Tehran University Medical Journal

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Background: Quality assurance is a prevention-oriented system that can be used to improve the quality of care, increase productivity and monitor the performance management in clinical laboratories. ISO 9001: 2000 requirements are a collection of management and technical systems designed to implement quality assurance and monitor performance management in organizations.
Methods: A checklist was prepared to monitor the preanalytical, analytical and postanalytical stages of laboratory performance management in 16 areas and all laboratory activities in 14 of the clinical laboratories of the Tehran University of Medical Sciences (TUMS) hospitals. Collected data were stored and statistically analyzed using SPSS software.
Results: The best performance, in which 77.73% of quality assurance indicators were observed, was found in Sina Hospital. However, only 57.56% of these indicators were fulfilled at Farabi Hospital, with the lowest-level performance among the clinical laboratories of TUMS hospitals. The highest level of compliance with quality assurance indicators was in the hematology departments and for facility demands in management areas. Overall, quality assurance indicators were appropriately followed in only 7% of the clinical laboratories.
Conclusion: The average quality assurance observation rate in the clinical laboratories studied was 67.22%, which is insufficient and must be remedied with stricter enforcement of the ISO 9001: 2000 regulations.

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Background: Although endometrial cancer is primarily a disease of the postmenopausal female, 25% of patients are premenopausal, with 3-5% in women 40 years old or younger. The younger group of women with endometrial carcinoma are frequently nulligravid with a history of infertility, and a strong desire to preserve fertility. This may pose a therapeutic dilemma for both patients and treating physician.
Case report: We reported 3 young patients with atypical complex hyperplasia or early stage endometrial cancer that treated with conservative hormonal therapy.
Conclusion: Medical treatment of young patients with endometrial carcinoma and complex atypical hyperplasia who wish to preserve fertility is a reasonable and appealing option. A comprehensive evaluation prior to counseling the patient should include A complete history and physical examination. A formal D&C with review of history with an experienced gyn-onc pathologist. Evaluation of the pelvic and abdomen preferably with contrast-enhanced MRI or transvaginal ultrasound. In patients found to have a clinical stage I grade I tumor and who want to preserve fertility , thorough counseling include risks and benefits, and explanation that the data is partial and incomplete due to the lack of appropriate controlled studies is mandatory. In patients considered for medical treatment, a high dose progestin regimen should be started with endometrial sampling every 3 months until complete regression of the tumor is documented. Although most responses are long standing, there is a small risk of progression during or after cessation of progestin therapy.

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Background: Creutzfeldt-Jakob disease (C-JD) is a rare disorder characterized with rapidly progressive mental decline, myoclonic jerk and finally death. The transmissible pathogen for this disease is a proteinaceous infectious particle termed prion. The prion protein is encoded by a gene (designated as PRNP) on the short arm chromosome 20.This disorder is diagnosed based on clinical findings, course of disease, EEG, MRI and confirmed with brain biopsy. Case report: A 56- year- old woman presented with confusion, disorientation, hyper somnolence, psychiatric problems such as hallucination, progressive mental deterioration and myoclonic jerks. She had history of several times phlebotomy with traditional and non sterile methods in two past years. She had no past history of other disease. Her illness was diagnosed based on clinical findings, course of her illness, typical MRI, EEG and rule out other dementing disease. She died after one month.
Conclusion: in any patients with psychiatric disorders, rapidly progressive mental deterioration and myoclonic jerks C-JD should be considered as an important diagnosis. Treatable dementing disease should be considered and ruled out at first. The significance of phlebotomy in C-JD has yet to be determined.

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Background: Tetralogy of Fallot is the most common cyanotic congenital heart disease. The systolic and diastolic function in both ventricles is altered even after successful corrective surgery for this defect with a transannular patch. Pulmonary regurgitation, a common complication after this treatment, is usually well tolerated in childhood. The aim of this study was to assess the combined diastolic and systolic function of both ventricles using the Doppler-derived myocardial performance index (Tei index) in patients who underwent surgical repair of tetralogy of Fallot using a transannular patch. In this article we discuss the impact of pulmonary regurgitation on right ventricular function and clinical outcome, the role of echocardiographic imaging, and current management strategies for patients with pulmonary regurgitation after this treatment.
Methods: Sixty eight patients with tetralogy Fallot were studied in Shahid Rajaie referral Cardiovascular Center during 2003-2005. The studied population, 36 male and 32 female with a mean age of 7.5±4 years and a history of corrective surgery for tetralogy of Fallot using a transannular patch. These patients were randomly selected and assessed by Doppler echocardiography.
Results: Fifty-seven patients (84%) had mild to moderate pulmonary regurgitation, whereas 11 patients (16%) had severe pulmonary regurgitation. Right ventricular Tei index was significantly increased in patients with severe pulmonary regurgitation compared those with mild to moderate pulmonary regurgitation (0.54±0.18 vs 0.24±0.11, P<0.01). Left ventricular Tei index was increased in patients with severe pulmonary regurgitation compared those with mild to moderate pulmonary regurgitation (0.46±0.22 vs 0.32±0.14, P<0.05).
Conclusions: The findings of this study suggest that pulmonary regurgitation is a serious complication after repair of tetralogy of Fallot with a transannular patch. Delaying surgery in such patients risks irreversible ventricular function.

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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: Cow's milk protein allergy (CMPA) is the most common food allergy during the first year of life. Strict avoidance of specific foods is the only accepted treatment for food-induced allergic reactions. This is often an unrealistic therapeutic option, since cow's milk is a basic food that is extensively used in infant formula. The recent preliminary experience of oral desensitization to cow's milk by Meglio & Patriarca seems promising. The object of this study was to investigate the desensitization of children with CMPA to cow's milk.

Methods: All the patients referred to the Allergology Department of the Children's Medical Center Hospital, Tehran from March 2004 to November 2005 suspected to have CMPA were evaluated. The patients were included in the intervention or control groups of the study. For the intervention group, Meglio's protocol was performed. We observed and examined the control group for at least 6 months. Eventually both groups were reevaluated for the symptoms and persistence of positive specific IgE for cow milk proteins.

Results: We enrolled 20 patients for oral desensitization and 13 patients were enrolled in the control group. Both groups were similar with regard to the mean age, sex and clinical symptoms. In 18 (90%) of the intervention subjects, oral desensitization with cow's milk was successfully performed. The entire protocol was completed by 14 (70%) of the intervention subjects. At the end of the six-month observation period, all the patients in the control group were still symptomatic after ingestion of cow's milk. The levels of specific IgE for cow's milk in the intervention group decreased significantly, which was not observed in the control group.

Conclusion: We successfully desensitized 90% of our CMPA patients. Considering that all the patients in the control group remained symptomatic after the period of observation and our promising results in oral desensitization with cow's milk, we can safely propose this protocol as a hopeful alternative in the treatment of CMPA. We speculate that oral desensitization to cow's milk does not alter the natural outcome of CMPA, but substantially increases the threshold dose necessary to elicit allergic symptoms.

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Background: Burnout is one of the most important factors in reduced productivity in organizations and involves physical and mental signs, especially in the human service professions. The role of nurses in the healthcare system is vital and motivation to ensure health security is extremely important. We carried out this research to examine the relationship between burnout and mental health in the nursing staff of educational hospitals of Tehran University of Medical Sciences.
Methods: A descriptive cross-sectional survey was conducted among 200 nurses selected via probable multistage sampling. We used three instruments in this study: 1) demographic questionnaire 2) General Health Questionnaire-28 (GHQ-28) and 3) Maslach Burnout Inventory (MBI).
Results: On the whole, using the MBI subscale, we found low levels of emotional exhaustion and depersonalization and high levels of reduced sense of personal accomplishment, both in frequency and intensity. The prevalence of symptomatic samples in the GHQ-28 was 43%, and two variables, burnout and poor mental health, were related (p<0.001). Burnout was to be related to gender, age and years of work. The correlation between poor mental health and years of work as well as hours of work in a week were significant.
Conclusions: Our results suggest that there is a strong correlation between poor mental health and burnout. Furthermore, the prevalence of symptomatic samples detected in our study using the GHQ-28 was much higher than that reported in studies of the general population. The high prevalence of symptomatic samples and high prevalence of burnout in the dimension of self accomplishment, especially in younger nurses, combined with the strong correlation between poor mental health and burnout all show that care should be taken to improve the stressful conditions that nurses face.

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Background: Sexual function in women may be affected by their menstrual cycle. Lack of sexual drive is a deficiency or absence of sexual fantasies and desire for sexual activity. This study aims at determining the changes in sexual desire during the menstrual cycle and those associated with premenstrual syndrome (PMS) and evaluates sexual desire during the menstrual cycle and the associated changes with PMS.

Methods: The sample for this cross-sectional study includes 150 women employed in factories in Tehran. The instruments for data collection were questionnaires and journals of premenstrual experiences.

Results: Analysis of the data showed that the mean age of the subjects was 31 years )standard deviation = 8.46(. The most frequent decrease in sexual desire was during the week prior to the start of menstrual bleeding (27.3%) and the least frequent was from the end of bleeding to one week before the next period of menstrual bleeding (5.3%). In 24.7% of the cases, an increase in sexual desire occurred during the middle of the menstrual cycle and 27.3% during the course of menstrual bleeding. Moreover, 10.7% of the subjects had an increase in sexual desire during the week before bleeding. Furthermore, a positive correlation was found between changes in sexual desire and PMS (p<0.001). In addition, a positive correlation was found between changes in sexual desire and breast tenderness, joint and muscle pain.

Conclusions: The sexual desire of women, with or without PMS, changes during the menstrual cycle. The greatest decrease in sexual desire occurs during the first week before menstrual bleeding in women with PMS. Such information can greatly help toward understanding and treatment in sexual therapy for couples.

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Background: Anxiety is a complex phenomenon with important results. In fact anxiety is a biologic process that has repetitive biological and physiological effect on the biological structure of brine. From long time ago anxiety and fear has bean one of the important psychological issues and for the control of anxiety different drugs with different mechanisms have been presented and understanding mechanisms that are involved lead us to newer drugs discovery. In this research the effect of morphine on the anxiety in the adult Male rats in the Ventral Tegmental area (VTA) and Nucleus Accumbens (NAc) was studied.

Methods: The elevated plus maze was used in combination with the percentage of time spent in the open arms of the maze (OAT %) and the percentage of entries into the open arms (OAE %) to measure anxiety. Increases in the OAT% and OAE% indicate an anxiolytic effect (reduction in anxiety), whereas decreases in the OAE% and OAT% indicate an anxiogenic effect. Adult male rats, weighing 200-240 grams, underwent surgery. After five days, the rats were injected with saline and three different doses of morphine (2.5, 5, and 7.5 µl/rat). Experiment one included the injections into the VTA. In the second experiment, these injections were in the NAc. Behavioral tests were conducted between 12 pm and 4 pm and each animal was used once for each experiment.

Results: In the first experiment, although these doses of morphine injected into the TVA had no effect on the OAE%, a dose of 5µl/rat increased the OAT%, showing a decrease in the animals' anxiety. In the second experiment, doses of 2.5µl/rat injected into the NAc induced a significant increase in the OAT% and OAE%, there by displaying decreased anxiety in the animal. However, no significant change in the activity of the animals was observed.

Conclusion: As a Result of these experiments, it seems that different doses of morphine can decrease anxiety, probably through interaction with gabaergic system.

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Background: Congenital scoliosis is a developmental disorder defined as a lateral curvature of the spine. Its progressive trend and complications, such as cosmetic problems, pain and pulmonary symptoms, have put scoliosis as an important skeletal deformity that should be corrected. One of the currently accepted methods of treatment is posterior spinal fusion (PSF) that may be performed with or without instrumentation. However, the use of implants in conjunction with PSF in congenital spine deformity has been debated over the past three decades primarily because of increased risk of neurological deficit and implant displacement. The aim of this study was to compare short-term and long-term outcomes of spinal fusion with and without posterior instrumentation in congenital scoliosis.

Methods: In this historical cohort study, 41 patients with congenital scoliosis were recruited. All patients underwent PSF surgery between 1977 and 1996. They were divided into two groups according to the use of instrumentation: 22 congenital scoliotic patients who were treated by PSF without any instrumentation (group A), and 19 instrumented PSF patients (group B). Instrumentation was mostly performed using the Harrington rod. The major curve angle was measured before surgery, two weeks and one year after PSF surgery and at the end of the follow-up period.

Results: The mean baseline curve angles were 66.3° and 69.1° in groups A and B, respectively. The mean Cobb angles one year after PSF were 43.1° and 38.4° in groups A and B, respectively. The mean follow-up period was 8 years (SD=3) and, at the end of this period, the final Cobb angles were 47.3° and 39.4° in groups A and B, respectively. Therefore, the final angle correction was 28.7% in patients without instrumentation and 43% in patients with instrumentation. The mean loss of correction was 5.5% and 4.3% in groups A and B, respectively. The final curve angles was significantly more corrected for those patients in whom instrumentation was used than those without instrumentation (p<0.05).

Conclusion: The treatment of congenital scoliosis can be very challenging despite the benefits of modern surgeries and instrumentation methods. The results of our study demonstrate that the application of an implant with PSF surgery may lead to increased improvement of the scoliotic curvature in the short-term and long-term periods, as well as a decrease in the loss of correction and the rate of reoperation. In addition, the low incidence of complications in our study indicates the safety of the posterior instrumentation for the treatment of congenital scoliosis.

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Background: The use of serial quantitative beta-human chorionic gonadotropin (β-HCG) with transvaginal ultrasound to enhance early diagnosis of ectopic pregnancy (EP) improves options for conservative treatment with methotrexate (MTX). The aim of this study was to evaluate the outcome of unruptured EP treated with a single dose of intramuscular MTX injection.

Methods: This clinical trial included 41 EP patients with specific inclusion criteria for medical treatment. For each patient, MTX (50 mg/ml) was administered intramuscularly and a repeat dose was given if the weekly decrease in the level of β-HCG was less than 15%. The therapy was considered successful if the level of β-HCG fell below 10 mIU/cc without surgical intervention.

Results: Overall, 78% of the patients were successfully treated, among whom 18.7% received second doses of MTX. Of the patients who were successfully treated, 60% presented with vaginal bleeding without pelvic pain however, of those patients in whom the treatment failed, 88% presented with pelvic pain together with vaginal bleeding. Furthermore, the presence of free peritoneal fluid on vaginal ultrasound was a significant predictor of treatment failure (p<0.005). There was no relation between the women's age, gravidity or parity, the size of the conceptus, gestational age, pretreatment serum β-HCG titer, endometrial thickness on vaginal ultrasound and the efficacy of treatment.

Conclusions: With a reasonably high success rate, we found systemic single-dose MTX treatment to be a safe, conservative therapy for EP. However, when free peritoneal fluid is noted upon transvaginal ultrasound or when the patient presents with pain, the threshold for surgical intervention may be lower.

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Background: Depressive disorders in children and adolescents are chronic and highly morbid. Few studies are carried out on antidepressant drugs for depressed youths, especially specific noradrenergic agents. Reboxetine is a selective norepinephrine reuptake inhibitor. This study was designed to evaluate the effect of reboxetine in childhood and adolescent depression.

Methods: Twenty patients of both genders, aged 7-17 years old, with major depressive or dysthymic disorders, as classified by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), participated in an 8-week clinical trial before-after study of reboxetine. Clinical semistructured interviews, based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS), were carried out. Reboxtine was initiated at a dose of 1 mg/day and increased up to 6 mg/day. Patients were assessed for changes in: depressive symptoms using the Children's Depression Inventory (CDI) and global functioning by the Children's Global Assessment Scale (C-GAS). Side effect questionnaire was also administered.

Results: There was a significant decrease in the ineffectiveness subscale (C factor) of CDI (p=0.006). Although the CDI scores decreased by 32.69%, this change was not significant (p=0.39). No significant change in C-GAS (p=0.2) was observed. Adverse effects were relatively mild to moderate and transient. The most common adverse effects were decreased appetite and sedation.

Conclusions: Reboxetine is relatively well tolerated and improves feelings of ineffectiveness among depressed children and adolescents however it does not improve all depressive symptoms. Double-blind, placebo and active comparator controlled studies and larger sample sizes are indicated.

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Background: The knee is the most commonly injured joint. The internal components of the knee include the meniscuses, the anterior cruciate ligament (ACL) and posterior cruciate ligaments (PCL). Magnetic resonance imaging (MRI) is now used widely because of its high accuracy and noninvasiveness. Our objective was to diagnose internal knee component injuries by MRI and compare its diagnostic value with that of arthroscopic surgery.
Methods: This process research study was carried out between May 2004 and September 2006 on 90 randomly selected patients admitted to the orthopedic ward of Baghiatollah Hospital, Tehran, Iran. Each patient had arthroscopic surgery after undergoing MRI by an expert radiologist.
Results: Out of 90 patients, 81 were male and nine were female. The mean age was 31.6 years (range: 17-71). Among patients with normal ACL as shown by MRI, 42.4% were shown by arthroscopy to have a ruptured ACL. The sensitivity and specificity of MRI in ACL abnormalities were 73% and 77%, respectively. Only 1.3% of the patients with normal PCL by MRI showed PCL rupture upon arthroscopic examination. The evaluation of the lateral meniscus by MRI had a sensitivity and specificity of 40% and 94%, respectively. Likewise, in the medial meniscus, sensitivity and specificity by MRI was 70% and 98%, respectively.
Conclusion: According to our study, considerable differences exist between MRI reports and arthroscopic findings in the diagnosis of internal knee injuries. We therefore conclude that sole reliance on MRI reports is not reasonable for making treatment decisions and MRI should be used as just one of the diagnostic tools, in conjunction with other methods, such as physical examination and arthroscopy.

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Background: About one-forth of the patients admitted to the emergency department complain of acute abdominal pain. According to surgical records, most surgeons believe that pain relief for these patients may interfere with the clinical examinations and the final diagnoses. As a result, analgesics are withheld in patients with acute abdominal pain until the determination of a definite diagnosis and suitable management plan. The purpose of this study was to evaluate the effect of analgesics on the evaluation course and treatment in acute abdomen.

Methods: Two hundred patients at a surgical emergency department with acute abdominal pain were enrolled in this prospective study and randomly divided into two groups at the time of admission. The case group consisted of 98 patients who received intravenous analgesia immediately after admission. The other 102 patients in the control group did not receive analgesia until a definite diagnosis was made. Diagnostic and therapeutic procedures were similar between the two groups. The primary and final diagnoses, and the time intervals between the admission and definite diagnosis, and that between admission and surgery were gathered and analyzed.

Results: The mean time to definitive diagnosis was 1.7 and 2.04 hours in the case and control groups, respectively. There was no statistically significant relationship between analgesic use and gender, age, time to definite diagnosis, or accuracy of the diagnosis. In fact, the time required to achieve a definite diagnosis and the time between admission and surgery were less in the group that had received analgesics.

Conclusions: In spite of the fact that analgesics remove the very symptoms that brings patients to the emergency room, appropriate use of analgesics does not reduce diagnostic efficiency for patients with acute abdominal pain.

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Background: Patch forms of glyceryl trinitrate (GTN), also known as nitroglyceril, have proved useful in the management of dysmenorrhea. Increased intrauterine pressure due to exaggerated myometrial contractions is an important factor in the pathogenesis of dysmenorrhea. In a recent study, it was found that GTN caused a significant reduction in the contraction frequency of human myometrial strips. The object of this study is to evaluate the efficacy of GTN ointment in treating primary dysmenorrhea.

Methods: In this double-blind randomized placebo-controlled study, we enrolled 112 unmarried subjects with the complaint of moderate to severe primary dysmenorrhea. They were between 18-30 years of age with normal BMI (19-27) and all had normal results upon examination by pelvic ultrasound. None of these patients had a history anemia, previous pelvic surgery or cardiovascular diseases. Randomly divided in two groups using odd and even numbers, 56 of the subjects received 5 mg 1% GTN ointment and another 56 received a placebo. Before starting the treatment, severity of pain was recorded using a visual scale method. Ointment A (GTN 1%) or ointment B (placebo) was applied to special papers which were in turn applied to the skin of the abdomen below the umbilicus, and left there for the entire treatment period of four hours. The severity of pain and side effects of the treatment were recorded at intervals of 15 min, 30 min, 1 h, 2 h and 4 h after application the treatment. After four hours, the treatment was removed and the skin checked for erythema.

Results: There was no difference in severity of pain 15 min after treatment, but pain was less severe in the GTN group from the 30-min interval through the 4-h interval, with the least pain felt at the 2-h interval. This decrease in pain lasted through the 4-h interval. Side effects, which were more common in the GTN group than the placebo group (P<0.05), included headache (48.3% vs. 19.5%, respectively), dizziness and flushing.

Conclusions: GTN performed well in relieving primary dysmenorrheal discomfort however, the side effect of headache reduced its efficacy and tolerability.

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Background: Post-menopausal hemorrhage is one of the most common complains in gynecologic clinics. More than 60% of these cases have abnormal findings in diagnostic work ups. There is contraversy about the best diagnostic method for evaluating post-menopausal hemorrhage. The aim of this study was to evaluate the results of Trans-Vaginal Ultrasonography and compare its result to ones derived from direct endometrial biopsy and Hysteroscopy findings.

Methods: In a cross-sectional study, menopausal women who attended the outpatient clinic of Arash Hospital, Tehran University of medical Sciences, from April 2005 to March 2006 with the complain of hemorrhage were evaluated. In all of these patients, after getting informed consent, Trans-Vaginal Ultrasonography, Dilatation and Curettage and Hysteroscopy were performed.

Results: The total number of 90 women was recruited to the study with the age range of 41-80 years. The mean age of participants was 53.84 ± 6 years and 4.3 ± 5.1 years had passed from their menopause. The mean thickness of endometrium, measured by Trans Vaginal ultrasonography was 6.25 ± 3.7 millimeter. In the biopsy derived specimens, the most finding pathological presentation was atrophy (48.9%) and the Proliferative endometrium had the second prevalence (36.7%). Atrophy (44.4%) and Proliferative endometrium (33.3%) were the most prevalent finding in Hysteroscopy. There was a significant difference in endometrial thickness between groups of different pathological findings. A significant difference in endometrial thickness was also seen between groups with different Hysteroscopic finding. By grouping the data according to endometrial thickness, it became evident that endometrial thickness can predict the outcome of endometrial biopsy and Hysteroscopic finding efficiently. We used ROC curves to find the best grouping threshold for endometrial thickness to achieve the best sensitivity and specificity.

Conclusion: Measuring the endometrial thickness by Trans-Vaginal Ultrasonography is an appropriate non-invasive test for screening post-menopausal hemorrhage. 

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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: Acute abdominal pain is a common complaint in an emergency setting. An immediate and precise diagnosis is necessary for reducing morbidity and mortality. Several studies have reported that CT scan increases diagnostic accuracy for patients with acute abdominal pain. This study was designed to evaluate the sensitivity, specificity and accuracy of spiral CT scan compared to that of abdominal ultrasound and plain radiography. 

Methods: We assessed the data of 91 consecutive patients, including 45 males and 46 females, ranging in age from 8 to 84 years (mean age 52.38 years) presenting to the emergency department of Sina Hospital, Tehran, Iran, with acute non-traumatic abdominal pain during the years 2003-2005. All patients underwent spiral CT scanning in addition, sonography and plain radiography were performed for 66 and 64 of the patients, respectively. The sensitivity, specificity and accuracy were calculated and compared, based on the final diagnosis, which was established with surgical, pathologic, and clinical follow-up. The data was analyzed by SPSS 13.0 software.

Results: Among the 91 patients examined, CT scan was reported to be normal in 15 patients (16.5%). The most common CT findings were aortic aneurysm (12.1%), pancreatitis (9.9%), ovarian cyst (7.7%), intestinal distension (7.7%), and hepatic cyst (7.7%). The overall sensitivity, specificity, and accuracy of unenhanced spiral CT were 92.2%, 92.86%, and 92.3%, respectively, whereas those of plain radiography were 13.2%, 72.7%, and 23.4%, respectively, and ultrasound 73.2%, 90%, and 75.7%, respectively.

Conclusions: This study suggests that plain radiography is an insensitive technique in the evaluation of nontraumatic acute abdominal pain presenting in the emergency department. Unenhanced spiral CT is accurate for adult patients with nontraumatic acute abdominal pain and should be considered as an alternative to radiography as the initial imaging modality.

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Background: There is dearth of reports from Iran regarding the prevalence of postterm pregnancy and its complications. The present study was conducted to evaluate the prevalence, management and outcome of prolonged pregnancies.

Methods: This cross-sectional study included data from the hospital records of all women referred to Shariati Hospital, Tehran, from 2001 to 2002 with pregnancies of more than 40 weeks in duration. Pregnancies ≥40-42 weeks were considered postdate and those more than 42 weeks postterm pregnancy. The data compiled from the hospital records were subjected to t, χ² and Mann-Whitney U tests.

Results: Of the 1500 deliveries in this hospital, 98 patients were included in this study, 66.3% of whom were nullipara and 33.7% multipara. The prevalence of postterm pregnancy was estimated to be 3.3%. Cervix dilation of 2 cm or less on admission occurred in 65 women (73.3%). The mean Bishop score was 4.31. Of the 62 fetuses that underwent assessment tests, 54 (87.1%) were normal. The median time between the last test and induction of labor was 2.1 days, and 2.6 days for cesarean deliveries, which was not a significant difference (P=0.6). Cervical ripening with misoprostrol was performed in 36 cases (36.7%) and was successful in 18 cases. In this group, the median time for cervical ripening in multiparas was significantly less than nulliparas (4 vs. 7 hrs, P=0.004). Women not subjected to cervical ripening had a higher cesarean rate than those who did undergo cervical ripening (74.7% vs. 66.1%), although this difference was not significant (P=0.9). Vaginal and cesarean delivery rates showed no significant difference between cases that underwent induction with oxytocin and those subjected to cervical ripening with misoprostol (P=0.9). The mean Apgar score was 9.5, with all scores above 6. There were no cases of neonatal hypoglycemia, hypocalcemia, NICU admission or prenatal death. The mean nursery stay was 1.84 days with a range of 1-8 days.

Conclusions: The prevalence of postterm pregnancies was 3.3% in this study, due in part to erroneous estimation of gestational age. Sonography exam in the first half of pregnancy can provide a better estimation of gestational age and thereby reduce the rate of postterm pregnancy. Cervical ripening and induction of labor shorten the duration of pregnancy however, whether it has any beneficial effect on neonatal outcome remains controversial.