteomas. Most patients had been endoscopically treated.
Conclusion: In small-to-medium-sized osteomas with no invasion into orbit or skull base, endoscopic surgery is the treatment of choice with minimum side-effects.

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Background: Recurrent aphthous stomatitis (RAS) is a common disease with unknown etiology. There is no curative treatment. Purslane is considered as a rich source of antioxidants with anti-inflammatory effects. The purpose of this study is to evaluate the effect of Purslane in the treatment of RAS.
Methods: A total of 50 patients were selected for this randomized triple-blind placebo-controlled clinical trial from School of Dentistry of Tehran University of Medical Sciences in 2011. All subjects were randomly divided into two groups. Groups A and B received placebo and Purslane, respectively, for three months. Pain intensity based on the visual analogue scale (VAS), the mean intervals of lesions occurrence, number of lesions and the mean duration of complete healing at baseline and at months 1, 2 and 3 were recorded. 
Results: While no patient complained from increased severity of pain, decreased severity of pain for 4, 3, 2, and 1 grades were recorded in %16, %20, 20%, and 40%, respectively, which were much higher than 4%, 8%, 8%, and 28%, respectively, in the control group. A significant decrease in pain intensity in VAS scores were seen after treatment in group B (P<0.001). The mean duration of complete healing showed significant differences (P<0.001) between groups A (-1.52±4.07 days) and group B (-6.56±4.50 days). The mean intervals between lesions also showed significant differences (P<0.001) between group A (17.88 days) and group B (33.12 days). No significant differences were found between group A and group B regarding to number of lesions. No serious side-effects occurred in either group.
Conclusion: According to our study, Purslane is clinically effective in treatment of RAS and considering the lack of side-effects during the study period, this medicine may be a favorable alternative treatment for recurrent aphthous stomatitis.

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Background: Nucleus accumbens (NAc) and prefrontal cortex (PFC) dopaminergic and glutamatergic systems are involved in regulating of locomotor activity behaviors. This study has investigated the interaction of NAc shell dopaminergic system and prelimbic glutamatergic systems in regulating locomotor activity and related parameters.
Methods: The aim of this study was the effect the drugs injection interaction in the brain of male Wistar rats on locomotor activity and related parameters, in the order of this purpose, open field apparatus that automatically recorded locomotor activity was employed. Unilateral intra-cerebral injection of drugs was done.
Results: Unilateral intra-prelimbic injection of D-AP7 (N-methyl-D-aspartic acid= NMDA receptor antagonist 0.25, 0.5 and 1μg/μl) did not alter locomotor activity behaviors. However, infusion of NMDA (0.9μg/μl) in this region increased locomotor activity (P<0.01), whereas decreased rearing (P<0.01) and grooming (P<0.01) which was blocked by D-AP7 (0.25μg/μl) (P<0.01). Moreover, unilateral infusion of SCH23390 (dopamine D1 receptor antagonist 0.25, 0.5 and 1μg/μl) into the left NAc shell did not alter locomotor activity. However, injection of SKF38393 (dopamine D1 receptor agonist 4μg/μl) into the left NAc shell increased locomotor activity (P<0.05) which was blocked by SCH23390 (0.25μg/μl) (P<0.01). Furthermore, the subthreshold dose infusion of SCH23390 (0.25μg/μl) into the left NAc shell reduced the effect of intra- prelimbic NMDA on locomotor activity (P<0.01). In addition, intra-NAc shell administration of the subthreshold dose of SKF38393 (1μg/μl) potentiated the middle dose (P<0.05), whereas decreased the higher dose of intra-left prelimbic NMDA response (P<0.05) on locomotor activity.
Conclusion: The results suggested a modulatory effect of the NAc shell dopaminergic system on increased locomotor activity by activating glutamate system in prelimbic.

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Background: Bone is one of the most common sites of metastatic disease in malignancies. Many of the cases are asymptomatic and may be diagnosed in primary or secondary follow-up, but in symptomatic cases pain is the prominent symptom which is mostly exaggerated at nights. The improved survival of cancer patients with bony metastases in recent years, specially in breast and prostate cancer, has given a greater importance to the careful choice of treatments in this setting. This can lead to a better quality of life, lower treatment cost, prevention of disabilities, less delay in primary cancer therapies, and decrease of life-threatening events for the patients. Here we review the metastatic disease of the bone and its treatments, with emphasis on local and systemic radiation therapy. Current literature about bone metastasis and its treatments was reviewed through a search of available databases on internet for papers published in 1995-2013. Special attention was given to the research trials and studies performed by the authors on this setting. Treatment of bone metastases consist of analgesics, radiotherapy, surgery and bisphosphonates. Control of bone metastases is a challenging process, necessitating a multi-disciplinary approach and teamwork between the treating physicians. Radiotherapy is the most useful modality for this purpose in oncology, given both as a local and systemic therapy. We hope that this review would be able to help in choosing the best treatment option for this common palliative situation in Iranian cancer patients.

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Background: Colorectal carcinoma is a common malignancy, in treatment of which pelvic radiotherapy plays an important role. But this may lead to azospermia. We designed a study to determine the delivered dose to the testis with thermoluminescence dosimetry (TLD) and compare it to the dose calculated by the Three-dimensional planning software. Methods: We measured the testicular doses by TLD the TLDs were fixed to the scrotum in six points anteriorly and posteriorly in two random fractions of the radiation course. All patients received a 50-50.4 Gy radiation dose to the pelvis in a prone position with standard fractionation and 3-dimensional planning, through three or four fields. The average dose of the TLD measurements was compared to the average of 6 relevant point doses calculated by the planning software. Results: In 33 patients with a mean age of 56 years, the mean testis dose of radiation measured by TLD was 3.77 Gy, equal to 7.5% of the total prescribed dose. The mean of point doses calculated by the 3-dimensional planning software was 4.11 Gy, equal to 8.1% of the total prescribed dose. A significant relationship was seen between the position of the inferior edge of the fields and the mean testis dose (P= 0.04). Also body mass index (BMI) was inversely related with the testicular dose (P= 0.049). Conclusion: In this study, the mean testis dose of radiation was 3.77 Gy, similar to the dose calculated by the planning software (4.11 Gy). This dose could be significantly harmful for spermatogenesis, though low doses of scattered radiation to the testis in fractionated radiotherapy might be followed with better recovery. Based on above findings, careful attention to testicular dose in radiotherapy of rectal cancer for the males desiring continued fertility seems to be required.

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Background: The mortality due to Coronary Artery Bypass Graft (CABG) in patients with chronic renal failure is more common than normal population. This study evalu-ates the impacts of prophylactic dialysis on decreasing mortality and morbidity of non- dialysis-dependent patients with renal failure after CABG surgery. Methods: In this study, fifty non-dialysis-dependent patients who were suffering from renal failure and needed to CABG, were selected by convenience sampling method. Se-quentially, they were allocated to prophylactic dialysis (n=20) and no prophylactic dialysis (n=30) groups, using a randomized block design. Exclusion criteria were under 18 year old patients and doing CABG for second time. Mortality rate and some complications such as acute renal failure, brain accident and atrial arrhythmias were compared between two groups after CABG. All cardiac surgeries were performed in a single centre and through a median sternotomy. P value less than 0.05 was considered as significant. Results: The mean age of patients was (65.3±9.9). The patients included %16 (n.8) of women and %84 (n.42) of men. There were 20 patients in intervention and 30 patients in control groups. Baseline characteristics were similar in two groups. Comparison be-tween intervention and control groups after surgery did not show any difference in mortality (P=0.14), acute renal failure (P=0.4), cerebrovascular accidents (P=1) and atrial arrhythmias (P=0.3), need to second surgery due to bleeding (P=1), need to dialysis (P=0.14), need to rehospitalization (P=1), duration of ventilator use (P=0.4), duration of need to hospitalization (P=0.11), duration of a patients stay in the Intensive Care Unit (P=0.4) and deep sternal infection (P=0.7) rates. Conclusion: According the results of this study, prophylactic dialysis, before conduct-ing CABG, does not have any significant effect on mortality and other complications. The only exception is lung complications in non-dialysis-dependent patients with renal failure.

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Background: The relationship of the base of appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position. These anatomic considerations have significant clinical importance in the context of acute appendicitis. The knowledge about the correct anatomical position of appendix may facilitate in generating an accurate diagnosis of appendicitis as well as assist in achieving a better prognosis and early treatment. The present study aimed to determine the anatomical location of the appendix in Iranian cadavers. Methods: This descriptive cross-sectional study was conducted on 200 cadavers who were referred to the Forensic Center of Tehran from March to September 2013. The data including age, sex, weight, and appendix length and position were collected and analyzed using SPSS software, version 16 (SPSS, Inc., Chicago, IL, USA). Results: In the present study, 200 cadavers were evaluated accidentally, of which 173 (86.5%) were males and 26 (13%) were females, and the mean age was 39.96 years±16.31 (SD). The mean wall thickness of the appendix was 9.78 cm±16.31 (SD). The mean appendix length was 9.86 cm±1.79 (SD) in men and 9.30 cm±1.56 (SD) in women. The appendix height was long in 20 cadavers (10%), short in 3 cadavers (1.5%), and moderate in 177 cadavers (88.55%) cadavers. The appendix position was posterior in 120 (60%), ectopic in 32 (16%), and pelvic in 48 (24%) cadavers. Conclusion: Majority of appendices examined in the present study were positioned at the posterior (Retrocecal) of pelvis. According to different positions of appendices in different populations and different races, the knowledge of appendix position in various populations is necessary for early diagnosis and treatment and fewer complications for related disease.

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Clostridium difficile (C. difficile) is an important factor in the development of the gastrointestinal diseases because of irrational antibiotic prescription and antimicrobial resistance. In the past, this bacterium was introduced as an agent of the infection in the hospitals called "hospital acquired Clostridium difficile infection". This infection is a main cause of morbidity and mortality internationally. But changing in the epidemiology of the infection was observed in recent years. People not taking antibiotics as well as any contact with the clinical system were hospitalized due to the infection named "Community-Associated Clostridium difficile infection". Furthermore, the hypervirulent strains of C. difficile were identified outside of the health care facilities in different sources such as environment, animals and food products. Today the role of C. difficile has not been confirmed as a zoonotic agent or foodborne pathogen. Taking into account, it should be taken attention to the sensitive individuals such as pregnant women, elderly and children for the consumption of the contaminated food products with C. difficile spores and probable cause of the infection in these individuals. For this purpose, presentation of the guidelines or the prevention strategies for the transmission of bacteria in the society as well as the healthcare facilities is important. In this review study, the history, the risk factors of disease and the reports of infection in the healthcare facilities and outside of this environment in Iran were discussed. Finally, we supposed that based on the isolation of C. difficile with different genetic profile in Iran in comparison with international ribotypes, the existence of native strains leading to the infection in the community and the healthcare facilities is possible. This hypothesis shows the significance of regional differences in the epidemiology and microbiology of disease. In addition, according to the present reports on the irrational prescription of the antibiotics in our country, it seems that C. difficile infection is increasing but any continuous monitoring is not being occurred for the supervision in Iran. Approving these hypotheses need to the careful and continuous assessment besides comprehensive examination of molecular epidemiology of disease in the organizations related to the health in Iran.

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Background: Small molecule Purmorphamin (PMA) is the agonist of smoothened protein in Sonic hedgehog (Shh) signaling pathway. Effect of purmorphamin small molecule on differentiation of mesenchymal cells into bone tissue has been studied previously. Use of Shh causes progression of neural differentiation, and the differentiated cells express specific neural markers. Neurofilament (NF) and acetylcholine esterase (Chat) are specific markers of motor neurons and their expression in differentiated cells indicates their conversion into motor neurons. The aim of this study was to evaluate the ability of PMA to differentiate the human endometrial stem cells (hEnSCs) into motor neurons.

Methods: This analytical study was done in Tehran University of Medical Sciences laboratory on September of 2015. In this study hEnSCs were enzymatically extracted from endometrial tissue. After third passages, the flow cytometry was done for mesenchymal stem cells markers. The mesenchymal stem cells were divided into control and differentiated groups. FBS 10%+DMEM/F12 was added to the culture medium of control group and the differentiating group was treated with differentiating medium containing N2, PMA, DMEM/F12, FBS, B27, IBMX, 2ME, FGF2, RA, BDNF. After 21 days immunocytochemistry (ICC) test was done for the expression of NF and Chat proteins and Real-time PCR analysis for expression of neural markers such as NF, Chat, Nestin and GFAP (as glial marker) at mRNA level.

Results: The flow cytometry analysis showed that hEnSCs were positive for mesenchymal markers CD90, CD105 and CD146 and negative for endothelial marker CD31, and hematopoietic marker CD34. The immunocytochemistry and Real time-PCR results showed that the cells treated with PMA expressed motor neuron markers of NF and Chat. Conclusion: According to the results of this study, it can be concluded that small molecule PMA has the potency to induce the differentiation of hEnSCs into neural cells, specifically motor neurons by activating Shh signaling pathway.

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