Vol 54, No 1 (2016)

Published: 2016-02-01

Review Article(s)

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    There are many published articles which cover current and future challenges of epidemiology. However, up until now, most of them are written by developed world epidemiologists. Therefore, despite a common use of assumptions, they did not have the opportunity to discuss the different range of practical tasks and priorities away from developed countries. The topics covered are; facing poverty, non-democratic government that has links to developed countries, man-made and natural disasters, handling low-quality data and accessing it, and finally improving contribution to the world epidemiological knowledge for the 21st century.

Original Article(s)

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    The effects of combined radiotherapy (RT) and chemotherapy in the severity of cytogenetic alterations expressed as micronucleus (MN) in peripheral blood lymphocytes of patients treated for esophageal cancer was evaluated. To do this, blood was obtained from 23 and 15 esophageal cancer patients scheduled for chemo-radiotherapy and RT alone, respectively, before, during, and after treatment. Blood samples were cultured in RPMI-1640 complete medium containing 1% phytohemagglutinin and incubated in a CO2 incubator. Cytochalasin-B was added to the cultures at a final concentration of 5μg/ml. Finally, harvesting, slide making, and analysis were performed according to standard procedures. Results indicate that there was no significant difference between the frequencies of MN in lymphocytes of individuals before being treated with RT alone or chemo-radiotherapy. In the middle of treatment, (after 12 fractions of RT) the frequency of MN increased significantly compared with their concurrent pre-treatment samples in both groups (four-fold). However, the frequency of MN observed for RT patients was not significantly different with those received chemo- and radiotherapy. At the end of treatment, (after 24 fractions of radiotherapy) an increase in the MN frequency was observed for chemo-radiation group significantly higher than RT group (P=0.022). Mild increase in MN frequency in lymphocytes of patients receiving chemoradiation only after the completion of treatment course might be indicative of resistance induced by chemotherapeutics to the clastogenic effects of radiation. Therefore, using these agents repeatedly for cancer treatment in combination with radiation might not cause severe adverse biological effects in normal tissues.

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    Arginine vasopressin as a supplementary vasopressor in septic shock restores vascular tone and mean arterial pressure, meanwhile decreases dose and exposure time to catecholamines. The objective of this study was to evaluate the effect of vasopressin on lactate and lactate clearance as markers of tissue perfusion during septic shock. In this prospective, randomized, controlled trial, 30 patients with septic shock were enrolled in two groups. One group received norepinephrine infusion (titrated to reach the target MAP of ≥65 mm Hg) and the other group in addition to norepinephrine, received vasopressin at a constant rate of 0.03 u/min. Serum lactate levels were assessed at baseline, 24 and 48 hours after randomization. Lactate clearance was estimated for each patient at 24 and 48 hours. Venous lactate was measured in both groups. Despite a tendency toward higher venous lactate at 24 and 48 hours in the norepinephrine group (3.1 vs. 2.5, P=0.67 and 1.7 vs. 1.1, P=0.47), the conflict was not statistically significant among them. While lactate clearance after 24 hours was significantly higher in vasopressin treatment group (46% vs. 20%, respectively; P=0.048), the 48-hour lactate clearance did not differ from statistic viewpoints despite their clinical values (66% vs. 40%, P=0.17). Although lactate levels did not significantly differ between treatment groups, lactate clearance at 24 hours was significantly higher in vasopressin group. This may be the effect of vasopressin effect on microcirculation and tissue hypoperfusion or its catecholamine sparing effect.

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    Lysozyme is a bactericidal enzyme whose structure and functions change in diabetes. Chemical chaperones are small molecules including polyamines (e.g. spermine), amino acids (e.g. L-lysine) and polyols (e.g. glycerol). They can improve protein conformation in several stressful conditions such as glycation. In this study, the authors aimed to observe the effect of L-lysine as a chemical chaperone on structure and function of glycated lysozyme. In this study, in vitro and in vivo effects of L-lysine on lysozyme glycation were investigated. Lysozyme was incubated with glucose and/or L-lysine, followed by an investigation of its structure by electrophoresis, fluorescence spectroscopy, and circular dichroism spectroscopy and also assessment of its bactericidal activity against M. lysodeikticus. In the clinical trial, patients with type 2 diabetes mellitus (T2DM) were randomly divided into two groups of 25 (test and control). All patients received metformin and glibenclamide for a three months period. The test group was supplemented with 3 g/day of L-lysine. The quantity and activity of lysozyme and other parameters were then measured. Among the test group, L-lysine was found to reduce the advanced glycation end products (AGEs) in the sera of patients with T2DM and in vitro condition. This chemical chaperone reversed the alteration in lysozyme structure and function due to glycation and resulted in increased lysozyme activity. Structure and function of glycated lysozyme are significantly improved by l-lysine; therefore it can be considered an effective therapeutic supplementation in T2DM, decreasing the risk of infection in these patients.

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    Ischemia-reperfusion injury is a possible cause of testicular damage and infertility after testicular torsion and detorsion. The purpose of this study was to evaluate the effect of ghrelin on testicular Ischemia-reperfusion damage. A total of 30 adult male rats were selected for the study and divided randomly into 3 groups, each containing 10 rats. Animals in the testicular torsion and ghrelin treated groups were subjected to unilateral 720°counterclockwise testicular torsion for 1 hour, and then reperfusion was allowed after detorsion for 7 and 30 days. The ghrelin-treated group and the other two groups received intraperitoneally 40 nmol of ghrelin and physiological saline 15min before detorsion, respectively. The animals were sacrificed at the end of reperfusion times, and their testes were taken for later histopathological examination. The seminiferous tubules diameter, germinal epithelium height, as well as volume densities in testicular torsion / detorsion plus saline group, were significantly lesser versus control group, which clearly indicates an ischemia-reperfusion injury. Ghrelin treatment resulted in a partial increment in examined histological parameters on day 30 after reperfusion. Current results showed that ghrelin ameliorates the testicular ischemia-reperfusion damage.

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    Enterobacter asburiae (E. asburiae) is a facultative anaerobic, non-spore-forming gram-negative rod-shaped bacterium belonging to the family of Enterobacteriaceae. It is an opportunistic pathogen that its strains are isolated from a variety of clinical and environmental specimens. Since powdered infant formula milk (PIF) is not a sterile product, it is an excellent medium for bacterial growth. The aim of this study was to isolate and identify E. asburiae from PIF in the neonatal intensive care unit (NICU) and determine antimicrobial susceptibility patterns of this bacterium. A total 125 PIF samples were purchased from drug stores between June 2011 to March 2012. E. asburiae was isolated according to FDA method. For final confirmation, biochemical tests embedded in the API-20E system were used. The drug susceptibility test was performed using the disc diffusion method according to CLSI recommendations. Out of the 125 PIF samples investigated, 2 (1.6%) samples were positive for E. asburiae. All isolated strains were uniformly susceptible to aztreonam, cefotaxim, amikacin, streptomycin, nalidixic acid, meropenem, tetracycline, ceftazidime, and colistin. Variable susceptibility was seen to the some antimicrobial agents tested. Each country should categorize its own designed guidelines for the preparation and handling of PIF adapted to the local environment. Moreover, the pathogenesis of the E. asburiae in infants hospitalized in NICU and other groups such as immunosuppressed patients and HIV infected individuals is uncertain and requires further study.

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    Asymptomatic malaria (ASM) has been implicated in the development of hemolytic crisis in infected sickle cell anemia (SCA) patients worldwide. This study surveyed steady state SCA Nigerian patients for ASM to investigate the influence of malaria prevention behaviors and age on parasitaemia and multiplicity of infection (MOI). A total of 78 steady SCA patients aged 5 – 27 years on routine care at three health facilities in Lagos were investigated for ASM by light microscopy and PCR with a multiplicity of infection determined by genotyping block 2 of merozoite surface protein 1 (msp1) gene of Plasmodium falciparum (P. falciparum). Use of malaria prevention measures was captured using a semi-structured questionnaire. The prevalence rates of ASM (due to Pf only) by microscopy and PCR were found to be 27.3% and 47.4% respectively (P < 0.05) with a Mean + SEM parasite density of 2238.4 + 464.3 parasites/uL. Five distinct msp1 genotypes [K1 (2), MAD20 (2), RO33 (1)] were detected and significant (P<0.05) disparity in allele frequencies (K1, 91.8%, MAD20, 32.4%; RO33, 18.9%) was found. The overall MOI was 1.43 and 37.8% of infections were polyclonal (P<0.05). ASM was associated with non-use of preventive measures and occurred in 62.1% of SCA patients aged < 10y with lower MOI of 1.3 compared to 38.1% in older patients with a higher MOI of 1.5 (P<0.05). We conclude that PCR improved the diagnosis of ASM among Nigerian SCA patients with infections being of low complexity and associated with non-use of preventive interventions and R033 msp1 allele selection.

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    This study was conducted to find out the prevalence, viral load and co-infection of HBV and HCV infection among patients seeking to hospital care in Mashhad, Iran. A total of 402 samples (349 samples for HBV and 53 for HCV) were received and were screened for hepatitis B and C during 2004 to 2014. Viral loads of HBV DNA and HCV RNA were quantified by real-time PCR. Among 349 collected samples, 229 (65.61%) were positive for HBV DNA and 36 (67.92%) for HCV RNA. Among the ones positive for HBV DNA and HCV RNA, HCV was more prevalent (86.11% Vs 58%) ,in male patients, a higher incidence was attributed to HBV than HCV (34.42 Vs 13.88%%). The incidence of co-infection of HBV and HCV was in 5 (1.88%) patients. Association of age and load of HBV, HCV showed that higher marginal viral loads found to be more common in the age groups of upper 30 years old (P=0.064, P=0.079, respectively). The present study provides the preliminary information about high HCV and HBV prevalence. Findings from the current study will be helpful for the better management and control of viral hepatitis among patients looking for hospital care.

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    The objective of the study was to evaluate the position of patient education measuring knowledge, attitude, and practice (KAP) among health care workers (HCWs). It is also aimed to emphasize the need for a real position for patient education. This survey was performed among a group of HCWs in Iran. The scores had an acceptable level. However, nurses, females and younger people received higher scores. The staff was already aware of patient education necessity and considered it as the duty of all medical team. Often HCWs cannot include patient education in their routine due to time shortage, lack of staff’s financial motivation, fatigue, and loads of work, etc. There is still need for a real training in the educational curriculum. Additionally, the various HCWs–related obstacles should be taken into account.

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    Melasma is a common acquired skin disorder. While different treatments are currently being used, in many cases it is refractory to treatment. According to the effects of topical steroids in decreasing skin pigmentation, we studied the efficacy of this new method for treatment of melasma. A total of 42 women with facial melasma, admitted to the department of dermatology of Hamadan, were enrolled in the study. They were divided randomly into two groups (A and B), group A (case) received subepidermal triamcinolone injections with a dose of 4mg per cc and 5mm  intervals until complete blanching of melasma lesions, and group B (control) received Kligman's formula (hydroquinone5%, tretinoin 0.1%, and dexamethasone 0.1%). At the first visit, we completed the MASI score papers, and we repeated that at weeks 4 and 8 of the study. We followed them for two months, every two weeks. At each visit, side effects and clinical response to treatment were noted. A decrease in MASI was observed in both group (11.57 ± 4.33 vs 9.31 ± 3.75 at 4th week and vs 8.01 ± 3.1 at 8th week, P-value < 0.001 in group A, and 10.46 ± 5.61 vs 9.76 ± 5.21 at 4th week and vs 8.96 ± 4.96 at 8th week, P-value< 0.001 in group B). In comparison between 2 groups, response to treatment was much better in group A than group B (P-value<0.001). In comparison to topical treatments, based on these findings, triamcinolone microinjection is a new, safe and strong therapeutic method for treatment of melasma.

Case Report(s)

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    Wandering spleen is an uncommon entity in adults and has been described only rarely with sigmoid volvulus, that rarely affects children and adolescents. It is usually described in adults.Wandering spleen characterized by the abnormal location of the spleen, caused by incomplete fusion of the four primary splenic ligaments, allowing the spleen to be mobile within the abdomen.The wandering spleen can lead to torsion and subsequent splenic infarction or rupture. Clinical suspicion plus urgent investigation and intervention are important. We present a rare clinical case of acute abdomen due to torsion of wandering spleen and volvulus of sigmoid in a 14-year-old girl presented with painful periumbilical mass. Detorsion of sigmoid occurred while undergoing exploratory laparotomy and splenectomy was performed. The possibility of torsion and its complication like gastric, pancreas tail and colon volvulus should be kept in mind in the differential diagnosis of the acute abdomen to avoid serious complications.

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    Guillain-Barre syndrome is a neurologic disorder that may appear after infection or major surgery.  Guillian-Barre syndrome following cardiac surgery is rare and only based on case reports, and we review all of the published cases. A 52-year-old man after 5 months suffering from chest pain was referred to our hospital and underwent coronary artery bypass graft for 3 vessel disease. The patient was discharged without complication on the 5th postoperative day. He presented Guillain- Barre syndrome after 12 months. He has not completely recovered weakness of upper extremities grade 4/5 with atrophy of both upper extremities remains after 18 months. This disorder is similar to classic GBS. It is important to be alert to de novo autoimmune neurological disorders after cardiac surgery. These disorders are similar to classic autoimmune disease and treated with standard therapies.

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    Lumbar disc herniation (LDH) is the most common cause of sciatica and only in about 10% of the affected patients, surgical intervention is necessary. The side of the patient (the side of most prominent clinical complaints) is usually consistent with the side of imaging (the side with most prominent disc herniation on imaging scans). In this case series, we presented our experience in four cases with huge intracanal LDH that a mismatch between the patient’s side and the imaging’s side was present. In these cases, for deciding to do the operation, the physicians need to rely more on clinical findings, but for deciding the side of discectomy, imaging characteristic (imaging side) may be a more important criterion.