Vol 54, No 7 (2016)

Published: 2016-07-09

Study Protocol


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    The aim of this randomized clinical study was to investigate the effectiveness of acetaminophen 650 mg or liquefied ibuprofen 400 mg in pain control of orthodontic patients during separation with an elastic separator. A total of 101 patients with specific inclusion criteria were divided randomly into three groups (acetaminophen, liquefied ibuprofen, and placebo). They were instructed to take their drugs one hour before separator placement and every six hours afterward (five doses in total). They recorded their discomfort on visual analog scales immediately after separator placement, 2 hours later, 6 hours later, at bedtime, and 24 hours after separator placement. Repeated measure analysis of variance (ANOVA) was used to compare the mean pain scores between the three groups. Data were collected from 89 patients. The pain increased with time in all groups. Pain scores were statistically lower in the analgesic groups compared with the placebo group (P.value<0.001), but no statistically significant difference was found in mean pain scores between the two drug groups (acetaminophen and liquefied ibuprofen) (P.value=1). Acetaminophen and liquefied ibuprofen have similar potential in pain reduction during separation.

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    Nephrotoxicity is a major side effect of cisplatin, a widely used chemotherapy agent. Morphine and other opioids are also used extensively in different types of cancer for the clinical management of pain associated with local or metastatic neoplastic lesions. In addition to its analgesic effects, morphine has also been reported to possess potential immunomodulatory and antioxidant properties. Herein, we investigated the effects of morphine in a rat model of cisplatin-induced nephrotoxicity. Following administration of a single dose of cisplatin (5 mg/kg), animals received intraperitoneal injections of morphine (5 mg/kg/day) and/or naltrexone (20 mg/kg/day), an opioid antagonist, for 5 days. Cisplatin-induced nephrotoxicity was detected by a significant increase in plasma urea and creatinine levels in addition to alterations in kidney tissue morphology. Levels of TNF-α and IL-1β were significantly increased in the renal tissue in cisplatin group. Moreover, glutathione (GSH) concentration and superoxide dismutase activity were significantly reduced in renal tissue in cisplatin group compared with control animals. Treatment with morphine aggravated the deleterious effects of cisplatin at clinical, biochemical and histopathological levels; whereas naltrexone diminished the detrimental effects of morphine in animals receiving morphine and cisplatin. Morphine or naltrexone alone had no effect on the mentioned parameters. Our findings indicate that concomitant treatment with morphine might intensify cisplatin-induced renal damage in rats. These findings suggest that morphine and other opioids should be administered cautiously in patients receiving cisplatin chemotherapy.

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    Since the elderly population is increasing rapidly in developing countries which may decrease the physical activity and exercise and in turn could affect the elderly’s quality of life, this study aimed to investigate the effect of progressive muscle relaxation on the elderly’s quality of life in Iran. In a randomized clinical trial, participants were randomly divided into intervention and control groups. For the intervention group, muscular progressive relaxation was run three days per week for three months (totally 36 sessions). In relaxation, a patient contract a group of his/her muscles in each step and relaxes them after five seconds and finally loosens all muscles and takes five deep breaths. Each session lasts for 45 minutes. The instrument of data gathering consisted of questionnaires on individual’s demographic data and quality of life SF-36. After intervention, quality of life increased significantly in the patients undergoing muscular progressive relaxation and fatigue severity decreased significantly in the intervention group compared to prior to intervention. In addition, there was a statistically significant difference in mean score of physical performance, restricted activity after physical problem, energy, socially function, physical pain, overall hygiene, and quality of life between intervention and control groups. By implementing regular and continuous progressive muscle relaxation, quality of life could be increased in different dimensions in the elderly and the context could be provided to age healthily and enjoy higher health and autonomy. Therefore, all of the therapeutic staffs are recommended to implement this plan to promote the elderly’s quality of life.

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    To determine whether the medical Treatment of anal fissure can be an effective alternative for surgery Methods: Retrospectively, we randomly selected 190 Patients being treated for anal fissure between the years 2005-2010 in 3 equal groups: group A: Patients who received medical treatment with topical nitroglycerin, group B: Patient treated with topical diltiazem, and group C: Patients underwent surgery. The results were then correlated with the statistical program SPSS using chi-square test. Main complaints of the patients were first anal pain and then bleeding. The response to treatments for relieving pain was: 77% in A, 83% in B, and 98% in group C. Response of treatments for fissure healing, in order of groups A, B and C was: 74%, 83%, and 94%. Despite good response to medical treatment, surgical treatment was more effective and medical treatment of choice in patients who are willing to have surgery.

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    The collection of data within the primary health care facilities in Iran is essentially paper-based. It is focused on family’s health, monitoring of non-infectious and infectious diseases. Clearly due to the paper-based nature of the tasks, timely decision making at most can be difficult if not impossible. As part of an on-going electronic health record implementation project at Tehran University of Medical Sciences, for the first time in the region, based on a comprehensive pilot project, four urban healthcare facilities are connected to their headquarters and beyond, covering all aspects of primary health care, for the last four years. Without delving into the technical aspects of its software engineering processes, the progress of the implementation is reported, selection of summarized data is presented, and experience gained thus far are discussed. Four years passed and if time is any important reason to go by, then it is safe to accept that the software architecture and electronic health record structural model implemented are robust and yet extensible. Aims and duration of a pilot study should be clearly defined prior to start and managed till its completion. Resistance to change and particularly to information technology, apart from its technical aspects, is also based on human factors.

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    Sjogren syndrome (SS) can occur alone, primary Sjogren syndrome, or in association with other rheumatic diseases, secondary Sjogren syndrome (sSS), such as Rheumatoid arthritis (RA). The occurrence of Sjogren syndrome with RA makes it course worse and increases high morbidity and mortality of RA. In this exploratory study we aim to determine the prevalence of sSS (diagnosed based on the revised version of American–European consensus Group Classification Criteria: AUCG-criteria), sicca symptoms (dry eye, dry mouth), positive autoantibody tests (Anti RO or Anti-LA antibodies), UWSFR (Unstimulated Whole Salivary Flow Rate), Schirmer and Lissamine test. In this cross-sectional study, eighty three consecutive RA patients (according to American College of Rheumatology criteria 1987) who were visited at rheumatology clinic of Razi General Hospital located in the north of Iran entered into our study. Our exclusion criteria was a positive history of past head and neck radiation treatment, Hepatitis C infection, acquired immunodeficiency disease (AIDS), pre-existing lymphoma, sarcoidosis, graft versus host disease, use of anticholinergic drugs (including neuroleptics, antidepressants, antihypertensive and parasympatholytics). They examined with UWSFR by a rheumatologist and with Schirmer test and Lissamine test by an ophthalmologist. Participants were 90.4% female with the mean age 48.3±13 years. Duration of RA was in 36.1% less than 5 years, in 22.9% 5-10 years, in 12.1% 11-15 years and in 28.9% more than 15 years. Our results demonstrated that the prevalence of sSS was 5.9% (CI:0.6%-10.5%). Number of 27.7% of RA patients positively responded to at least one question about sicca symptoms. Among objective tests, only Positive UWSFR and Lissamine test were significantly more common in RA patients with sSS in comparison to ones without sSS (P<0.001, P=0.01 respectively). In RA patients, we found a linear trend between sicca symptoms and aging (P=0.02). In patients with sicca symptoms, among tests that used for assessing decrease in saliva or tear production, only USWFR significantly more common (P=0.01). In conclusion: In RA population in North of Iran prevalence of sSS was less than 10%. In them, a significant linear trend existed between aging and sicca symptoms. Among objective tests of AUCG-criteria (except for lip biopsy that was not performed in the current study) only UWSFR and Lissamine test were significantly more common in patients with sSS in comparison ones without it.

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    Flushing is a condition with episodic attacks of redness of the skin with a sensation of warmth or burning, this disease causes emotional and functional problems in patients. There is various treatments for this condition; one of them is the use of botulinum toxin-A (BTA). In this prospective pilot study we studied the effect of Botulinum toxin-A (BTA) effect on DLQI of patients with facial flushing, we compared the DLQI before and after treatment. The number of 24 women with facial flushing admitted to the department of dermatology of Hamadan Farshchian Hospital, with the age range of 18 to 60 was enrolled in the study. Patients completed Dermatology Quality of life Index questionnaire before and one month after treatment. In our study 1 unit of BTA was injected intracutaneously per square cm in both sides of cheeks, to a total dose of 30 units per session. All of 24 patients completed the study. The mean age was 37.79±13.13. In all patients, DLQI decreased, and in two months follow up, the mean of DLQI improved from 8.08±1.17 to 4.5±1.21 (P.value<0.005). Based on this study BTA is an effective and safe treatment for facial flushing.

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    Acquired azole resistance in opportunistic fungi causes severe clinical problems in immunosuppressed individuals. This study investigated the molecular mechanisms of azole resistance in clinical isolates of Candida glabrata. Six unmatched strains were obtained from an epidemiological survey of candidiasis in immunocompromised hosts that included azole and amphotericin B susceptible and azole resistant clinical isolates. Candida glabrata CBS 138 was used as reference strain. Antifungal susceptibility testing of clinical isolates was evaluated using Clinical and Laboratory Standards Institute (CLSI) methods. Complementary DNA-amplified fragment length polymorphism (cDNA-AFLP) technology, semi-quantitative RT-PCR, and sequencing were employed for identification of potential genes involved in azole resistance. Candida glabrata Candida drug resistance 1 (CgCDR1) and Candida glabrata Candida drug resistance 2 (CgCDR2) genes, which encode for multidrug transporters, were found to be upregulated in azole-resistant isolates (≥2-fold). Fatty acid activator 1 (FAA1) gene, belonging to Acyl-CoA synthetases, showed expression in resistant isolates ≥2-fold that of the susceptible isolates and the reference strain. This study revealed overexpression of the CgCDR1, CgCDR2, and FAA1 genes affecting biological pathways, small hydrophobic compounds transport, and lipid metabolism in the resistant clinical C.glabrata isolates.

Case Report(s)

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    We present a case of caustic ingestion by a 1.5-year-old boy. The caustic agent was drain opener which is a strong alkaline substance. Children in Iran and many other countries are still exposed to not “child proof” (child resistant packaging) toxic substance containers. Ingestion of caustic agents may lead to necrosis, perforation, and strictures. Substances that are ingested more frequently are liquid alkali material which causes severe, deep liquefaction necrosis. Common signs and symptoms of caustic agents are vomiting, drooling, refusal to drink, oral burns, stridor, hematemesis, dyspnea, dysphagia and abdominal pain. Even if no oropharyngeal lesion is seen, a significant esophageal injury which can lead to perforation and stricture cannot be ruled out. If abdominal pain or rigidity, substernal, chest or back pain exists, visceral perforation should be considered. The first thing to be checked is airway assessment. A lot of patients should be admitted to intensive care unit, and endoscopic evaluation, surgical intervention, long-term hospitalization, and worsening quality of life or among the complications. Preventive measures especially at the country level and approving proper legislation for obligating the related industries to produce child proof containers for house hold toxic products are the urgent measures to be followed by all of us.

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    We present a woman referred with underlying non-Hodgkin's lymphoma (NHL) masquerading clinically with Guillain-Barré syndrome (GBS) like syndrome. At first evaluation, chest CT-Scan along with brain and whole spine MRI were normal. Electrodiagnostic studies were in favor of acute generalized polyradiculoneuropathy. Laboratory evaluation revealed hypoglycorrhachia. She treated with plasmapheresis after two weeks; she was discharged from hospital, but neurological recovery was not complete. After 6 months, she came back with acute onset of weakness in lower limbs, back pain, fever and urinary incontinence. Pinprick and light touch complete sensory loss was found beneath umbilicus. Thoracic MRI with contrast revealed a dorsal epidural mass extending smoothly from T8 to T12 (10 cm) with spinal cord compression. She underwent urgent laminectomy for spinal cord decompression. Histological examination revealed small round cell tumor suggestive of malignant T-cell type lymphoma. In cases with Guillain-Barré syndrome presentation, systemic hematologic disorders such as non-Hodgkin's lymphoma should be considered as one of the differential diagnosis of underlying disease.

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    A 40-year-old male patient with suicidal ingestion of one tablet of aluminium phosphide was referred to the department of toxicology emergency of Baharloo Hospital, Tehran, Iran. The garlic odor was smelled from the patient and abdominal pain and continuous vomiting as well as agitation and heartburn were the first signs and symptoms. Systolic and diastolic blood pressures at the arrival time were 95 and 67 mmHg, respectively. Gastric lavage with potassium permanganate (1:10,000), and 2 vials of sodium bicarbonate through a nasogastric tube was started for the patient and the management was continued with free intravenous infusion of 1 liter of NaCl 0.9% serum plus NaHCO3, hydrocortisone acetate (200 mg), calcium gluconate (1 g) and magnesium sulfate (1 g). Regarding the large intravenous fluid therapy and vasoconstrictor administering (norepinephrine started by 5 µg/min and continued till 15 µg/min), there were no signs of response and the systolic blood pressure was 49 mmHg. At this time, hydroxyethyl starch (HES) (6% hetastarch 600/0.75 in 0.9% sodium chloride) with a dose of 600 cc in 6 hours was started for the patient. At the end of therapy with HES, the patient was stable with systolic and diastolic blood pressure of 110 and 77 mmHg, respectively. He was discharged on the 6th day after the psychological consultation, with normal clinical and paraclinical examinations. This is the first report of using HES in the management of AlP poisoning and its benefit to survive the patient.