Ahmadreza Dehpour, PharmD, PhD
Vol 57, No 6 (2019)
Rheumatoid arthritis (RA) is the most common autoimmune inflammatory disease of joints among adults. Regulatory T cells (Treg) control immune responses in this illness. Through the expression of FoxP3, a Treg transcription factor, Vitamin D keeps autoimmune diseases in check. Yet, the molecular mechanism of FoxP3 expression by vitamin D is not well-inspected. It may influence FoxP3 expression via epigenetic changes. This study aimed to investigate the correlation between plasma levels of vitamin D and the demethylation of the TSDR region in Foxp3 promoter in patients with RA. Twenty untreated RA patients and 41 healthy controls participated in this study. Plasma levels of 25-OH vitamin D were measured by competitive ELISA method. The demethylation of TSDR regions in Foxp3 gene was also assessed using the quantitative Methylation Specific PCR (qMSP) method. The demethylation of TSDR region was significantly lower in RA patients compared with healthy controls (P=0.006). Vitamin D plasma levels were significantly higher in RA patients rather than healthy people (P=0.034). There was no statistically significant correlation between vitamin D plasma levels and demethylation of TSDR region. As expected, epigenetic alternation showed considerable difference between RA patients and healthy controls, but about vitamin D correlation with methylation modification, more studies are needed.
In this study, we aimed to compare the efficacy of laryngeal mask airway (LMA) versus endotracheal tube in the early rescue surfactant administration in premature neonates with respiratory distress syndrome (RDS). This randomized, clinical trial evaluated 60 premature neonates with RDS. Numbered envelopes randomly assigned 30 neonates to the intervention group to receive 2.5 ml/kg/dose surfactant (Curosurf) via LMA and 30 to the control group to receive 2.5 ml/kg/dose surfactant via an endotracheal tube using the INSURE technique, exclusively during the first two hours of life. There were no differences in the requirement for mechanical ventilation (23.3% vs. 20%, P=0.75), requirement for second dose surfactant (13.3% vs. 6.7%, P=0.67), bronchopulmonary dysplasia (13.3% vs. 6.7%, P=0.67), pneumothorax (6.7% vs. 0%, P=0.49), and intraventricular hemorrhage (10% vs. 10%, P=1) between neonates who received surfactant via LMA versus those who received surfactant via endotracheal tube. LMA seems to be an effective and less invasive alternative to endotracheal intubation for surfactant delivery in premature neonates with RDS.
Colonoscopy is a painful, embarrassing and short-term procedure that needs temporary sedation and rapid recovery. The aim of this study was to compare the sedation and analgesia eﬀect and hemodynamic changes due to bolus intravenous injection of dexmedetomidine and ketamine during elective colonoscopy. This clinical trial was conducted on 70 patients aged 20-70 years, candidates for elective colonoscopy, who randomly divided into two equal groups. For all patients 0.03 mg/kg midazolam 10 min before procedure was injected. Fentanyl 1 µ/kg was administrated in both groups 5 min before procedure, and one min before colonoscopy. K group received 0.5 mg/kg ketamine and D group received 1 µ/kg dexmedetomidine. Then, the normal saline infusion was used as maintenance. Fentanyl 25-50 µg was prescribed as the rescue dose if needed during the procedure. Hemodynamic changes, sedation level during procedure, patients and colonoscopists satisfaction were recorded in recovery. The mean heart rate and mean blood pressure was significantly less in the dexmedetomidine group than in the ketamine group. All of the patients in the ketamine group were deep to moderately sedated during colonoscopy, and the amount of fentanyl required in this group is much less than dexmedetomidine group (68.02±25.63 vs 91.45±38.62 µg P-0.003). In terms of satisfaction, only 42% of patients in the dexmedetomidine group were completely satisfied with colonoscopy, while 65% of Ketamine group had complete satisfaction with colonoscopy (P=0.001). The level of colonoscopist satisfaction during colonoscopy was similar in both group, and complete satisfaction was 43%. In patients undergoing colonoscopy, IV bolus injection of dexmedetomidine in comparison with ketamine provides less patients satisfactory and low level of sedation with supplemental multiple doses of fentanyl during the procedure.
The birth of a neonate with chromosomal abnormalities, e.g. Down syndrome has very serious problems for family, society, and for the neonate itself, and therefore prenatal evaluation is imperative in determining the fate of the fetus. This research aimed to assess the association and accuracy of amniocentesis with first-trimester combined screening. In this study, specimens from 1066 cases were analyzed for free Beta human chorionic gonadotropin, pregnancy-associated plasma protein A, along with nuchal translucency and nasal bone ultrasonography from October 2013 till November 2014. Upon observing positive screening, mothers underwent amniocentesis. Finally the amniocentesis results were compared with that of first-trimester screening. Our results determined a direct relation between the high age of the mother and gravidity with P of 0.001 and 0.020 with positive first-trimester screening. Our study attained a 92% accuracy rate of amniocentesis due to one case of mosaicism of trisomy 21, that was not diagnosed, because it was not requested by physician. Only 12 (17.1%) cases out of 70 (mothers with positive first-trimester screening) showed positive amniocentesis, which had a significant relationship with chromosomal abnormality. First trimester combined screening has very high accuracy (94.6%) in prediction of genetic abnormalities. The probability of positive first-trimester screening is directly influenced by number of factors, including the mother age and gravidity. Amniocentesis is necessary for all of mothers with positive first-trimester screening and will almost always detect chromosomal abnormalities.
Acute poisoning is nowadays a common medical emergency. The important point about admitting patients with acute poisoning is its timely and early diagnosis. However, the rate of consistency between clinical diagnosis and autopsy of patients with acute lethal poisoning has not been investigated broadly. The goal of this study was to compare the clinical symptoms of poisoned deceased patients through autopsy and toxicology at Tehran’s Medico-Legal Organization. A cross-sectional study was conducted on all the admitted poisoning cases at Baharloo Hospital in 2014 to 2015 who passed away and were referred to Kahrizak Autopsy Hall. Through investigating the medical records of the Hospital and Autopsy Hall, the researcher examined and compared the existent files. The collected data were entered into SPSS 16. Data were analyzed using Cohen’s kappa coefficient. In all, 98 people who had died from acute poisoning were investigated. The most common causes of poisoning were drugs (49%), followed by pesticides (39%). The least common cause of poisoning was alcohol (1%). The most common poisonous drugs were opioids. The most common causes of death based on hospital records and autopsy results were rice tablets and high-dose opioid poisoning. Using Cohen’s kappa coefficient, the rate of agreement between the causes of death in hospital records and autopsy results was estimated at 0.744. Bearing in mind the consistency of clinical diagnosis with postmortem autopsy results, we may begin life-saving management of patients of acute poisoning in the shortest possible time.
This study was conducted to determine the effect of purgative Manna and clofibrate on unconjugated hyperbilirubinemia of term neonates. In this randomized clinical trial study, sixty neonates suffering from unconjugated hyperbilirubinemia were evaluated. The neonates were divided into three groups using balanced block randomization. Group A (control group-received only phototherapy), group B (intervention group-received purgative Manna and phototherapy) and group C (intervention group-received clofibrate and phototherapy). After the intervention, the amount of serum bilirubin reduction was compared between groups. There was no significant difference among group A, B, and C in terms of serum bilirubin reduction in 24, 48 and 72 hours after starting the intervention (P>0.05). The hospital stays in the control group was significantly longer than the intervention groups (P<0.05). No side effects were observed related to using purgative Mienna and clofibrate. The present study showed that prescribing of purgative Manna and clofibrate has no effect on reduction of serum bilirubin level in term neonates with unconjugated hyperbilirubinemia. Thus, it seems that the administration of these drugs is not necessary. Further studies in this regard are recommended.
The pathophysiology of coronary arteries slow flow phenomenon is related to the microvascular and endothelial disorder. The role of copper and selenium in the development of microvascular and endothelial disorders, as well as atherosclerosis, has been proven in previous studies. The aim of this study was to evaluate the serum copper and selenium concentrations in patient with coronary slow flow phenomenon to find a probable relationship between them. In this study, 125 patients who referred to Ghaem Hospital in Mashhad for angiography were selected based on entry and exit criteria. Patients were divided into 5 groups according to the results of angiography. Blood samples of these patients were evaluated about the levels of copper and selenium. Finally the correlation between these levels and the intensity of coronary arteries slow flow (based on TIMI scores) was evaluated. In the present study, serum selenium and copper concentrations did not show a significant correlation with the intensity of coronary arteries slow flow (P>0.05). In the present study, no significant correlation was found between copper and selenium serum concentrations and coronary arteries slow flow based on TIMI. Further studies are recommended to investigate this association.
Hepatitis B virus infection (HBV) is a leading cause of increased mortality and morbidity in renal transplant subjects. The purpose of this project was to investigate the prevalence of HBV in patients with renal transplant and compare it with the general population in Duhok city, Iraq. Then, the impact of HBV infection on graft function was evaluated. A total of 560 renal transplant subjects and 2975 volunteers were recruited in this study. All subjects were examined for HB surface antigen (HBsAg) positivity. Then, all HBsAg positive subjects were tested for viral load, alanine transaminase (ALT), aspartate aminotransferase (AST), serum creatinine and HBV profile. All HBsAg positive renal transplant subjects received treatment and were followed up for 24 months. It was found that 6/560 (1.1%) of the renal transplant subjects were HBsAg positive while 30/2975 (1.09%) of the volunteers were positive for HBsAg (P>0.05). After initiation of medications, viral load became undetected within 6 months of treatment. Serum creatinine levels were normal at the end of the study. No major side effects were recorded. The prevalence of HBV in renal transplant subjects was similar to the prevalence in general population. HBV infection did not show any negative effect on the graft function. Further study is needed with a larger sample size to explore the long term effect of the infection on graft functionality.
There are limited data on the lesion volume changes following spinal cord injury (SCI). In this study, a meta-analysis was performed to evaluate the volume size changes of the injured spinal cord over time among animal studies in traumatic SCI. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive electronic search of English literature of PubMed and EMBASE databases from 1946 to 2015 concerning the time-dependent changes in the volume of the spinal cord following mechanical traumatic SCI. A hand-search was also performed for non-interventional, non-molecular, and non-review studies. Quality appraisal, data extraction, qualitative and quantitative analyses were performed afterward. Of 11,561 articles yielded from electronic search, 49 articles were assessed for eligibility after reviewing of titles, abstracts, and references. Ultimately, 11 articles were eligible for quantitative synthesis. The ratio of lesion volume to spinal cord total volume increased over time. Avascularity appeared in spinal cord 4 hours after injury. During the first week, the spinal subarachnoid space decreased. The hemorrhagic lesion size peaked in 1 week and decreased thereafter. Significant loss of gray and white matter occurred from day 3 with a slower progression of white matter damage. Changes of lesion extent over time is critical in pathophysiologic processes after SCI. Early avascularity, rapid loss of gray matter, slow progression of white matter damage, and late cavitation are the pathophysiologic key points of SCI, which could be helpful in choosing the proper intervention on a timely basis.
We aimed to present a patient with phytobezoar causing small bowel obstruction after Roux-en-Y gastric bypass. Thirty-year-old woman with a history of prior Roux-en-Y gastric bypass due to morbid obesity three years ago presented with colicky abdominal pain, distention, nausea, vomiting, and obstipation. Initial abdominal X-ray showed various distended small bowel loops with air-fluid levels. The patient was taken to operation room for laparoscopic exploration, and a phytobezoar was found in distal jejunum. The bezoar was fragmented and flushed through cecum. The patient tolerated the surgery and her symptoms relieved without complication. Moreover, she received dietary consultation in order to prevent future recurrences. Small bowel obstruction in a patient with prior abdominal surgery is mainly caused due to adhesions, stenosis of anastomosis and hernias. An uncommon cause for obstruction is bezoar formation. The majority of patients with bezoars have a history of gastric surgery. Diagnostic imaging is not always helpful, and surgical exploration is sometimes required for diagnosis. Treatment is mainly surgical, but conservative medical treatment is also reported to be helpful. Apart from removal of bezoar, a dietary consultation is required to avoid eating habits leading to bezoar formation. Bariatric surgery is becoming more common; thus its complications are becoming more common as well. Majority of patients with bezoars have a prior history of gastric surgery. Therefore it is important to maintain a high level of suspicion for timely diagnosis of bezoars in patients with prior history of bariatric surgery, especially Roux-en-Y gastric bypass.
Pulmonary sequestration is a relatively rare congenital malformation characterized by an abnormal mass of dysplastic lung tissue. This mass is separated from the bronchopulmonary tree and vascularized by an aberrant systemic artery. Pulmonary sequestration common symptoms are chest pain, persistent dry cough, shortness of breath, hemoptysis, and recurrent attractions of pneumonia. We report a case of a 45-year-old man who suffered from recurrent cough for one year and bleeding with pain in the left chest. He was eventually diagnosed with intralobar pulmonary sequestration. Surgical removal of the sequestration generally has good outcomes.
As dissemination of Tuberculosis (TB) to soft tissue is not a usual finding, sometimes it is not considered for differential diagnosis and, if so, is overlooked by most health care professionals. Although rare, TB should be considered in the differential diagnosis of cysts of the thigh, especially in endemic areas. We report the case of an 80-year-old female presented with cyst with purulent discharge in her lateral left thigh that was persistent to other surgical and antibiotic treatments. Polymerase chain reaction (PCR) showed positive results for TB. Anti-tubercular therapy had promising results. Our case serves to highlight the importance of considering a reactivated TB infection in individuals with chronic discharge, especially if symptoms are not classic or fail to respond to conventional therapy. Histological study and MRI are useful tools to guide diagnosis, with confirmation provided by PCR.