A randomized, prospective, double-blind, placebo-controlled trial of the effect of topical diltiazem on posthaemorrhoidectomy pain

AIM

Spasm of the internal anal sphincter plays a role in haemorrhoidal disease and may be a source of anal pain after haemorrhoid surgery. In this study, we investigated the effect of topical diltiazem (DTZ) on postoperative pain following Milligan-Morgan haemorrhoidectomy.

METHOD

After haemorrhoidectomy, 33 patients were randomly assigned to receive DTZ ointment (2%; n = 16) or a placebo ointment (n = 17). Ointments were applied to the perianal region three times daily for 7 days. A Visual Analogue Scale was used to assess postoperative pain. The primary end-point was reduction in postoperative pain.

RESULTS

Patients using the DTZ cream had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week, and total and daily narcotic analgesic use was higher in the placebo group. There were no differences in morbidity between the two groups.

CONCLUSION

Perianal application of DTZ cream after haemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial, with no increase in associated morbidity.

Contributing risk factors for orthopedic device related infections in sina hospital, tehran, iran

BACKGROUND

In spite of decreasing incidence of orthopedic device-related infections to 1%, nowadays, device-related infection still remains a diagnostic, therapeutic and cost-related problem. The objective of this study is to evaluate the contributing risk factors for orthopedic device-related infections in Sina Hospital, Tehran, Iran.

METHODS

Three hundred and thirty patients who underwent orthopedic device implantation from 2002-2006 were enrolled; among them, 110 patients were complicated with infection. Descriptive and logistic regression analyses were performed to determine the risk factors for device related infections.

RESULTS

Patients with infection were older compared to those without infection. The Staphylococcus aureus was the commonest organism. A correlation was observed between wound infection and external fixation, an underlying health condition, and addiction which were independent risk factors for a device related infection.

CONCLUSION

Orthopedic device-related infection puts a great financial burden on patients and hospital resources and could lead to morbidity and mortality in patients. So, appropriate pre and postoperative wound care for dirty wounds, especially when external fixators are used, and in patients with poor conditions or addiction should be done with more caution.

Changes in liver enzymes and bilirubin after coronary artery bypass grafting using acute normovolemic hemodilution

The aim of this clinical case-control trial was to compare postoperative early jaundice and transient liver damage in patients receiving autologous or homologous blood transfusion in coronary artery bypass grafting (CABG) surgery. In this randomized clinical trial 40 patients scheduled for CABG were randomly allocated to ANH (Acute Normovolemic Hemodilution) group or control group. Both groups were compared in relation to bilirubin (total and direct), alanine transferase (ALT), aspartate transferase (AST) and alkaline phosphatase (ALP) in the first 24 hours. There was a significant difference in bilirubin (total and direct) change between groups (both p<0.00001). However, there were no changes in ALT, AST and ALP compared with baseline values, and there were no differences in the values between the two study groups. Our randomized, double blinded case control study suggested that patients receiving autologous blood (ANH group) following CABG had significantly lower bilirubin levels compared to patients who received homologous transfusion. However larger studies with more patients are needed to confirm the results.

Trends of diabetes according to body mass index levels in Iran: results of the national Surveys of Risk Factors of Non-Communicable Diseases (1999-2007)

AIMS

The prevalence of diabetes is increasing dramatically worldwide. Less is known about whether this trend is similar among obese and lean individuals.

METHODS

We analysed the data sets of three cross-sectional national surveys in adults aged 25-64 years: the National Health Survey-1999 (n=21,576), and the national Surveys of Risk Factors of Non-Communicable Diseases (SuRFNCD)-2005 (n=70,981) and SuRFNCD-2007 (n=4233). Diagnosed diabetes was ascertained, and height and weight were measured in all surveys. In SuRFNCD-2005 and SuRFNCD-2007, fasting plasma glucose was used to identify subjects with newly diagnosed diabetes (≥ 7 mmol/l) and impaired fasting glucose (5.6 - 6.9 mmol/l) among individuals not reporting diabetes.

RESULTS

The prevalence of diagnosed diabetes (after adjustment for age, sex and residential area) was 2.5, 4.0 and 4.6% in 1999, 2005 and 2007, respectively. The total prevalence of diabetes increased from 7.7% in 2005 to 8.7% in 2007, about half of which was attributed to newly diagnosed disease (in both surveys). The prevalence of diabetes increased in all categories of obesity, with the most evident trend being among subjects with body mass index <25 kg/m(2) .

CONCLUSIONS

The prevalence of diabetes among Iranian adults has increased more than 1.8-fold in a period of only 8 years since 1999. This is the first report from Iran, and urgent measures need to be taken in order to prevent the progression and worsening of the problem and emergence of its undesired consequences.

Short-term effect of changes in smoking behaviour on emphysema quantification by CT

BACKGROUND

The effect of smoking cessation and smoking relapse on lung density was studied using low-dose CT.

METHODS

Spiral, multidetector, low-dose CT was performed on 726 current and former smokers (>20 pack-years) recruited from a cancer screening trial. Lung density was quantified by calculating the 15th percentile density (PD15), which was adjusted to predicted total lung capacity. Data were analysed by linear regression models.

RESULTS

At baseline mean PD15 was 45 g/l in former smokers (n=178) and 55 g/l in current smokers (n=548), representing a difference of 10 g/l (p<0.001). After smoking cessation (n=77) PD15 decreased by 6.2 g/l (p<0.001) in the first year, and by a further 3.6 g/l (p<0.001) in the second year, after which no further change could be detected. Moreover, the first year after relapse to smoking (n=18) PD15 increased by 3.7 g/l (p=0.02).

CONCLUSIONS

Current smoking status has a major influence on lung density assessed by CT, and the difference in lung density between current and former smokers observed in cross-sectional studies corresponds closely to the change in lung density seen in the years after smoking cessation. Current smoking status, and time since cessation or relapse, should be taken into account when assessing the severity of diseases such as emphysema by CT lung density.

Sequence variants at CHRNB3-CHRNA6 and CYP2A6 affect smoking behavior

Smoking is a common risk factor for many diseases. We conducted genome-wide association meta-analyses for the number of cigarettes smoked per day (CPD) in smokers (n = 31,266) and smoking initiation (n = 46,481) using samples from the ENGAGE Consortium. In a second stage, we tested selected SNPs with in silico replication in the Tobacco and Genetics (TAG) and Glaxo Smith Kline (Ox-GSK) consortia cohorts (n = 45,691 smokers) and assessed some of those in a third sample of European ancestry (n = 9,040). Variants in three genomic regions associated with CPD (P < 5 x 10(-8)), including previously identified SNPs at 15q25 represented by rs1051730[A] (effect size = 0.80 CPD, P = 2.4 x 10(-69)), and SNPs at 19q13 and 8p11, represented by rs4105144[C] (effect size = 0.39 CPD, P = 2.2 x 10(-12)) and rs6474412-T (effect size = 0.29 CPD, P = 1.4 x 10(-8)), respectively. Among the genes at the two newly associated loci are genes encoding nicotine-metabolizing enzymes (CYP2A6 and CYP2B6) and nicotinic acetylcholine receptor subunits (CHRNB3 and CHRNA6), all of which have been highlighted in previous studies of smoking and nicotine dependence. Nominal associations with lung cancer were observed at both 8p11 (rs6474412[T], odds ratio (OR) = 1.09, P = 0.04) and 19q13 (rs4105144[C], OR = 1.12, P = 0.0006).

Impact of slow and delayed graft function on kidney graft survival between various subgroups among renal transplant patients

OBJECTIVE

Renal allografts with excellent graft function show good long-term outcomes, while grafts with delayed function have been associated with poor long-term survivals, although few reports have analyzed outcomes among these groups. We compared first-week postoperative graft function among renal transplant patients to analyze the impact of slow graft function (SGF) and delayed graft function (DGF) on graft survival.

MATERIALS AND METHODS

Renal transplantations were performed from 362 unrelated, 46 related, and 163 deceased donors. Kidney transplant patients were divided into 3 groups according to their initial graft function. First-week dialyzed patients formed the DGF group. Nondialyzed patients were divided into a SGF or an excellent graft function (EGF) cohort according to whether the serum creatinine at day 7 was higher vs lower than 2.5 mg/dL, respectively.

RESULTS

Of the 570 renal transplant recipients, DGF was observed in 39 patients (6.8%), SGF in 64 (11.2%), and EGF in 467 (81.8%). There was no significant difference in SGF vs DGF between patients who received kidneys from unrelated vs related living or deceased donors. Graft survival was worse among the DGF than the SGF or EGF patients, with no significant difference between the last 2 groups. The 6-month graft survivals were 74%, 93%, and 96%; the 3-year graft survivals were 70%, 88%, and 90%, respectively (P < .001).

CONCLUSIONS

We observed a similar impact of EGF and SGF on kidney graft survival. Kidney transplant recipients who developed DGF showed worse graft survival than those with EGF or SGF.

Efficacy of partially hydrolyzed guar gum-added oral rehydration solution in the treatment of severe cholera in adults

BACKGROUND

Partially hydrolyzed guar gum (PHGG) is a water-soluble fiber if added to oral rehydration solution (ORS) and undergoes fermentation in the colon liberating short chain fatty acids (SCFAs). SCFAs potentiate the effect of ORS, reducing the severity of diarrhea.

AIM

To examine the effect of PHGG-added ORS in reducing the stool output and duration of diarrhea in adult cholera.

METHODS

195 male patients were studied in a randomized controlled trial: (a) 65 received ORS + 25 g PHGG; (b) 65 received ORS + 50 g PHGG, and (c) 65 received ORS alone (control). Major outcomes were stool weight and duration of diarrhea.

RESULTS

No significant differences were found in mean +/- SD stool weight (g/kg b.w.) during the first and second 24 h. In the subgroup analysis (excluding very high purging patients, stool weight in the first 24 h was >10 kg), the stool weight (g/kg b.w.) was significantly reduced in the first 24 h in both groups receiving PHGG (PHGG 25 g, 136 +/- 68 vs. PHGG 50 g, 144 +/- 49 vs. control, 176 +/- 43, p = 0.01).

CONCLUSION

PHGG-added ORS might have a beneficial effect in moderately purging adult cholera. However, further studies are warranted to confirm the preliminary findings.

Insulin resistance is an independent correlate of increased urine albumin excretion: a cross-sectional study in Iranian Type 2 diabetic patients

AIMS

To assess the association of insulin resistance with increased urinary albumin excretion (UAE) in a cohort of Iranian Type 2 diabetic patients.

METHODS

Three hundred and sixty-one men and 472 women with Type 2 diabetes were enrolled from three different outpatient clinics (Tehran, Iran) during the period 2005-2008. Patients with obstructive uropathy, severe heart failure, liver disease, cancer, autoimmune disease and macroalbuminuria were not included. Microalbuminuria (MA; defined as UAE >or= 30 mg/day) was found in 242 (29.1%) patients; 591 (70.9%) subjects had normoalbuminuria (UAE < 30 mg/day). Insulin resistance was assessed using homeostasis model assessment of insulin resistance (HOMA-IR).

RESULTS

HOMA-IR index values were higher in subjects with MA than those with normoalbuminuria (P < 0.00001). Adjusted values (for age, sex and duration of diabetes) of UAE and HOMA-IR were 11.81 +/- 7.51 (mg/day) and 3.30 +/- 2.21 in normoalbuminuric and 75.36 +/- 55.57 (mg/day) and 4.98 +/- 3.22 in the MA group, respectively (P < 0.00001 for all). Multiple regression analysis showed that UAE was predicted by HOMA-IR, independently of age, duration of diagnosed diabetes, triglycerides, waist circumference, metabolic control, blood pressure and related treatments (P < 0.00001). When patients were categorized into quartiles of HOMA-IR, those of the fourth quartile (i.e. the most insulin resistant) were at a higher risk of increased UAE than other quartiles [odds ratio (OR) 3.7 (95% confidence intervals 2.7-6.2)].

CONCLUSIONS

In Iranian Type 2 diabetic patients, albuminuria was strongly associated with insulin resistance. HOMA-IR is an independent predictor of UAE.

Day-care management of severe and very severe pneumonia, without associated co-morbidities such as severe malnutrition, in an urban health clinic in Dhaka, Bangladesh

BACKGROUND

Management of severe and very severe pneumonia in children relies on hospital-based treatment, but practical barriers often prevent children in areas with the highest rates from receiving hospital care.

OBJECTIVE

To develop and prospectively evaluate a day-care clinic approach, which provided antibiotics, feeding and supportive care during the day with continued care provided by parents at home, as an effective alternative to hospitalisation.

METHODS

Children aged 2-59 months with severe or very severe pneumonia without associated co-morbidities, denied admission to hospital because of lack of beds, were enrolled at Radda Clinic, Dhaka and received antibiotics, feeding and supportive care from 08:00 to 17:00 every day, while mothers were educated on continuation of care at home during the night.

RESULTS

From June 2003 to May 2005, 251 children were enrolled. Severe and very severe pneumonia was present in 189 (75%) and 62 (25%) children, respectively, and 143 (57%) were hypoxaemic with a mean (SD) oxygen saturation of 93 (4)%, which increased to 98 (3)% on oxygen therapy. The mean (SD) day-care period was 7 (2) days. Successful management was possible in 234 children (93% (95% CI 89% to 96%)), but 11 (4.4% (95% CI 2.5% to 7.7%)) had to be referred to hospital, and six (2.4% (95% CI 1.1% to 5.1%)) discontinued treatment. There were no deaths during the day-care study period; however, four children (1.6% (95% CI 0.6% to 4.0%)) died during the 3-month follow-up period, and 11 (4.4% (95% CI 2.5% to 7.7%)) required hospital admission.

CONCLUSION

Severe and very severe pneumonia in children without associated co-morbidities such as severe malnutrition can be successfully managed at day-care clinics.

Uterine myometrium as a cell patch as an alternative graft for transplantation to infarcted cardiac myocardium: a preliminary study

PURPOSE

Currently, only a small fraction of patients are able to receive reperfusion therapy for myocardial infarctions. We hypothesize that myometrial cell patch transplantation could be an alternative approach for the treatment of myocardial infarction.

DESIGN

We performed a preliminary study to determine the feasibility of this novel therapeutic approach in a rabbit model.

PROCEDURES

Six adult female New Zealand rabbits were used. Myocardial infarction was induced by left anterior descending artery ligation. A segment of uterus was removed via a laparotomy incision, and this uterine segment was transplanted as an autologous graft over the infarcted myocardium, which was then reinforced by greater omentum. Statistical methods and outcome measures: Hemodynamic measurements and histological studies.

MAIN FINDINGS

All uterine myometrial patches survived in the test animals. Fluoroscopic hemodynamic measurements were made for ejection fractions at 8 weeks after the application of the uterine patch. Histological study demonstrated well-healed myometrial-myocardium junctions with minimum scar tissue. Angiogenesis occurred in the transplanted myometrium. Connexin 43 expression was demonstrated in the transplanted patches.

CONCLUSION

Our noncontrolled preliminary rabbit experiments indicate that patches of uterine myometrium reinforced by greater omentum can be used as autologous transplant therapy for infracted myocardium. This is an innovative technique that could lead to future treatment for individuals who may suffer from an infarcted myocardium and may not be eligible for traditional reperfusion therapy.

Weight preserving image registration for monitoring disease progression in lung CT

We present a new image registration based method for monitoring regional disease progression in longitudinal image studies of lung disease. A free-form image registration technique is used to match a baseline 3D CT lung scan onto a following scan. Areas with lower intensity in the following scan compared with intensities in the deformed baseline image indicate local loss of lung tissue that is associated with progression of emphysema. To account for differences in lung intensity owing to differences in the inspiration level in the two scans rather than disease progression, we propose to adjust the density of lung tissue with respect to local expansion or compression such that the total weight of the lungs is preserved during deformation. Our method provides a good estimation of regional destruction of lung tissue for subjects with a significant difference in inspiration level between CT scans and may result in a more sensitive measure of disease progression than standard quantitative CT measures.

Day-care management of children with severe malnutrition in an urban health clinic in Dhaka, Bangladesh

Management of severely malnourished children with associated complications relies on hospital-based treatment. Implementation of a standardized protocol at the Dhaka Hospital, ICDDR,B reduced case fatality approximately 50%. We developed and prospectively evaluated a day-care clinic approach that provided antibiotics, micronutrients and feeding during the day with continued care by parents at home at night as an alternative to hospitalization. Severely malnourished children aged 6-23 months denied admission to hospital were enrolled at Radda Clinic, Dhaka and received protocolized management with antibiotics, micronutrients and milk-based diet from 8:00 am to 5:00 pm each day, while mothers were educated on continuation of care at home. They were transitioned to the day-care nutrition rehabilitation (NR) unit of Radda Clinic following resolution of acute illness, received NR diet (Khichuri, halwa and milk-based) daily until children attained 80% weight-for-length. From February 2001 to November 2003, 264 children were enrolled; 52% were boys and 78%, 21% and 1% had marasmus, marasmus-kwashiorkor and kwashiorkor, respectively. Only 13% had severe malnutrition alone while 35% had pneumonia, 35% had diarrhea and 17% had both pneumonia and diarrhea. The mean (SD) duration of acute and NR phases were 8 (4) and 14 (13) days, respectively. Children gained weight [mean (SD) g/kg day] more rapidly during acute 10 (7) than NR phase 6 (5). Successful management was possible in 82% (95% CI 77-86%) children, 12% discontinued treatment and 6% referred to hospitals. Only one child died during NR phase. Severely malnourished children can be successfully managed at existing day-care clinics using a protocolized approach.

Efficacy and tolerability of racecadotril in the treatment of cholera in adults: a double blind, randomised, controlled clinical trial

BACKGROUND

The enkephalins, endogenous opiate substances, act as neurotransmitters along the entire digestive tract where they elicit intestinal antisecretory activity without affecting intestinal transit time or motility. Racecadotril, through inhibition of enkephalinase, reinforces the physiological activity of endogenous enkephalins and, therefore, shows intestinal antisecretory activity.

AIM

We conducted the study to determine the role of racecadotril as an adjunct to the standard treatment of cholera in adults.

METHODS

The study was a double blind, randomised, placebo controlled clinical trial involving 110 adult male cholera patients who received either racecadotril or placebo in addition to standard cholera treatment. The major outcome measures (stool output, oral rehydration solution (ORS) intake, requirements for unscheduled intravenous fluid infusion, and duration of diarrhoea) were compared between the groups.

RESULTS

Of 110 patients enrolled, 54 received racecadotril and 56 received placebo. Admission clinical characteristics were comparable between the groups. There was no significant difference in (mean (SD)) total stool output (racecadotril v placebo 315 (228) v 280 (156) g/kg), total ORS intake (390 (264) v 369 (240) ml/kg), or duration of diarrhoea (35 (15) v 32 (13) hours) between the groups. Clinical success, defined as resolution of diarrhoea within 72 hours of initiation of study intervention, was similar in both groups (racecadotril v placebo 96% v 89%). The number of patients receiving unscheduled intravenous infusions was not significantly different between the groups (racecadotril v placebo 22% v 14%). No drug related adverse effect was noted.

CONCLUSION

The study demonstrated that racecadotril therapy, although found to be safe, does not provide additional benefit in the treatment of severe cholera in adults.

Factors involved in the re-emergence of malaria in borderline of Iran, Armenia, Azerbaijan and Turkey

The borderline of Iran with Azerbaijan, Armenia and Turkey had been considered a malaria free region. However, in 1991, after the independence of the southern countries of the former Soviet Union, a new threat of malaria importation emerged from those countries into Iran, which was affected by serious epidemics of Plasmodium vivax malaria. Various factors can affect malaria resurgence in this region, such as socioeconomic conditions, especially the displacement of massive populations from war-stricken zones in the Republic of Azerbaijan. Accordingly, in some parts of West-Azerbaijan, East-Azerbaijan, Ardebile and Gilan provinces of Iran, several malaria foci were observed. Construction of dams, people traveling from neighboring countries to Iran, urbanization, irrigation projects, lack of malaria vector control, shortage of drug supplies are also major factors in malaria outbreaks in the region. An investigation was carried out on the bionomics of the main malaria vectors in the region. The result showed that Anopheles sacharovi plays an important role in malaria transmission and An. maculipennis and An. superpictus can be secondary vectors. Larvae were found in slow flowing water and channels with water plants. They were more abundant in June. The parity rate of blood-fed females was high in May. An. sacharovi is active from May to October with two peaks of activity, which occur in August and October. The population of this species is higher in animal shelters with a zoophicity of 95%. About 90% of bites took place in the second half of the night. A CDC light trap can also catch this species. Susceptibility testing using the WHO-recommended diagnostic doses of insecticides, revealed that this species is resistant to DDT and dieldrin, but susceptible to malathion, fenitrothion, propoxur, bendiocarb, lambdacyhalothrin, permethrin, cyfluthrin, etofenprox and deltamethrin.

Hyperimmune bovine colostrum in the treatment of shigellosis in children: a double-blind, randomized, controlled trial

Immunological approaches have been considered as an alternative therapeutic option for the treatment of enteric infections over the past few years. Hyperimmune bovine colostrum (HBC) is a potentially innovative immunological option in the management of shigellosis together with traditional antibiotic therapy. Children aged 1-12 y with a history of bloody mucoid diarrhoea of less than 5 d duration were enrolled after their stool specimen was found to be positive for Shigella dysenteriae type I antigen by a rapid diagnostic fluorescent antibody staining test. They were randomized to receive either HBC containing very high titres of antibody against S. dysenteriae type I antigen or bovine colostrum (BC) without any antibody. The study group received 100 ml of HBC three times a day orally for 3 d and control group received BC. Children also received pivmecillinam in a dose of 50 mg kg(-1) d(-1) in four divided doses orally for 5 d. Admission characteristics of the 34 children in the HBC group and 35 in the BC group were comparable. No significant differences were observed in duration of diarrhoea, fever, anorexia, abdominal pain, tenesmus, stool frequency or visible blood in the stool between the groups. Two (6%) children in the study and five (14%) in the control group remained stool culture positive for S. dysenteriae type 1, even after 5 d of sensitive antimicrobial therapy.

CONCLUSION

The results indicate that HBC as an adjuvant is unable to show any beneficial effect in reducing the stool frequency, duration or severity of childhood shigellosis due to S. dysenteriae type I infection.

Effect of an energy-dense diet on the clinical course of acute shigellosis in undernourished children

To date there have been few reports on the impact of dietary intervention on the clinical course of acute shigellosis. Current management of acute shigellosis is primarily focused on antibiotic therapy with less emphasis on nutritional management. In a randomised clinical trial, we examined the role of an energy-dense diet on the clinical outcome in malnourished children with acute dysentery due to shigellosis. Seventy-five children aged 12--48 months with acute dysentery randomly received either a milk--cereal formula with an energy density of 4960 kJ/l (test group) or a milk-cereal formula with energy of 2480 kJ/l (control group) for 10 d in hospital. In both milk-cereal formulas, protein provided 11 % energy. In addition, the standard hospital diet was offered to all children and all children received an appropriate antibiotic for 5 d. The mean food intakes (g/kg per d) in the test and control groups were: 112 (SE 2.28) and 116 (SE 3.48) on day 1; 118 (SE 2.72) and 107 (SE 3.13) on day 5; 120 (SE 2.25) and 100 (SE 3.83) on day 10. The mean energy intakes (kJ/kg per d) in the test and control groups respectively were: 622 (SE 13.2) and 315 (SE 11.3) on day 1; 655 (SE 15.1) and 311 (SE 7.98) on day 5; 672 (SE 14.7) and 294 (SE 11.1) on day 10. The food and energy intakes were mostly from the milk-cereal diet. There was no difference between two groups in resolution of fever, dysenteric (bloody and or mucoid) stools, stool frequency and tenesmus. However, vomiting was more frequently observed among the test-group children during the first 5 d of intervention (67 % v. 41 %, There was an increase in the mean weight-for-age (%) in the test group compared with the control group after the 10 d of dietary intervention (6.2 (SE 0.6) v. 2.7 (SE 0.4), In addition, resolution of rectal prolapse was better (26 % v. 8 %, in the test group v. control group after 5 d, and 13 % v. 6 %, after 10 d of dietary intervention. Supplementation with a high-energy diet does not have any adverse effect on clinical course of acute shigellosis and reduces the incidence of rectal prolapse in malnourished children.