Tehran University Medical Journal

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Carpal tunnel syndrome (CTS) is considered by researchers because of its high prevalence, and several studies have been done to find the causes and factors which increase the chance for the syndrome. These studies have shown relationships between this syndrome with some physical parameters like wrist dimensions, weight and systemic conditions. There is no investigation on risk factors in CTS in our country. So the main goal of this research is to find and introduce predisposing factors for carpal tunnel syndrome. Methods: Seventy patients and 33 controls 22 to 70 years old were studied. Standard methods for median and ulnar nerve studies were used and questionnaires included physical measurements, history of diseases and personal information were completed for each person. Results: Patients had higher wrist ratio (mean difference, 0.0267, P<0.001), weight (mean difference: 6.098, P<0.001) and body mass index (mean difference: 3.376, P<0.001). Regression analysis showed strong positive relation between wrist ratio and median latencies. The strongest correlation was found between wrist ratio and median minus ulnar distal sensory latencies (Y2=0.4014, P<0.0001). No relation was found between weight and body mass index with median latencies. Seventy-nine percent of patients and 48.5% of controls had wrist ratio of 0.7 or greater (P<0.05). Seventy-two percent of patients with repetetive hand activities and 78% with associated conditions had wrist ratio of 0.7 or greater. Seventy-six percent had wrist ratio less than 0.7. No relationship was found between obesity, diabetes, thyroid disorders, rheumatoid arthritis, taking oral contraceptive, hysterectomy, oophorectomy, menopause and repetetive hand activities with involvement of carpal tunnel syndrome. Discussion: Wrist dimensions seem to be an important predictor for carpal tunnel syndrome also in patients with associated conditions. If individuals with squarer wrists are involved in special conditions, they may show symptoms of the syndrom. Carpal tunnel syndrome is caused by many factors but wrist dimensions seem to be a predisposing factor and provides an explanation for bilateral involvement or familial occurrence of it.

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This study was focused on analysis of expenditure on all the medical services given at Neuro-Surgery Department of Imam-Khomeini Hospital in the year of 1994 (1373). In this study, all the information on descriptive method and the techniques of cost analysis and cost per unit of service provided accountancy, were analysed. 573 patients were considered in this study. 522 of them underwent 13 different types of neuro-surgery operations. 92.6% of them total departmental costs were related to current expenditures and 7.4% of that was related to the capial expenditures. The personnel costs with 49% was the highest portion of the total costs. Percentage wise, the costs were as follows: Medicine, materials and equipment 22%, food 17.6%, depreciation 7.4%, fuel, water, electricity and telephone 3.5%. The mean duration of stay was 16.3 days for every in-patient. The percentage of occupied bed was 58% if the percentage of desired bed occupancy was supposed 80%, therefore, 22% of the bed, plus 3512 bed-day were gone wasted. The real cost of med-care policy need to be more rational for the operation and hospitalization. It should be mentioned that the wasted time was 886 hours and wasted cost was 71, 708, 410 Rials in operation room.

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An appropriate approach to surgical patients in emergency situations needs meticulous consideration, especially those with incarcerated inguinal hernias, since delay or inappropriate treatment may lead to severe complications or even death. According to this fact, medical records of patients with incarcerated inguinal hernias referred to emergency department of Sina hospital were surveyed during a 40 year period by a retrospective study. Routine criteria indicating strangulation in incarcerated inguinal hernia were compared between a group of patients with intestinal necrosis and those without this complication. Among 87 patients with relatively complete records which were all operated (immediately or with some delay), 13 patients had intestinal necrosis for whom intestinal resection was performed. The comparison between the gangrenous group and those without grangrene according to the mean interval between the onset of symptoms and hospitalization, body temperature, pulse rate and WBC count, was performed by student t-test, but no significant difference was found. Considering the safety of surgery especially for anterior herniorrhaphy which ia familiar to all surgery residents, the authors suggest immediate operation through ant. approach for incarcerated inguinal hernias

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Fine-needle aspiration biopsy for the diagnosis of breast lesions has been used for more than six decades and has been established as an effective procedure in Europe for many years. In order to evaluate the accuracy of fine-needle aspiration with histopathologic confirmation, a retrospective study was performed in Iranian Center for Breast Cancer, using a computer database over one year period. All women who had had fine-needle aspiration breast biopsy with histopathologic diagnosis included open excisional biopsy or mastectomy specimen. A total of 49 patients fulfilled the criteria. The test had a 93% sensitivity, 73% specificity, 65% positive predictive value, and 95% negative predictive value. Fine-needle aspiration is a sensitive test that Van be useful as an adjuct in the diagnosis of breast cancer.

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To determine if pre-operative combined chemoradiation therapy increase sphincter preservation in the treatment of low-lying rectal cancer, 15 patients were treated with pre-operative chemoradiation: 5FU plus mitomycin C plus 4500-5000 Rad concurrent external beam radiotherapy between Jan 1997 and Jan 1999. There were 10 men and 5 women (Mean age: 49 y) with the diagnosis of invasive resectable primary adenocarcinoma of distal rectum limited to pelvis. Median tumor distance from anal verge was 3.3 cm (Range 0-5 cm) and half of the patients were absolute candidate for abdominoperineal resection. After 4-6 weeks, all patients were undergone proctectomy and eventually sphincter preservation surgery was done on 9 patients with colonal anastomosis. Function of sphincter was excellent in 6 of them (66%) and good in 3 patients (33%). There was no case of incontinence. Complications of surgery were minimal: One case of stricture (10%) and one case of partial rupture of anastomosis (10%). Complete pathologic response was achieved on one patient (6.6%) and combined pre-operative chemoradiation has changed the plane of surgery from abdominoperineal resection to sphincter saving in 69.2% of patients.

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Many studies have shown the effectiveness of photorefractive keratectomy (PRK) in correction of vision in low and moderate Myopia. To evaluate the results of 193-nm exeimer laser photorefractive keratectomy for highly Myopic eyes, we reviewed refractive outcome of 43 eyes of 30 patients. Most eyes were treated with 1-step operation, using a 6 mm optical zone. 43 eyes were treated for Myopia, which were between -6.40 and -16.90 diopters. The mean pre-operative refraction was -9.50 D. All eyes were followed for at least 12 months. At 12tht month visit, 30.2% and 60.5% of eyes achieved correction within 1 and 2 D of attempted correction, respectively. At this time, 62.7% of eyes obtained 20/40 visual acuity or better uncorrected. At 1 year, 13% and 8% of eyes lost 3 and 4 lines of best-corrected visual acuity, respectively. Also 13% of eyes lost 2 lines. 12 months after PRK, 5 eyes developed corneal haze grade 2 and 2 eyes, grade 3 (0-5 scale). There was much undercorrection seen in this group compared with patients undergoing PRK for low and moderate Myopia. Photorefractive keratectomy for high Myopia, though effective, is not a safe and accurate procedure and is less predictable and stable than performing it for low and moderate Myopia.

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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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The most common cardiovascular surgery in the world and Iran as well, is CABG. One of the most important post-operative complication of this operation, that increase morbidity and mortality, is peri-operative MI. Incidence of peri-operative MI in CABG operations is between 2.5 to 5.5%. In this study we determined the prevalence and incremental risk factors of peri-operative MI in 300 consequative CABG operation, in the Imam Khomeini hospital. Diagnostic criteria for peri-operative MI were positive ECG finding (New and persistent Q.wave) and positive CPK-MB (Serum level>100 unit) at 3 different time: 1) Just before operation in the ward, 2) Just after operation in the ICU, 3) First post-operation day (At 8 A.M). In 300 patients positive ECG findings were seen in 7% (21 cases), positive CPK-MB was 12.7% (38 cases) and both of them were positive in 5% (15 cases). Therefore the prevalence of peri-operation MI was 5% (15 cases). Incremental risk factors in the patients with peri-operative MI were history of diabetes mellitus, hypertension, hyperlipidemia, left main disease, and endarterctomy. Therefore because of high incidence of peri-operative MI in CABG operation we should try to change the risk factors and decrease the prevalence of this complication.

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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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PTK (Phototherapeutic Keratectomy) is the use of laser in corneal diseases. We can replace PTK for many other invasive procedures. The objective of this study is the assessment of this procedure in several cases in our practice. This investigation was a retrospective study, which was conducted based on comparison of 11 eyes with corneal eschars, induced by recurrent corneal erosions, pterygium surgery, corneal dystrophies and trachoma from 1994 to 1995. The mean age of cases was 32 years. The mean augmentation rate in hyperopia after one month was 1.5 diopter, and after one year it was 1 diopter. Although in two cases, the cylinder more than one diopter was induced, the mean rate for it was not increased significantly. One patient with recurrent erosion, who had not replied to any treatment, had no any complaint during one year follow up. During the follow up procedure, there were no any cases of vision loss among the patients.

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The objective of this study was to examine the correlation between both midfollicular FSH/LH ratio and number(s) of follicles with ovarian hyperstimulation syndrome (OHSS) in patients with polycystic ovarian syndrome (PCOS). This was carried out in IVF unit at Mirza Kouchak Khan Hospital. To induce ovulation, PCOS patients were stimulated with gonadotropines. Fifty four PCOS patients with normal basal level of FSH, LH were studied prospectively. 22 patients did not receive HCG and stimulation cycle was canceled due to OHSS. 32 patients received HCG and stimulation cycle was completed. In all patients mid-follicular (day 8 of stimulation protocol) serum FSH/LH ratio was measured. On the same day number of ovarian follicles were also counted using vaginal sonography. In canceled cycles, LH on day 8 was shown to be low along with increased number of follicles. The risk of cycle cancelation raised twice with one increment of FSH/LH ratio. Also, with increase of one follicle the risk of cycle cancellation increased 1.3 times. To induce ovulation by gonadotropine stimulation in PCOS patients, the dose should be carefully monitored. Measuring FSH/LH ratio and number of follicles on day 8 of stimulation protocol are reliable guides in order to predict those patients prone to develop OHSS.

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Valvular and coronary artery disease are among the most important causes of disability and death in the world and Iran as well. Every year, half a million death because of these diseases is reported in United State. The incidence of degenerative and valvular diseases of heart is increasing. Considering the industrialization of our country, the incidence of these kind of problems are increasing as well. In this study, there is an attempt to recognize the causes of cardiac surgery. We conducted a retrospective study in 915 cardiac surgery patients (630 CABG and 285 valve replacement) from 1374 to 1377. In CABG patients, there were 46 cases of reoperation (78.3 percent male 21.7 percent female). The most reoperations for bleeding was less than 24 hours in 90.3 percent. In valvular patients the causes of reoperation were: A) Valvular complications (female/male=3/1), B) Non valvular complications (female/male=1/3). The most common nonvalvular complication was bleeding (66.6 percent). The most common valvular complication was bioprosthetic valve degeneration. The meantime between two operation in valvular complications was 11.8 years. In all cases (915) the incidence of bleeding was 3.8 percent, mediastinitis 0.8 percent, cardiac tamponade 0.8 percent and GI bleeding 0.5 percent.

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Valvular and coronary artery disease are among the most important causes of disability and death in the world and Iran as well. Every year, half a million death because of these diseases is reported in United State. The incidence of degenerative and valvular diseases of heart is increasing. Considering the industrialization of our country, the incidence of these kind of problems are increasing as well. In this study, there is an attempt to recognize the causes of cardiac surgery. We conducted a retrospective study in 915 cardiac surgery patients (630 CABG and 285 valve replacement) from 1374 to 1377. In CABG patients, there were 46 cases of reoperation (78.3 percent male 21.7 percent female). The most reoperations for bleeding was less than 24 hours in 90.3 percent. In valvular patients the causes of reoperation were: A) Valvular complications (female/male=3/1), B) Non valvular complications (female/male=1/3). The most common nonvalvular complication was bleeding (66.6 percent). The most common valvular complication was bioprosthetic valve degeneration. The meantime between two operation in valvular complications was 11.8 years. In all cases (915) the incidence of bleeding was 3.8 percent, mediastinitis 0.8 percent, cardiac tamponade 0.8 percent and GI bleeding 0.5 percent.

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Teratomas are emberyonal neoplasms derived from totipotential cells that contain tissue from at least two and more often three germ layers (ectoderm, enoderm and mesoderm) in the midline or paraxial location from brain to sacrococcygeal region. The primary objective of this study is to determine this rather common newborn and children teratomas in different areas of the body. The secondary objective is studying the incidence and its pathology and comparison of the data with literatures. In this research, 91 involved children in two hospital of the Tehran university of medical sciences from 1982 to 1999 has been studied. From 91 children 60 cases were sacrococcygeal teratoma, 14 cases were sacrococcygeal and pelvic (tot...74), 9 cases in ovaries, 3 cases in the retroperitoneum 2 cases oropharyngeal, 2 cases in testis and one case in neck area. From these cases, 71 were neonate, the rest were infant or were more than 2 years old. From the cases 88 underwent surgical treatment, 3 cases died because of surgical complications and 3 cases died before operation. In this study, 84 percent of teratomas were benign and 16 percent were malignant. The comparison of these findings with literature showed little differences.

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

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

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A 25-year-old woman with a history of five years of bilateral verrucous hyperkeratosis and darkening of both nipples and areolae is reported herein. The histopathology was suggestive of hyperkeratosis of areola and nipple. Hyperkeratosis of areola and nipple is a rare condition which is seen unilaterally or bilaterally in both sexes. Three types of hyperkeratosis of areola and nipple are described: type I is literally the extension of epidermal nevus, type II is associated with ichthyosis and acanthosis nigricans, and type III is an idiopathic or isolated nevoid form. The patient presented herein is a case of bilateral hyperkeratosis of areolae and nipples associated with benign acanthosis nigricans. In other words, the patient was suffering from type II hyperkeratosis of areolae and nipples.

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

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

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

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

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Introduction: Coronary artery disease (CAD) and its complications are the most prevalent etiology of mortality all over the world and diabetes mellitus (DM) is one of its risk factors. In this study prevalence of MI and unstable angina have been compared with different kinds of retinopathy and their severity.

Materials and methods: This study is a descriptive, cross sectional one that performed on 100 patients admitted in Imam, Farabi and Amir Alam Hospitals.

Results: Most important findings are as below: 1) Non-proliferative diabetic retinopathy (NPDR) are more prevalent than proliferative diabetic retinopathy (PDR), 41 Vs 17 cases, and 24 person were normal in MI population. And 12 persons had NPDR and 2 PDR and 5 normal in unstable angina. 2) Different diabetic retinopathy lesion were: 23 Venous dilation, 22 aneurysme, 18 hemorrhagic, 11 neovascularization, 10 macula edema, 6 retroretinal detachment, 2 gliosis. 3) on the point of presence or absence of diabetic retinopathy (DR), 72 percent had some kind of DR and 28 percent had nothing. Finally, in MI population 58 patients (70 percent) had DR and 24 patients (30 percent) didn't have any. In unstable angina 14 patients (77 percent) had diabetic retinopathy and 4 didn't have (23 percent).

Conclusion: Regarding the lack of facilities and shortcoming of necessary data, it was not possible to conduct a prospective investigation in this item, so the design and implementation of a prospective study based on enough cases and controls is strongly recommended.

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

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

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

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