Tehran University Medical Journal

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Despite improvement of mechanical ventilation devices for infants, lung injury still causes morbidity and mortality in many cases. To determine the effect of high frequency oscillatory ventilation (HFOV) in infants with severe respiratory failure, 10 neonates were evaluated prospectively. Mean gestational age of these patients was 35 weeks and alveolar-arterial oxygen gradient (A-aDo2) and the ratio of arterial to alveolar oxygen pressure (a/A) immediately before HFO were 610 torr and 0.072 respectively. These neonates were received inspired oxygen concentration of >95% with a mean airway pressure of 12 cm H2O by conventional mechanical ventilation. The A-aDo2 and a/A after 6 and 24 hrs on HFO was not significant in those infants with survived compared with those who died. Comparison of 3 alive neonates with 7 deaths, demonstrate that pulmonary hypoplasia, HMD accompanied with asphyxia, congestive heart failure with pneumonia are associated with poor outcome. The mean a/A ratio during 24hrs of HFO in the alived HMD group was 0.75 compared with 0.25 in those who died. It is possible that we can use this as a prognostic factor in survival. In this study, the positive effect of HFOV was demonstrated in those with no predisposing factors such as pulmonary hypoplasia, congestive heart failure, pneumonia and asphyxia.

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This descriptive study is carried out to determine the effectiveness of family planning programmes in Iran for years 1991-96. The study revealed the following outlines: Contraceptives prevalence rates increased from 42% to 67% during years 1991-96. Zaro couples years of protection increased for norplant, injectable contraceptive, IUD, vasectomy and tubectomy, but for candom it is decreased in year 1996 (Comparing to earlier years of the study). A decrease in use failure rate of contraceptives was observed during the period of the study.

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This was a retrospective review of a consecutive series of patients with spinal disease in year 2000, who underwent posterior fusion and instrumentation with Harrington distraction and Cotrel-Dobousset system to evaluate causes of hardware failure. Many cases of clinical failure has been observed in spinal instrumentation used in spinal disorder like spondylolisthesis, fractures, deformities, … . Thirty six cases that were operated because of spinal disorders like spondylolisthesis, fractures, deformities, …, were included in this study. Seventeen of this cases had breakage of device. Factors like age at surgery, type of instrumentation, angles before and after surgery and …, were compared in two groups of patients. The most common instrument breakage was pedicle screw breakage. Pseudoarthrosis was the main factor that was presented in failure group (P value<0.001). Other important causes were, age of patient at surgery (P value=0.04), pedicle screw placement off center in the sagittal or coronal plane of the pedicle (P value=0.04). Instrumentation loads increased significantly as a direct result of variations in surgical technique that produce pseudoarthrosis, pedicle screw placement off center in the sagittal plane of the pedicle, or using less than 6 mm diameter screw. This factor can be prevented with meticulous surgical technique and using proper devices.

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Background: The etiology of End Stage Renal Disease (ESRD) in every community differ according to genetic, nutrition, and public health status. ESRD,the terminal stage of chronic renal failure,needs replacement therapy otherwise could lead to death. The aim of the study is to determine the relative frequency of ESRD etiology in hemodialysis patients of Gilan province.

Methods:This descriptive study was performed on 407 patients who were being hemodialysis in all hemodialysis centers of the Gilan province from September 2002 to September 2003. The original data was collected from the medical records of patients.

Results: The most prevalent causes were: hypertension 35.4% unknown etiology 16.2% diabetes melitus 13.8% , glomerulopathies 9.6% , urologic causes 9.1%, cystic kidney diseases 7.6 % other causes 5.9 % congenital 2.5%.

Conclusion: In our study hypertension was the first etiology of ESRD, followed by unknown causes, however nephrology textbooks indicate diabetes melitus as the primary and hypertension as the secondary etiology of ESRD,.

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Background: For patients requiring chronic hemodialysis, the preferred site for vascular access is an autogenous arteriovenous fistula. Although a properly formed fistula is advantageous because it is less susceptible than other types of vascular accesses to infection and clot formation and can last longer than any other types of vascular access, AV fistula has a high rate of early failure that can increase immediate cost and complications. In this study, the prognostic value of physical examination of arteriovenous fistula by the surgeon at the end of the surgery was evaluated.
Methods: In the general surgery ward of Imam Khomeini Hospital in 326 chronic renal failure patients, 354 arteriovenous fistula operations were accomplished by two surgeons from 1377 to 1381 (ca. 1998 to 2002). The performance of each fistula was divided into the following groups by the surgeon at the end of operation: 1) systolic and diastolic thrill, 2) systolic thrill 3) souffle 4) pulse 5) not functional. Clinical function of the fistula was evaluated by the same surgeon in the following days if no souffle or thrill, early failure was detected on initial inspection.
Results: In the 354 cases of arteriovenous fistula, the total early failure rate was 12.7%. The lowest early-failure rate was 3.5% in the systolic and diastolic thrill group. The highest early-failure rate was in the not functional group (P<0.001). There was no correlation between early failure and age, sex, surgeon and location of fistula.
Conclusion: Optimally, an arteriovenous fistula has a thrill with a soft compressible pulse. At the end of each operation, if the surgeon cannot detect a thrill at the fistula site, can find only pulse, or if the function is otherwise unsatisfactory, considering of a new arteriovenous fistula may be required, however it is better to postpone the surgery.

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Background: Over the last 35 years, quinacrine has been used to sterilize more than 150,000 women in 40 countries, first in the form of slurry and now in the form of cylindrical pellets. Some studies confirmed the tubal occlusion by hysterosalpyngo-graphy, but this method increases the chance of failure. Only a few studies on tubal occlusion have used transvaginal sonography for confirmation, and there were some doubts about the effect of quinacrine on the endometrium. We performed this study to evaluate the tubal scar and endometrial pattern by ultrasound and to determine the feasibility, acceptance, and side effects of quinacrine sterilization (QS) in Iranian women
Methods: This prospective clinical trial was done at the Vali-e-Asr Reproductive Health Research Center of the Tehran University of Medical Sciences between April 2005 and July 2006. One hundred sexually active women ranging from 30 to 47 years of age, who had at least two children above two years old, requesting sterilization, were sterilized by this method. By the end of menstrual bleeding, seven pellets, each containing 36mg quinacrine, were inserted in the uterine fundal area via the cervical canal. The procedure was repeated one month later. Three cycles after the first step, transvaginal sonography was performed to visualize the tubal scar and determine the endometrial pattern. Patients were followed at one and three years after initiation of the procedure.
Results: All women were satisfied with the procedure. There were no side effects. No pregnancies had occurred, nor were there endometrial thickness abnormalities. Scar formation was visible in the tubes. Conclusion: Quinacrine sterilization is a useful method for women and can be recommended to family planning services as an ambulatory procedure due to its efficacy, simplicity, acceptance and cost effectiveness.

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Background: Insect stings can cause local or systemic reactions that range from mild to fatal, and are among the most common causes of anaphylaxis. The major allergens of honeybee venom are phospholipase A₂, hyaluronidase, acid phosphatase, allergen C and melitin. Phospholipase and melitin induce hemolysis, rhabdomyolysis and liver damage due to cell membrane breakdown, damage of the vascular endothelium and activation of the inflammatory response. Rhabdomyolysis has been implicated as the cause of acute renal failure in approximately 5-7% of cases. However, bee stings are a rare cause of rhabdomyolysis, and are usually associated with 50 or more stings. It has been reported that more than 250 bee stings are capable of causing death in humans.

Case report: We report two cases of massive honeybee stings (>2000) with rhabdomyolysis, hemolysis and acute renal failure who survived with full recovery, and two cases of >500 honeybee stings who survived without significant complications.

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Background: Atherosclerotic vascular disease is a major cause of morbidity and mortality in patients with end-stage renal diseases on maintenance hemodialysis. Early atherosclerotic changes of the arterial wall can be evaluated by measuring intima-media thickness (IMT), and looking for the presence and structure of plaques and parameters of vascular resistance. In this study we investigated the relationship between carotid IMT and pulsatility index (PI) or resistive index (RI) values in hemodialysis patients.

Methods: Sixty hemodialysis patients (27 females and 33 males median age 41.7 years) and 60 healthy volunteers (32 females and 28 males, median age 37.8 years) underwent ultrasonography of common carotid artery for the determination of IMT, PI and RI.

Results: Bilateral IMT was significantly higher in hemodialysis patients than in control group (P<0.001). Left carotid artery RI and PI were found to be significantly higher in hemodialysis patients than in the controls (P<0.001). Right carotid artery RI and PI had no significant statistical differences between the two groups (P=0.18 and P=0.78, respectively). There was a moderately significant negative correlation between the left carotid IMT and left RI and PI in the controls (r= -0.42, P=0.001 and r=- 0.43, P<0.001, respectively).

Conclusion: PI and RI values of the left coronary artery increased as did IMT in hemodialysis patients. Therefore, measurement of RI and PI values together with IMT are recommended for early diagnosis of atherosclerosis in hemodialysis patient.

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Background: The purpose of this study was to determine the prevalence and associated factors for postoperative pulmonary complications (PPCs) and extubation failure in patients having undergone intracranial surgery.

Methods: In this retrospective study done in Firozgar Hospital during 2008-2010, we followed up 254 patients through a clinical questionnaire and observation of the clinical course of participants in pre- and post-operative periods.

Results: Overall, 40 (15.74%) patients had postoperative pulmonary complications. The most common PPC was pneumonia, which was seen in 24 patients (60% of complications). The average duration of ventilation in patients with PPC was significantly higher (16.8.±10 vs. 5.09±4.5 days P=0.001) than patients without the complication. The mean Glasgow coma scale (GCS) after surgery in patients with PPC was significantly lower (11.±4 vs. 13.2±3 P=0.001) than the rest of the patients. Moreover, the mean age of patients with PPC was significantly higher (64.02±14 vs. 41.6.±17 years P=0.001). Average duration of stay in ICU in patients with PPC was also higher (24.±27 vs. 8.7±0.5 P=0.001).

Conclusion: GCS before surgery and failed extubation independently of other variables were significantly associated with pulmonary complications independent of other variables.

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Background: Renal transplantation is the preferred therapeutic method for patients with end-stage renal disease. Patients with renal failure have significant associated medical conditions, such as cardiovascular disease. The suitable anesthesia for renal transplantation requires minimal toxicity for the transplanted organ, as well as sufficient pain relief and maintenance of optimal blood pressure and intravascular volume to keep renal functions. The aim of this study was to improve our experience of spinal anesthesia in patients undergoing renal transplantation.
Methods: Sixty consecutive patients scheduled for elective renal transplantation over a period of two years who consented for spinal anesthesia were enrolled in the study. Intraoperative hemodynamic, intravenous fluids and infused blood products, duration of surgery, urine output and arterial blood gas and intensity of pain score in the recovery room were monitored. We also noted intraoperative and postoperative complications.
Results: Spinal anesthesia was satisfactory in all, but in five patients they required supplementation with general anesthesia for excessively prolonged surgery. There were no significant intraoperative hemodynamic changes. The total intravenous fluid used during surgery was 65.15±7.2 mL/kg, the mean surgical time was 170±22 min. The mean of mean arterial pressure (MAP) during the operation was 98±12 mmhg. There was no significant acidosis at the end of the operation (PH=38±0.03). Also the mean intensity of pain was 4±2 in recovery and a few of patients suffered from bladder catheter bladder discomfort in the recovery room (8 patients).
Conclusion: Spinal anesthesia is a successful regional anesthetic technique in well selected patients for renal transplantation. A successful outcome in this technique is dependent on close intra-operative monitoring, optimization of intravascular fluid volume and keep the hemodynamic status in optimal range.

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Background: HIV infection reduces the immune system and is the most significant factor in the spread of TB in recent years and one of the causes of death in HIV -seropositive patients. TB is the most commonly diagnosed opportunistic infection and the most frequent direct cause of death among HIV infected patients. The HIV infection can accelerate progression of TB infection to active TB disease. Among patients with active TB, those with HIV co-infection have the greatest risk for relapse. Regardless of increasing rate of TB and HIV in Iran, we decided to s urvey outcome of TB in HIV positive patients who treated with standard regimens in the years 2003-2012.

Methods: This retrospective cohort study was conducted on HIV-positive patients with TB referred to Behavioral Diseases Consultation Center and Infectious Diseases Ward of Imam Khomeini Hospital from 2003 to 2012. Outcome was defined as failure, relapse and mortality. Moreover, the relationship between outcomes and number of CD4, co-trimoxazole and antiretroviral intake, type of TB and AIDS defining illness was studied. Results: This study had 135 patients, 8 (5.9%) were females and 127 (94.1%) were males. The mean age of the patients was 40.14+10.02 and the most way to catch HIV in this study was intravenous drug user. There were 3 (2.22%) cases of failure, 15 ( 11.1%) relapse , and 21 ( 15.8%) deaths. Antiretroviral therapy, AIDS defining illness, type of TB and co-trimoxazole intake did not soley affect relapse. CD4 level was the most effective variables in relapse [ Hazard ratio: 0.392 (0.11-1.4) Relative Risk: 0.809 (0.593-1.103) (P=0.068) ]. However, regard to CI95%, the impact of CD4 on relapse is not significant and antiretroviral intake was the most important and effective variable in increasing their survival. Hazard ratio: 0.137 (0.141-0.45) Relative Risk: 0.686 (0.513-0.918) (P=0.001) Conclusion: Overall, receiving antiretroviral was the most important factor influencing the outcome of patients.

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Background: Advanced glycation end-products (AGEs) came up with the recent researches regarding new biomarkers for the diagnosis of heart failure. AGEs are the end products of non-enzymatic glycation and oxidation of proteins, lipids and nucleotides during Maillard biochemical reaction. Although it has been known that AGEs have a role in the pathogenesis of chronic heart failure (CHF), information regarding its role and its pathogenetic mechanism is very limited. The aim of this study was to find any relationship between AGEs with the etiology and severity of chronic heart failure.
Methods: This study is a prospective cross sectional study that enrolled 85 patients with chronic heart failure. Measurement of left ventricle ejection fraction (LVEF) was done by echocardiography. Blood samples were collected for measuring AGEs just before or after echocardiography assessment (in the same session). Measurement of AGEs was done by the enzyme-linked immunosorbent assay (ELISA) method. The relationship between AGEs with the severity of CHF and as well as the etiology of CHF were evaluated via SPSS-15.
Results: Of 85 patients 48 (56.5%) patients were male and 37 (43.5%) were female Mean±SD of their ages was 55.8±13.4 years old (ranges from 27 to 84 years). Correlation coefficient between LVEF and AGEs was 0.269 (P=0.013). Mean of AGEs in patients with and without ischemic etiology of their heart failure were 16.8±9.8µg/ml and 11.6±7.3 µg/ml, respectively. Although trend was in favor of ischemic heart failure, the difference between two groups was not statistically significant (P= 0.141).
Conclusion: According to this study the rate of AGES could be helpful in the diagnosis and assessment of severity of CHF. Based on our findings, higher blood levels of AGEs in the ischemic CHF cases, also it could be concluded that in the future this marker may be used for etiologic differentiation of heart failure syndrome.

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Background: The use of Methotrexate (MTX) is a good and common practice for the treatment of women who were diagnosed early with ectopic pregnancy (EP). The aim of this study is to determine the predictors of treatment failure with a single dose of MTX injection. Methods: In this quasi-experimental research, we studied 70 women with ectopic preg-nancies who were treated with MTX, according to a single dose protocol from 2010 to 2013. EP was diagnosed whenever an intrauterine gestational sac was not identified by transvaginal ultrasonography (TVUS), accompanied by an abnormal rise or plateau in human chorionic gonadotropin (beta-hCG) concentration. Briefly, women with ectopic pregnancies were considered candidates for MTX treatment if they were hemodynami-cally stable did not desire surgical therapy, agreed to weekly follow-up and did not have hepatic, hematologic, or renal disease. A Patient was considered a treatment suc-cess (group 1) if her beta-hCG levels decreased ≤10 m IU/ml after the first dose of MTX. Treatment failure (group 2) was defined as the need for a second or a third dose of MTX or surgery. The following risk factors were compared between the two groups: serum beta-hCG on the days 1 and 4, a ≥ 15% decrease in serum beta-hCG between the days 1-4 of the treatment, age, parity, gravidity, the size of the ectopic mass and the endometrial thickness. Results: The success rate of MTX treatment was 77.1%. There were no significant dif-ferences between the two groups in regard to the age, parity, gravidity, the size of ec-topic mass and the endometrial thickness in vaginal sonography, but the mean serum beta-hCG concentration on days 1 and 4 was lower in the success group than the failure group. We also observed a ≥ 15% decrease in serum beta-hCG in 80.9% of the women from the success group and in 38.5% of the cases whose treatment had failed. The presence of fetal heart activity was seen in only one patient and this patient’s treatment failed. Two patients had previous history of ectopic pregnancy and the treatment of both ended in failure. Conclusion: Among women with ectopic pregnancies who were candidates for MTX treatment, a high serum beta-hCG concentration on the days 1-4 and also a ≤ 15% fall in serum beta-hCG between the days 1-4 treatment, are the most important factors associated with the failure of the treatment with a single dose MTX protocol. It is better to use these factors for making decisions about the initiation of the treatment or the continuation of it.

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Primary ovarian insufficiency (POI), commonly referred to premature ovarian failure, is defined as ovarian failure before the age of 40 years. It is the loss of ovarian function caused by a process directly affecting ovaries. Cancer therapy which includes surgery, radiotherapy, and chemotherapy influence ovarian function, leading to premature menopause and loss of fertility. POI is idiopathic in most cases (74-90%). The known causes, in addition to anticancer treatment, are other processes like chromosomal abnormalities, autoimmunity, and natural aging can result in secondary ovarian failure, which is detected by an increase in serum gonadotropin levels (FSH and LH). There are evident risks of POI in women treated for cancer. Those who receive anticancer treatments have an increased risk of developing POI. There by, anticancer drugs and radiation therapy are considered as the most common toxins of ovaries. Although cancer incidence rates in women less than 50 years old continue to increase during recent years, mortality rates are dramatically decreasing due to modern advances in treatment. Increasing numbers of survivors are now confronted with the long-term consequences of exposure to these treatments. The pool of primordial follicles in the ovary is fixed and any injury to the ovary can potentially reduce this ovarian reserve, effectively advancing the patient’s reproductive age, thus narrowing the window of reproductive opportunity. Ovarian failure occurs in a significant percentage of childhood cancer survivors and many of them will seek care for reproductive dysfunction. Nevertheless, Embryo cryopreservation, oocyte cryopreservation, ovary tissue cryopreservation, ovarian suppression and oophoro-pexy are some options to preserve fertility in these groups. As a result, having foreknowledge of potential treatment related ovarian failure will allow the physician to give a better counsel to patients and their family regarding the importance and timing of fertility preservation by giving an estimated window of fertility. The objectives of the current review are to report on the etiology of POF induced through cancer therapy.

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Background: Cerebral arteriovenous malformations are rare congenital anomalies presenting as different symptoms depending on their size and the age of patient. Congestive heart failure is a rare condition in neonatal period and is most common due to structural heart defects, but rarely may be a result of peripheral shunts such as cerebral arteriovenous malformation.

Case presentation: A term male newborn infant who was delivered by Caesarean Section in Chamran Hospital, Ferdows, South Khorasan Province, June 2016. The infant was admitted to neonatal care unit due to nonreactive nonstress (NST) with normal Apgar score. In first postpartum visit, a systolic heart murmur was detected. Echocardiography showed small atrial septal defect secundum type and patent foramen ovale (PFO). He presented clinical manifestations of heart failure after 72 hours of birth. Antibiotic and treatment of heart failure was started. Following excluding most common etiologies of heart failure such as sepsis, anemia and arrhythmias, for detecting less common conditions such as cerebral vascular aneurism a transfontanelle ultrasonography was performed which showed dilated cerebral venous system. Magnetic resonance imaging (MRI) and Magnetic resonance venography (MRV) revealed a large congenital cerebral arterio-venous malformation (CAVM), in right cerebral hemisphere. Finally, he was expired 9 days after birth due to severe heart failure before any definitive treatment for closing CAVM could be done. 

Conclusion: CAVM are extremely rare vascular anomalies in newborns which may present occasionally as congestive heart failure in neonatal period. So after excluding other most common etiologies of heart failure such as structural heart defects, screening CAVMs should be done. Inspite of early diagnosis, usually they have extremely poor prognosis.

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Background: Heart failure is one of the most common cardiovascular disorders and is considered a chronic, progressive and debilitating disorder. The medical treatment of this disease is accompanied by many problems. Today, stem cells are being used increasingly to reduce the problems of heart failure treatments. Since pro-inflammatory cytokines play an important role in the prognosis and progression of cardiovascular disease, the present study aimed to investigate the effect of intravenous injection of human amniotic membrane mesenchymal stem cells on the levels of interleukins 4 and 12 in the serum of male rats in the heart failure model.
Methods: This is an experimental study that was conducted from October 2018 to May 2019 in the Physiology Research Center of Iran University of Medical Sciences. In this study, 28 male wistar rats (180-200 gr) were randomly divided into four groups: control group, heart failure group, heart failure group that received culture medium and heart failure group that received mesenchymal stem cells by intravenous injection. After 30 days, echocardiography was done and then serum levels of interleukin 4 and 12 were measured in these groups by Elisa test.
Results: The results of this study showed that intravenous injection of human amniotic membrane mesenchymal stem cells into male rats with heart failure, improved echocardiographic parameters such as ejection fraction (EF) and fractional shortening (FS) in the cell injection group compared to the heart failure group (P<0.05). Also, the levels of inflammatory cytokines IL-4 and IL-12 were significantly reduced in the cell injection group compared to rats with the heart failure group (P<0.05).

Conclusion: Due to the improvement of cardiac parameters and the reduction level of inflammatory cytokines in this study, it seems that human amniotic membrane mesenchymal stem cells play an important role in improving heart failure by reducing the level of inflammation.

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