Hepatocyte growth factor may accelerate healing in chronic leg ulcers: a pilot study

BACKGROUND

Hepatocyte growth factor (HGF) is a heparin-binding protein with mitogenic, motogenic and morphogenic activities for various cell types. The regenerative properties of HGF have been the object of several animal and in vitro studies in recent years.

OBJECTIVE

To investigate the physiological and therapeutic effects of HGF on chronic leg ulcers.

METHODS

HGF in gel form was locally applied, once daily for 7 days, to 15 of 19 chronic leg ulcers in 11 elderly patients. All patients had previously been treated by conventional methods and their leg ulcers had been in stable conditions for between 1 and 14 years. Any signs of allergy, discomfort or pain were reported daily. Microcirculation perfusion in the ulcers, compared to the intact contiguous skin, was determined by laser Doppler at the beginning of the study, after 1 week and again after 3 months (in seven patients). Ulcer size and characteristics were also documented.

RESULTS

It was observed that microcirculatory perfusion, which might reflect the angiogenic effect of HGF, was statistically significantly correlated (r = 0.94, p < 0.002) to ulcer area reduction in the treated ulcers. Excellent (84-100% area reduction) or partial healing (58-59%) was seen in eight out of 11 patients. No control group was included in this pilot study, which must be completed by proper control studies.

CONCLUSION

This study suggests that HGF may heal chronic leg ulcers, possibly by improving the microcirculation. Proper control studies need to be performed.

Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes

OBJECTIVES

To compare the Conventional, Specified, Expanded and Combined Apgar scoring systems in predicting birth asphyxia and the adverse early neurologic outcomes.

METHODS

This prospective cohort study was conducted on 464 admitted neonates. In the delivery room, after delivery the umbilical cord was double clamped and a blood samples was obtained from the umbilical artery for blood gas analysis, meanwhile on the 1- , 5- and 10- minutes Conventional, Specified, Expanded, and Combined Apgar scores were recorded. Then the neonates were followed and intracranial ultrasound imaging was performed, and the following information were recorded: the occurrence of birth asphyxia, hypoxic Ischemic Encephalopathy (HIE), intraventricular hemorrhage (IVH), and neonatal seizure.

RESULTS

The Combined-Apgar score had the highest sensitivity (97%) and specificity (99%) in predicting birth asphyxia, followed by the Specified-Apgar score that was also highly sensitive (95%) and specific (97%). The Expanded-Apgar score was highly specific (95%) but not sensitive (67%) and the Conventional-Apgar score had the lowest sensitivity (81%) and low specificity (81%) in predicting birth asphyxia. When adjusted for gestational age, only the low 5-minute Combined-Apgar score was independently associated with the occurrence of HIE (B = 1.61, P = 0.02) and IVH (B = 2.8, P = 0.01).

CONCLUSIONS

The newly proposed Combined-Apgar score is highly sensitive and specific in predicting birth asphyxia and also is a good predictor of the occurrence of HIE and IVH in asphyxiated neonates.

Candida glabrata prosthesis infection following pyelonephritis and septicaemia

Candida glabrata is a well-known cause of lower urinary tract infections. Systemic infections caused by this organism are less common, but have increased dramatically in recent years. Prosthesis infection caused by C. glabrata is extremely rare. We report a case of prosthesis failure due to C. glabrata 5 y after candidaemia and pyelonephritis caused by this organism. The same C. glabrata strain was isolated from both infections, as confirmed by the random amplified polymorphic DNA (RAPD) method.

Incidence and risk factors of neonatal hypothermia at referral hospitals in Tehran, Islamic Republic of Iran

To identify the incidence rate and risk factors of neonatal hypothermia at referral hospitals in Tehran, Islamic Republic of Iran, 900 neonates were randomly selected. Body temperature was measured repeatedly at different time points after birth. More than 50% became hypothermic soon after birth. Multiple regression analysis showed that low birth weight, low gestational age environmental temperature, low Apgar score, multiple pregnancy and receiving cardiopulmonary resuscitation were significantly associated with hypothermia. These findings suggested that there is an urgent need to sensitize and educate all levels of staff dealing with neonates in our country.

Incidence of cleft lip and palate in Tehran

The purpose of this study was to assess the epidemiology and some of the possible risk factors causing oral cleft in Tehran. The study was a 7-year retrospective study from March 1998 to March 2005. Twenty-five live births with cleft lip and/or palate (CL+/-P) were born between 20 March 1998 and 20 March 2005 from the total of 11,651 live births in a maternity hospital in Tehran. After recognizing the child as a cleft patient, previous and following children born were recognized as a noncleft sample. Cleft and noncleft samples were compared for variables such as gender, mother's age, parity, consanguineous marriage and infant's weight, and then analyzed with Chi-square. The overall incidence was 2.14 per 1000 live births. CL+ P is more prevalent, which was 52% and the least incidence was for "only cleft lip'' patients, which was 12%. This study reveals that the incidence of oral clefts in Tehran is higher than many other countries. Consanguineous marriage and low birth weight in cleft group were significant statistically from those of noncleft group.

Hepatocyte growth factor levels in cerebrospinal fluid: a comparison between acute bacterial and nonbacterial meningitis

The organotrophic functions of the hepatocyte growth factor (HGF) have been the subject of several studies. In the more recent studies, this function has been reported in the brain. In the present study, we have measured the levels of HGF in cerebrospinal fluid (CSF) and sera from 78 patients divided into 6 different groups according to central nervous system (CNS) infection and control. Quantitative measurements of HGF in the CSF and serum were performed by an enzyme-linked immunosorbent assay. Elevated values of CSF HGF were found in the patients with acute bacterial/probable bacterial meningitis (P<.001), compared with nonbacterial CNS infections and facial palsy, as well as with a control group without signs of CNS involvement. The values of CSF HGF were not correlated to blood-brain-barrier disruption in the groups. These observations might indicate an intrathecal production of HGF in acute bacterial/probable bacterial meningitis.

Phenobarbital versus morphine in the management of neonatal abstinence syndrome, a randomized control trial

BACKGROUNDS

Evaluating the efficacy of the loading and tapering dose of Phenobarbital versus oral Morphine in the management of NAS.

METHODS

This randomized, open-label, controlled trial was conducted on 60 neonates born to illicit drugs dependent mothers at Vali-Asr and Akbar-Abadi hospitals, Tehran, Iran, who exhibited NAS requiring medical therapy. The neonates were randomized to receive either: Oral Morphine Sulfate or a loading dose of Phenobarbital followed by a tapering dose. The duration of treatment required for NAS resolution, the total hospital stay and the requirement for additional second line treatment were compared between the treatment groups.

RESULTS

The Mean ± Standard Deviation for the duration of treatment required for the resolution of NAS was 8.5 ± 5 days in the Morphine group and 8.5 ± 4 days in the Phenobarbital group (P = 0.9). The duration of total hospital stay was 12.6 ± 5.6 days in the Morphine group and 12.5 ± 5.3 days in the Phenobarbital group (P = 0.7). 3.3 % in the Morphine group versus 6.6 % in the Phenobarbital group required adjunctive treatment (P = 0.5).

CONCLUSIONS

There were no significant differences in the duration of treatment, duration of hospital stay, and the requirement for adjunctive treatment, between the neonates with NAS who received Morphine Sulfate and neonates who received a loading and tapering dose of Phenobarbital.

TRIAL REGISTRATION

This study is registered at the Iranian Registry of Clinical Trials ( www.irct.ir ) which is a Primary Registry in the WHO Registry Network. (Registration Number =  IRCT201406239568N8 ).

Molecular analysis of Malassezia species isolated from hospitalized neonates

Malassezia species are a part of the skin microflora of neonates. Under certain circumstances, they can cause diseases ranging from simple pustulosis to lifethreatening fungemia in newborn infants. Little information is available about the epidemiology of Malassezia species in neonates. In the present study, we successfully isolated Malassezia yeasts from 68.7% of hospitalized neonates. Using the polymerase chain reaction-restriction fragment length polymorphism method (PCR-RFPL), M. furfur (88.06%) was identified as the most isolated species, followed in frequency by M. globosa (10.48%), M. obtusa (0.73%), and M. slooffiae (0.73%). Among the variables studied, only a longer stay in the ward resulted in a higher colonization rate. Using multiple logistic regression, only the type of hospital and ward had some effects on the colonization rate. Our results supported the hypothesis that neonates acquire Malassezia flora through direct contact with their mothers or hospital personnel.

Comparison of the Combined versus Conventional Apgar Scores in Predicting Adverse Neonatal Outcomes

Objectives

Assessing the value of the Combined-Apgar score in predicting neonatal mortality and morbidity compared to the Conventional-Apgar.

Methods

This prospective cohort study evaluated 942 neonates (166 very preterm, 233 near term, and 543 term) admitted to a tertiary referral hospital. At 1- and 5-minutes after delivery, the Conventional and Combined Apgar scores were recorded. The neonates were followed, and the following information was recorded: the occurrence of severe hyperbilirubinemia requiring medical intervention, the requirement for mechanical ventilation, the occurrence of intraventricular hemorrhage (IVH), and neonatal mortality.

Results

Before adjusting for the potential confounders, a low Conventional (<7) or Combined (<10) Apgar score at 5-minutes was associated with adverse neonatal outcomes. However, after adjustment for the gestational age, birth weight and the requirement for neonatal resuscitation in the delivery room, a depressed 5-minute Conventional-Apgar score lost its significant associations with all the measured adverse outcomes; after the adjustments, a low 5-minute Combined-Apgar score remained significantly associated with the requirement for mechanical ventilation (OR,18.61; 95%CI,6.75–51.29), IVH (OR,4.8; 95%CI,1.91–12.01), and neonatal mortality (OR,20.22; 95%CI,4.22–96.88). Additionally, using Receiver Operating Characteristics (ROC) curves, the area under the curve was higher for the Combined-Apgar than the Conventional-Apgar for the prediction of neonatal mortality and the measured morbidities among all the admitted neonates and their gestational age subgroups.

Conclusions

The newly proposed Combined-Apgar score can be a good predictor of neonatal mortality and morbidity in the admitted neonates, regardless of their gestational age and resuscitation status. It is also superior to the Conventional-Apgar in predicting adverse neonatal outcomes in very preterm, near term and term neonates.

Exhaled breath condensate and serum levels of hepatocyte growth factor in pneumonia

Hepatocyte growth factor (HGF) is a protein produced by mesenchymal cells in many organs, which can stimulate epithelial growth. An enhanced production and concentration of HGF is observed after injuries. The lung is one of the major sources of HGF. By cooling exhaled air, a condensate is formed containing molecules from bronchi and alveoli. In order to investigate HGF-concentration and time course in pneumonia, paired serum and exhaled breath condensate was collected from 10 patients with pneumonia, 10 patients with non-respiratory infections and 11 healthy controls. The concentration of HGF was measured by an immunoassay kit. In the acute phase HGF-levels in breath condensate and serum were significantly higher in the patients with pneumonia compared to the control groups. Similar concentrations in breath condensate were seen in healthy controls and in patients with non-respiratory infections. In the patients with pneumonia a decrease in serum HGF was seen already after 4-7 days while HGF values in breath condensate remained elevated even after 4-6 weeks. These results might imply local product on of HGF in the lungs and a long repair and healing process after pneumonia.

High serum hepatocyte growth factor levels in the acute stage of community-acquired infectious diseases

Acute serum levels of hepatocyte growth factor (HGF) were studied in 6 clinical groups with (i) gastroenteritis, (ii) skin and soft tissue infection, (iii) urinary tract infection, (iv) septicemia, (v) influenza, and (vi) chronic hepatitis C in comparison with a normal control group using an enzyme-linked immunosorbent assay method. We found that serum HGF levels were significantly higher in patients with acute infectious diseases (p < 0.0001) compared to patients with chronic viral hepatitis and healthy controls. Serum HGF and CRP levels were correlated significantly (r=0.65, p < 10(-7)). We conclude that serum HGF levels are elevated in patients with acute infectious diseases.

Hepatocyte growth factor (HGF) in patients with pneumonia: a comparison between survivors and non-survivors

Hepatocyte growth factor (HGF) is a multifunctional growth factor. After lung injury HGF is secreted in the lung and promotes reconstruction of the damaged organ. We measured, retrospectively, the serum HGF concentrations collected on admission in 55 patients with bacterial pneumonia, using an enzyme-linked immunosorbent assay (ELISA). The patients were divided into 3 groups: Group 1 was survivors with normal liver function (n = 14), Group 2 was survivors with abnormal liver function (n = 31) and Group 3 was non-survivors (n = 10). Median concentrations of HGF were elevated in Groups 1 and 2; and no statistically significant difference between these 2 groups was found. Group 3 had a median HGF concentration within the reference range, significantly lower than both Group 1 and Group 2. In addition LDH was significantly higher in non-survivors as compared with survivors. The combination of LDH and HGF concentrations discriminated between survivors and non-survivors (sensitivity 0.90 and specificity 0.96). The results support the hypothesis that increased levels of HGF might be a natural part of the healing process of lung injury, irrespective of liver involvement, and that patients without increased HGF levels, especially those with concomitant liver function impairment, may have a poor prognosis.

Comparison of Complications and Efficacy of NIPPV and Nasal CPAP in Preterm Infants With RDS

Background:

Respiratory distress syndrome (RDS) is one of the most common diseases in neonates admitted to NICU. For this important cause of morbidity and mortality in preterm neonates, several treatment methods have been used. To date, non-invasive methods are preferred due to fewer complications.

Objectives:

Herein, two non-invasive methods of ventilation support are compared: NCPAP vs. NIPPV.

Patients and Methods:

This is a randomized clinical trial. Premature neonates with less than 34 weeks gestation, suffering from RDS entered the study, including 151 newborns admitted to Vali-Asr NICU during 2012-2013. Most of these patients received surfactant as early rescue via INSURE method and then randomly divided into two NCPAP (73 neonates) and NIPPV (78 neonates) groups. Both early and late complications are compared including extubation failure, hospital length of stay, GI perforation, apnea, intraventricular hemorrhage (IVH) and mortality rate.

Results:

The need for re-intubation was 6% in NIPPV vs. 17.6% in NCPAP group, which was statistically significant (P = 0.031). The length of hospital stay was 23.92 ± 13.5 vs. 32.61 ± 21.07 days in NIPPV and NCPAP groups, respectively (P = 0.002). Chronic lung disease (CLD) was reported to be 4% in NCPAP and 0% in NIPPV groups (P = 0.035). The most common complication occurred in both groups was traumatization of nasal skin and mucosa, all of which fully recovered. Gastrointestinal perforation was not reported in either group.

Conclusions:

This study reveals the hospital length of stay, re-intubation and BPD rates are significantly declined in neonates receiving NIPPV as the treatment for RDS.

Hepatocyte growth factor in patients with coronary artery disease and its relation to periodontal condition

Hepatocyte growth factor (HGF) is an angiogenic, cardioprotective factor important for tissue and vascular repair. High levels of HGF are associated with chronic inflammatory diseases, such as coronary artery disease (CAD) and periodontitis, and are suggested as a marker of the ongoing atherosclerotic event in patients with CAD. Periodontal disease is more prevalent among patients with CAD than among healthy people. Recent studies indicate a reduced biological activity of HGF in different chronic inflammatory conditions. Biologically active HGF has high affinity to heparan sulfate proteoglycan (HSPG) on cell-membrane and extracellular matrix. The aim of the study was to investigate the serum concentration and the biological activity of HGF with ELISA and surface plasmon resonance (SPR), respectively, before and at various time points after percutaneous coronary intervention (PCI) in patients with CAD, and to examine the relationship with periodontal condition. The periodontal status of the CAD patients was examined, and the presence of P. gingivalis in periodontal pockets was analyzed with PCR. The HGF concentration was significantly higher, at all time-points, in patients with CAD compared to the age-matched controls (P< 0.001), but was independent of periodontal status. The HGF concentration and the affinity to HSPG adversely fluctuated over time, and the biological activity increased one month after intervention in patients without periodontitis. We conclude that elevated concentration of HGF but with reduced biological activity might indicate a chronic inflammatory profile in patients with CAD and periodontitis.

Serum thyroid stimulating hormone, total and free T4 during the neonatal period: Establishing regional reference intervals

CONTEXT

Congenital hypothyroidism (CH), the most common etiology of preventable mental retardation in children, is estimated to be more prevalent among Asian population.

AIMS

Since thyroid function tests (TFTs) varied among different ages and geographical regions, in this study, the neonatal thyroid reference intervals in a healthy neonatal population is determined for the first time in Iran.

SETTINGS AND DESIGN

A cross-sectional study performed on 246 healthy term newborns aged between 2 days and 1 month.

MATERIALS AND METHODS

Blood samples were obtained by venipuncture from all subjects. The median, 2.5(th), 5(th), 95(th), and 97.5(th) percentile of serum thyroid-stimulating hormone (TSH), as well as the total and free T4 were assessed among different age groups.

STATISTICAL ANALYSIS USED

Predictive Analytics Software (PASW Statistics 18) was used for the analysis.

RESULTS

Serum TSH, total and free T4 concentration peaked in 5(th) to 7(th) days of life, continued over 2 weeks, then decreased and started reaching to adult reference range. A significant negative correlation between age and serum concentration of TSH (P = 0.02), total T4 (P = 0.01) and free T4 (P = 0.01) was found.

CONCLUSION

This study yielded fairly different values for TFTs compared compared values found in other countries and also different from values reported for laboratory kits we used. These differences were assumed to be due to variations in ethnicity, age, and laboratory methods used. Due to the lack of international standardization, conducting multicenter studies helps in making a more precise evaluation of thyroid status in neonates.

Association of SP-B gene 9306 A/G polymorphism (rs7316) and risk of RDS

BACKGROUND

Respiratory distress syndrome (RDS) is a severe pulmonary disease predominantly affects preterm newborns. Polymorphisms of surfactant-protein genes have been mostly evaluated as the candidate contributors in genetics of RDS. However the results are divers in different studies. We aimed at investigating the association of surfactant protein B (SPB) gene 9306 A/G polymorphism (rs7316) with RDS development.

METHOD

Three hundred and eighty newborns with gestational age of less than 34 weeks were included in a multicenter case-control study. Respiratory distress (RD) was scored according to Downes' scoring system. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method was used for genotyping.

RESULT

One hundred and eighty-four neonates showed RDS and 196 did not. Gestational age (GA) was significantly lower in the RDS group compared with the controls. AA genotype and A allele were found more frequently in the RDS group than the controls (96.2% versus 63.8% and 98.1% versus 80.6%, respectively) (p =.0001).

CONCLUSIONS

This is the first report of association of SFTPB rs7316 polymorphism with RDS development in Iranian newborns. The current study suggests that GA <28-weeks is the most important factor in predisposition to RDS. Genetic background in terms of SP-B gene might be involved in predisposition to RDS in premature neonates.

Assessment of Hearing Loss by OAE in Asphyxiated Newborns

BACKGROUND

Severe birth asphyxia (apgar < 7 at the 5th minute of birth) is recognized as a hearing loss risk factor by the joint committee on infant hearing (JCIH). About half of the newborns with hearing loss do not indicate any sign and risk factor at birth. Accordingly, the joint committee recommended performance of hearing screening test in 2000, especially for babies born with risk factors.

OBJECTIVES

The aim of this study was to evaluate hearing loss in asphyxiated neonates. Early diagnosis would result in early treatment of these newborns.

PATIENTS AND METHODS

We assessed the relationship between asphyxia and hearing impairment in newborns admitted to a referral hospital, Tehran, Iran within 3 years (2003 - 2006). Hearing problems were diagnosed and followed by otoacoustic emission (OAE) in the third and fifth days of birth. Asphyxiated neonates with abnormal OAE were referred to an ENT specialist; second OAE and tympanometry were carried out after 2 weeks. Based on the results, newborns underwent treatment or were discharged.

RESULTS

Of 149 asphyxiated neonates, 80 had mean first minute apgar score of 4.01, and mean 5th minute score was 7.24. Two percent (3/149) of asphyxiated neonates had abnormal OAEs. No statistical correlation was found between the 5th minute apgar score and abnormal OAE (P value = 0.391). However, a significant relationship between the mean birth weight and abnormal OAE (P value = 0.0406) was found.

CONCLUSIONS

It seems that birth asphyxia is not correlated with hearing loss.

Undergraduate medical education programme renewal: a longitudinal context, input, process and product evaluation study

The purpose of this study was to utilize the Context, Input, Process and Product (CIPP) evaluation model as a comprehensive framework to guide initiating, planning, implementing and evaluating a revised undergraduate medical education programme. The eight-year longitudinal evaluation study consisted of four phases compatible with the four components of the CIPP model. In the first phase, we explored the strengths and weaknesses of the traditional programme as well as contextual needs, assets, and resources. For the second phase, we proposed a model for the programme considering contextual features. During the process phase, we provided formative information for revisions and adjustments. Finally, in the fourth phase, we evaluated the outcomes of the new undergraduate medical education programme in the basic sciences phase. Information was collected from different sources such as medical students, faculty members, administrators, and graduates, using various qualitative and quantitative methods including focus groups, questionnaires, and performance measures. The CIPP model has the potential to guide policy makers to systematically collect evaluation data and to manage stakeholders' reactions at each stage of the reform in order to make informed decisions. However, the model may result in evaluation burden and fail to address some unplanned evaluation questions.

Development of the First Guideline for Professional Conduct in Medical Practice in Iran

INTRODUCTION

Professional behavior is first learned at the university. One of the necessary considerations in maintaining the professional environment of the university is establishing a set of codes for the behavior of physicians and medical students. This paper describes the process of developing the professional code of conduct in Tehran University of Medical Sciences, Tehran, Iran.

METHODS

A review of Iranian and international literature was performed to develop the first draft of the guideline. In sessions of group discussion by the authors, the articles of the draft were evaluated for relevancy, clarity, and lack of repetition. The draft was sent for evaluation to all participants, including the medical faculty members, residents, and medical students, four times and necessary corrections were made according to the comments received.

RESULTS

The final guideline included 76 behavior codes in 6 categories, including altruism, honor and integrity, responsibility, respect, justice, and excellence. The codes of the guideline cover the physicians' commitments in the physician-patient, physician-colleague, and instructor-student relationships in order to improve the quality of the services.

CONCLUSION

The Islamic and Iranian culture were taken into consideration in developing the guideline. Accordance with the administrative and educational conditions of the universities was ensured in developing the guideline and its acceptance was ensured through extensive surveys. Thus, it is expected that this guideline will be very effective in enhancing professional commitment in medical universities.

Duration of Breastfeeding and Maternal-Related Factors in Iran, Systematic Review and Meta-Analysis

BACKGROUND

Although the benefits of breastfeeding are commonly approved, there remains a significant discrepancy between maternal practices and World Health Organization (WHO) guidelines in some countries.

OBJECTIVES

We had two aims in this study; average duration of breastfeeding, and its maternal determinants.

DATA SOURCES

A web-based citation index was used for citing documents.

STUDY ELIGIBILITY CRITERIA AND PARTICIPANTS

We included observational studies evaluating breastfeeding duration among children who were at least two years old and not older than five were included in Iran.

SYNTHESIS METHODS

The pooled mean and mean differences were considered. Heterogeneity was evaluated with the I² statistic.

RESULTS

The pooled mean of breastfeeding duration was calculated at 17.31 months. Children with younger mothers and lower birth orders had shorter durations of breastfeeding. Women with a high school and higher education level had early cessation of breastfeeding in comparison with less educated women.

LIMITATIONS

The main limitation of the current study was lack of librarian assistance.

CONCLUSIONS

The pooled mean of breastfeeding duration in Iranian children aged 2-5 was less than WHO recommendations. Accurate identification of the effect a mother's level of education has on duration of lactation requires standardized categorization.

IMPLICATIONS OF KEY FINDINGS

Raising awareness among women can be an effective strategy in increasing the duration of lactation.