Clinical and Laboratory Characteristics of Pediatric Scorpion Stings: A Report From Southern Iran.

OBJECTIVE: Scorpion stings are a major public health problem in many countries, particularly in pediatrics. Children are more susceptible to severe clinical manifestations of envenomation. The aim of this study is to determine the epidemiological and clinical characteristics of pediatric scorpionism in Hormozgan province of Iran during 2012. METHOD: This was a cross-sectional study being conducted during 2010 in Hormozgan, the southern province of Iran. We included 350 patients admitted to emergency unit of the hospitals of 8 cities of Hormozgan with impression of scorpion envenomation. The clinical and epidemiological characteristics as well as the treatment and outcome were recorded. RESULTS: The prevalence rate of pediatric scorpion stings in the province was 1.8 in 1000 children. The mean age of the patients was 5.75 ± 4.54 (range, 1-18) years. There were 208 (59.5%) boys and 142 (40.5%) girls among the patients. The most common site of sting was sole to knee in 94 (26.8%) followed by hand in 61 (17.4%) and fingers in 47 (13.4%). The most common presenting symptom was vomiting in 236 (67.4%) followed by localized pain in 131 (37.3%), erythema in 120 (34.2%), and edema in 119 (33.9%). The highest and lowest frequency occurred in July (17.7%) and January (3.2%), respectively. Nocturnal envenomations (53.7%) were more common than diurnal (46.3%). Most of scorpionism were mild (83.4%) that all evolved to cure, without any deaths. CONCLUSIONS: The results demonstrate the pediatric scorpionism is a public health problem in Hormozgan province of Iran, and special attention should be paid to prevention and treatment.

Epidemiology, Regional Characteristics, Knowledge, and Attitude Toward Female Genital Mutilation/Cutting in Southern Iran.

INTRODUCTION: Female genital mutilation/cutting (FGM/C), also known as female circumcision, is an ancient traditional procedure that involves partial or total removal of the female external genitalia for nonmedical reasons. Although it is well described in African and some Arabic countries, data from Iran are scarce. AIM: To describe the epidemiology, regional characteristics, knowledge, and attitude toward FGM/C in Southern Iran. METHODS: This cross-sectional study was conducted during a 36-month period from 2010 to 2013 in Hormozgan, a southern province of Iran near the Persian Gulf. We included 780 women in six major rural areas of the province who referred to healthcare centers for vaccination, midwifery, or family planning services. All participants underwent complete pelvic examination to determine the type of FGM. The questionnaire consisted of several sections such as demographic and baseline characteristics, and two self-report sections addressing the knowledge and attitude toward FGM/C and its complications. Baseline sociodemographic characteristics including age, educational level, marital status, religion, and nationality were the independent variables. RESULTS: Among the participants, 535 (68.5%) had undergone FGM/C. FGM/C was associated with higher age (P = 0.002), Afghan nationality (P = 0.003), Sunni Islam as religion (P = 0.019), illiteracy (P < 0.001), and family history of FGM/C in mother (P < 0.001), sister (P < 0.001), and grandmother (P < 0.001). Ancient traditions in the area (57.1%) were mentioned as the most important factor leading to FMG/C. Urinary tract infection was the most common reported complication (60.4%). CONCLUSION: FGM/C is a common practice in rural areas of Southern Iran. It is associated with increased age, illiteracy, Sunni Islam religion, Afghan nationality, and positive family history. Lack of knowledge toward FGM/C is the main cause of its high prevalence and continuation in the area.

Effect of immobilization on urine calcium excretion in orthopedic patients with pelvic fracture treated by skin traction.

OBJECTIVES: To determine the effects on urine calcium excretion of immobilization by skin traction in patients with pelvic fracture. METHODS: In a prospective study, a consecutive series of patients with pelvic fracture treated by skin traction were enrolled. Serum (calcium, phosphorous, alkaline phosphatase, sodium, potassium, uric acid, BUN, creatinine) and fasting urine calcium, creatinine, sodium, potassium and uric acid were checked within 48 hours of hospitalization and at 7, 14 and 21 days of immobilization and then after 3 months of mobilization. Trends in changes of variables were recorded. RESULTS: Fifty five patients were enrolled in this study; they were 45 (81.8%) males and 10 (18.2%) females with a mean age 19.4 ± 12.7 years. We found that serum levels of calcium (p = 0.004), phosphorous (p = 0.047) and alkaline phosphatase (p = 0.001) increased significantly during the 3 weeks of immobilization. In the same way, urine calcium/ urine creatinine ratio increased significantly in the study period (p = 0.004). No symptomatic renal stone formation was observed during the study period. CONCLUSIONS: Immobilization even in short term causes hypercalciuria in orthopedic patients. Although it is transient and improves with subsequent mobilization, it is needed to be considered specifically by the team caring for this group of patients.

Determinants of poor outcome in patients with hepatitis A infection: a four-year retrospective study in Shiraz, Southern Iran.

There are 1.4 million estimated cases of hepatitis A every year worldwide. We aimed to detect the correlates of poor outcome in patients with hepatitis A virus (HAV) infection. In this four-year retrospective study, which was conducted in Shiraz, Southern Iran, data of all hospitalized HAV patients were analyzed by SPSS and STATA. Out of 110 HAV patients, 8 (7.3 %) developed hepatic encephalopathy, and 7 (6.4 %) died. The results show that 19 years of age is a cutoff level for predicting mortality, with a sensitivity of 42.9 % and specificity of 91.3 %, and with an area under the curve (AUC) of 0.595 (95 % CI, 0.309-0.881). Every one-year increase in age adds 3 % to the mortality rate from severe hepatitis A. The cutoff level of alanine aminotransferase (ALT) for predicting death is 1819.5 IU/L, with a sensitivity of 100 %, specificity of 68 %, and AUC 0.877 (95 % CI, 0.777-0.977). Every 100 IU/L increase in ALT is associated with a 0.1 % increase in the risk of death. Patients from large families (OR, 0.583, 95 % CI, 0.46-0.74) and those who are not the firstborn child of their family (OR, 0.287, 95 % CI, 0.146-0.564) have better outcome. Adult patients with hepatitis A who are first children, are from a small family, or have a very high level of ALT are more prone to a poor outcome of this infection. Public education and establishment of a national surveillance system for HAV and an HAV vaccination program for high-risk populations should be regarded among the priorities of the health system of Iran.

Double versus single cervical cerclage for patients with recurrent pregnancy loss: a randomized clinical trial.

AIM: To compare the effectiveness of the double cervical cerclage method versus the single method in women with recurrent second-trimester delivery. METHOD: In this randomized clinical trial, we included 33 singleton pregnancies suffering from recurrent second-trimester pregnancy loss (≥2 consecutive fetal loss during second-trimester or with a history of unsuccessful procedures utilizing the McDonald method), due to cervical incompetence. Patients were randomly assigned to undergo either the classic McDonald method (n = 14) or the double cerclage method (n = 19). The successful pregnancy rate and gestational age at delivery was also compared between the two groups. RESULTS: The two study groups were comparable regarding their baseline characteristics. The successful pregnancy rate did not differ significantly between those who underwent the double cerclage method or the classic McDonald cerclage method (100% vs 85.7%; P = 0.172). In the same way, the preterm delivery rate (<34 weeks of gestation) was comparable between the two study groups (10.5% vs 35.7%; P = 0.106). Those undergoing the double cerclage method had longer gestational duration (37.2 ± 2.6 vs 34.3 ± 3.8 weeks; P = 0.016). CONCLUSION: The double cervical cerclage method seems to provide better cervical support, as compared with the classic McDonald cerclage method, in those suffering from recurrent pregnancy loss, due to cervical incompetence.

The diminishing trend of ß-thalassemia in Southern Iran from 1997 to 2011: the impact of preventive strategies.

The marginal zones of the Caspian Sea and the Persian Gulf have a higher prevalence of thalassemia compared to other regions of Iran. This disease has disabled many people and resulted in increasing health care costs. The aim of this study was to assess the incidence of ß-thalassemia (ß-thal) and to evaluate the outcome of applied preventive strategies over a 14-year period in Fars Province, Southern Iran. This cross-sectional study comprised all new cases of ß-thal recorded during 1997-2011. The data were obtained from the Non-Communicable Diseases Surveillance Department of Shiraz University of Medical Sciences, Shiraz, Iran, and are presented as mean ± standard deviation (SD). The Fars Health Network System screened 840 686 males and females applying for marriage certificates. Among the carriers, 50.5% cancelled their marriages, 42.5% married, and 7.0% did not show up at the clinics. The rate of cancelled marriages has reduced since 2000, when marriage candidates were given the option of prenatal diagnosis. From 2000 to 2011, a total of 3539 married couples were referred for prenatal diagnosis. Of these, 806 fetuses were found to carry thalassemia and 800 aborted. It is impressive to note that while 101 cases of thalassemia were recorded in 1997, this figure was reduced to two cases by 2011. This study has established that an integrated primary health care approach, with good infrastructure for implementing successful strategies, can significantly reduce the incidence of ß-thal.

Posterior-only approach for treatment of irreducible traumatic Atlanto-axial dislocation, secondary to type-II odontoid fracture; report of a missed case, its management and review of literature.

INTRODUCTION AND IMPORTANCE: Odontoid fracture (OF) is among the most common and challenging cervical spine fractures in regards to the treatment and surgical approach. Atlanto-axial dislocation (AAD) is considered a significant complication after failed non-surgical treatment of OF. Traditionally, it requires anterior odontoidectomy followed by posterior C1-C2 reduction and fusion. In latest studies, Atlanto-axial joint (AAJ) remodeling in a posterior-only approach has got attention. CASE PRESENTATION: We herein present a 30-year-old man with missed type-II OF, presenting with irreducible anterior AAD and progressive neurological deficit. Old non-united OF with dorsal callous formation, compressing spinal cord, was detected. The patient underwent correction of the deformity and reduction of the fracture utilizing the posterior-only approach. AAJ remodeling, callous release and C1-C2 fusion was performed in standard prone position, under fluoroscopic guide and intraoperative electrophysiological monitoring. The patient had uneventful surgery and postoperative course and was neurologically intact with appropriate alignment in 6-month follow-up. CLINICAL DISCUSSION: The irreducible AAD following type-II OF could be successfully treated with posterior-only approach (C1-C2 fusion). CONCLUSION: Type-II OF is considered unstable requiring surgical management. Close follow-up and appropriate patient education is mandatory in non-surgical treatment. Irreducible AAD has been managed with anterior odontoid resection and posterior fusion. Several complications of anterior surgery, makes posterior-only approach a noticeable choice.

Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients.

BACKGROUND: Pelvic fractures are among the most devastating traumatic injuries accompanied by high morbidity and mortality rate leading to catastrophic outcomes and haemodynamic consequences. Although Advanced Trauma Life Support (ATLS) recommends performing pelvic radiography in all major blunt trauma patients, several lines of evidence recommend that it can be limited to those blunt trauma patients who are haemodynamically unstable or have positive pelvic physical examination. Thus, we performed this study in order to evaluate the efficacy of routine pelvic radiography in haemodynamically stable, high-energy, blunt trauma patients. METHODS: This was a prospective cross-sectional study including all the haemodynamically stable, high-energy, blunt trauma patients with negative pelvic physical examination referring to our trauma centre during a 5-month period (May-September 2010). Pelvic radiographies were performed and reviewed for abnormalities. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested and reviewed. RESULTS: During the study period, 1679 high-energy blunt trauma patients referred to our centre out of which 389 were haemodynamically stable and had negative pelvic physical examination. Pelvic radiography was found to be normal in all the patients except one (0.25%) who had pelvic fracture. Only three patients required CT imaging out of which two (0.5%) were found to be normal. CONCLUSIONS: Pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination.

Time analysis of fatal traffic accidents in Fars Province of Iran.

OBJECTIVE: To analyze the time factor in road traffic accidents (RTAs) in Fars Province of Iran. METHODS: This study was conducted in Fars Province, Iran from November 22, 2009 to November 21, 2011. Victims'information consisted of age, sex, death toll involving dri- vers or passengers of cars, motorcycles and pedestrians, and site of injury etc. Accidents were analyzed in relation to hour of the day, season of the year, lighting condition including sunrise, sunset, daytime and nighttime. RESULTS: A total of 3 642 deaths (78.3% were males, and the ratio of males to females was about 3.6:1) were studied regarding their autopsy records. There was a steady increase in fatal accidents occurring at midnight to 15:59. The risk of being involved in a fatal traffic accident was higher for those injured between 4:00 to 7:59 than at other times (OR equal to 2.13, 95% CI 1.85-2.44). The greatest number of fatal RTAs took place in summer. Mortalities due to RTA during spring and summer were more pronounced at 20:00 to 23:59 and midnight to 3:59, whereas mortalities in fall and winter were more pronounced from 12:00 to 15:59. CONCLUSION: The high mortality rate of RTA is a major public health problem in Fars Province. Our results indicate that the time is an important factor which contributes to road traffic deaths.

Outcome of early versus late ileostomy closure in patients with rectal cancers undergoing low anterior resection: A prospective cohort study.

BACKGROUND: Protective loop ileostomy is performed following low anterior resection (LAR) in patients with rectal cancer to reduce the complications of primary anastomosis. The optimal timing for ileostomy closure remains controversial. The aim of the current study was to compare the effects of early (<2 weeks) versus late (≥2 months) closure of the stoma in patients with rectal cancer undergoing LAR on surgical outcome and complications rates. METHODS: This prospective cohort study was conducted in two referral centers in Shiraz, Iran, during a 2-year period. We have consecutively and prospectively included adult patients with rectal adenocarcinoma who underwent LAR followed by protective loop ileostomy in our center during the study period. The baseline, tumor characteristics and complication as well as outcome was recorded in a 1-year follow-up and was compared between early and late ileostomy closure. RESULTS: Overall, 69 patients (32 in early and 37 in late group) were included. The mean age of the patients was 59.40 ± 9.30 years and there were 46 (66.7%) men and 23 (33.3%) women. Patients undergoing early closure of the ileostomy had significantly shorter operation duration (p<0.001) and lower intraoperative bleeding (p<0.001) compared to late ileostomy closure. There was no significant difference between two study groups regarding the complications. Early closure was also not found to be a predictive factor of post-ileostomy closure complications. CONCLUSION: Early closure (<2 weeks) of ileostomy after LAR in patients with rectal adenocarcinoma is a safe and feasible technique which is associated with favorable outcome.

Modifications of miRNAs in intervertebral disc degeneration: a key to the future development of genetic-based therapies.

Intervertebral disc degeneration (IDD) is the main cause of low back pain, which is a healthcare concern associated with high social and economic burden. The current medical and surgical therapies are inadequate and ineffective. Several miRNAs have been identified that modulate (via up- or down-regulation) the pathogenesis of IDD through various signaling pathways. Understanding the nature of this regulation and their signaling pathways will enable researchers to manipulate miRNA regulation to develop miRNA-based therapies. The development of miRNA-based therapies opens a future window through which to decrease the IDD process or regenerate the intervertebral disc. In the near future, the obstacles associated with miRNA-based therapies will be overcome and these therapies will move from the bench to the bedside.

Effects of serum fibrinogen correction on outcome of traumatic cranial surgery: A randomized, single-blind, placebo-controlled clinical trial.

BACKGROUND: Traumatic brain injury (TBI) is strongly associated with coagulopathy that occurs in 25-35% of patients. This complication is linked to higher mortality and morbidity. Recent lines of evidance have supported administration of fibrinogen concentrate (FC) in patients with severe TBI, while its efficacy remains controversial. In this study we aim to evaluate the effectiveness of serum fibrinogen level correction from 1.5 and 2.0 g/l to more than 2.0 g/l in patients with severe TBI undergoing traumatic cranial surgery. METHOD: This randomized, single-blind, placebo-controlled clinical trial included trauma patients who had abbreviated injury scale (AIS) more than 3 in head and below 3 in other organs. FC was administered intravenously to patients with severe TBI undergoing TBI to correct the fibrinogen level above 2 g/l. Patients were randomly assigned to FC and control groups. The amount of intra-operative blood loss, packed cell (PC) transfusion, formation of new intracranial hemorrhage, and hemovac drainage were compared between the two study groups. RESULTS: Forty-seven of 65 participants received the study intervention within 40-112 min of admission. Intra-operative PC transfusion was higher in FC group (80%) compared to control group (55.5%) while the differance was not statistically significant (p > 0.05). Intra-operative blood loss was significantly higher in control group than FC group (P = 0.036). Chance of re-operation and new intracranial hematoma were not significantly different between two study groups. CONCLUSION: Early delivery of FC, decreases intraoperative bleeding. Although based on our findings it has no other effect on other parameters, further multicenter studies are recommended to investigate the role of early FC administration in management of post traumatic coagulopathy.

Effect of Dexmedotomdine hydrochloride (Percedex®) on functional outcome of patients with moderate and severe traumatic brain injury.

Traumatic brain injury (TBI) is considered among the leading causes of morbidity and mortality worldwide being associated with significant social and economic burden. The best sedative regimen in TBI patients is yet to be identified. This study was designed to determine the effects of dexmedotomdine hydrochloride (Percedex®, DEX) on functional outcome of patients with moderate and severe traumatic brain injury (TBI). This was a retrospective cohort study including patients with severe (3-8) and moderate (9-13) TBI referring to a level I trauma center. We studied two groups of patients, those receiving DEX or routine sedation regimen in neurointensive care unit (NICU). The main outcome measures were the Glasgow outcome scale extended (GOSE) at 3 and 6-month. We have also recorded ICU and hospital length of stay (LOS) and the tracheostomy rate. We included 138 patients in two study groups (each including 69). The baseline characteristics were comparable between groups. DEX was associated with lower LOS in hospital (p = 0.002) and NICU (p = 0.003). The GOSE was comparable between two study groups at 3 (p = 0.245) and 6-month (p = 0.497). Multivariate regression analysis revealed that after LOS of NICU and hospital stay adjustment, DEX group experienced significantly improved 6-month GOSE with the average improvement in score of 0.92 compared to the control group (p = 0.041). DEX administration in patients with moderate and severe TBI was associated with decreased NICU and hospital LOS and improved functional outcome at 6-month.

Atypical Scheuermann's disease with severe kyphosis and negative sagittal balance in the thoracolumbar region: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Scheuermann's kyphosis is a structural deformity of the thoracolumbar spine that is classified in typical (thoracic) and atypical (lumbar and thoracolumbar) Scheuermann's disease. Surgical intervention is reserved for those with progressive kyphosis, intractable pain and neurological impairment. Although, previous literature focuses on the correction of the thoracic kyphosis (TK), recent lines of evidence recommend considering all the sagittal balance parameters when performing a surgery. We herein, report a posterior-only approach in a patient with Scheuermann's kyphosis, considering all the sagittal balance parameters. CASE PRESENTATION: The patient was a 17-year-old boy with a kyphotic deformity in the lumbar region, with urinary retention and upper back intractable pain. The preoperative physical examination was normal except for a kyphotic gait. The patient was first treated with thoracic lumbosacral orthoses (TLSO) brace that was not effective; consequently, the patient underwent posterior only approach (pedicular screw fixation along with Smith-Peterson osteotomy) with correction of the sagittal balance and kyphosis. The patient's sign and symptoms improved significantly. The surgery was uneventful and no complication was recorded. The 1-year follow-up revealed normal neurological examination and normal sagittal balance parameters. CLINICAL DISCUSSION: Atypical Scheuermann's kyphosis with neurological impairment and progressive kyphosis should be treated with surgical intervention. CONCLUSION: Considering the sagittal parameters of the spine, the surgical intervention should be designed to correct the kyphosis and the other indices of the sagittal balance. Posterior-only approach is safe and effective method for correction of the TK and improving the signs and symptoms of the patients.

Acute supratentorial subdural hematoma after craniocervical junction arachnolysis in a patient with posttraumatic syringomyelia; case report and literature review.

In patients with SAA rapid CSF drainage while performing durotomy must be avoided by utilizing cotton pads and lowering the head level to avoid catastrophic complications.

The role of routine chest radiography in initial evaluation of stable blunt trauma patients.

BACKGROUND: Radiology plays an important role in evaluation of a trauma patient. Although chest radiography is recommended for initial evaluation of the trauma patient by the Advanced Trauma Life Support course, we hypothesized that precise physical examinations and history taking accurately identify those blunt trauma patients at low risk for chest injury, making routine radiographs unnecessary. Thus, this study was performed to investigate the role of chest radiography in initial evaluation of those trauma patients with normal physical examination. METHODS: In this prospective cross-sectional study, all the hemodynamically stable blunt trauma patients with negative physical examination result referred to our trauma center during a 4-month period (March-June 2009) were included. Chest radiographies were performed and reviewed for abnormalities. RESULTS: During the study period, 5091 blunt trauma patients referred to our center, out of which, 1008 were hemodynamically stable and had negative physical examination result. Only 1 (0.1%) patient had abnormal chest radiography that showed perihilar lymphadenopathy, unrelated to trauma. CONCLUSION: Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making for performing chest radiography in blunt trauma patients based on clinical findings would be efficacious and resource saving.

Subclavian flap aortoplasty and preservation of left upper extremity circulation using an interposition graft.

OBJECTIVES: To introduce a surgical technique to maintain left upper limb blood flow after subclavian flap aortoplasty (SFA). METHODS: Five patients (9 to 23 months of age) with a diagnosis of long-segment aortic coarctation underwent conventional SFA. A Gore-tex graft was interposed between the stump and the proximal descending aorta to maintain perfusion of subclavian artery. RESULTS: All patients had a patent Gore-tex graft and normal blood flow of the subclavian artery and left upper limb. One patient expired and four others were discharged with a mean follow-up of 48 months. On follow-up all patients had normal development of the left upper limb and no signs of limb ischemia. Echo findings revealed normal arch flow with normal flow in the Gore-tex graft and left upper extremity. CONCLUSIONS: Interposing a Gore-tex graft between the subclavian artery stump and proximal descending aorta concomitant with SFA can be safely performed in infants with long-segment aortic coarctation, with preservation of left upper extremity circulation.

Fatal motorcycle accidents in Fars Province, Iran: a community-based survey.

OBJECTIVE: To identify the main characteristics of victims of motorcycle accidents in Fars Province, Iran. METHODS: This cross-sectional study was conducted in Fars Province which has the fourth largest population of all 31 provinces in Iran from March 2009 to June 2010. We included data from all 542 recorded cases of fatalities due to motor vehicle accidents. Data were recorded from the forensic medicine registry consisting of demographic and accident-related information. Demographic information consisted of name, age, sex, status of fatal victim (motorcycle driver vs passenger) and educational level. RESULTS: Of the 2 345 autopsy records from the forensic medicine archives, 542 (23.1%) gave the cause of death as motor vehicle accidents. Mean age of these victims was (31.4+/-6.5) years, and the male to female ratio was 28. Head injury was the most common cause of death in these victims, and overall they tended to have a low level of education. Motorcycle accidents frequently involved younger age groups (15-35 years), and head trauma related with non-use of a helmet was the most common cause of death. CONCLUSIONS: Head injury is frequent among victims in the province we studied. This situation may be related to the victims' low socioeconomic status and little education regarding traffic laws leading to speeding and disregard of these laws along with their weak enforcement.

Epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran: a community-based survey.

OBJECTIVE: To determine the epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran. METHODS: This cross-sectional study was conducted in Fars Province of Iran during a 29-month period from March 2009 to July 2011. The data were from the Fars Forensic Medicine Registry. In 4 923 recorded road traffic accident fatalities, 971 deaths were due to pedestrian accidents. The demographic and accident-related information were analyzed by SPSS version 11.5. P value less than 0.05 was considered significant. RESULTS: The mean age of decedents was (47.2+/-26.2) years, ranging from 6 months to 103 years old. Males accounted for 69.8% of all deaths. Fatal accidents were most common in September; 56.1% of the fatal injuries occurred on intracity roads and 33.1% on extracity roads. Fatal head injuries were present in 60.54% of cases. Evaluation of the injury site and the cause of death found that they were significantly associated with age, interval between injury and death. Besides, the type of roads played an important role in mortality. CONCLUSION: Although the clinical management of trauma patients has been improved in our country in the recent decade, decreasing the burden of injuries needs coordination among trauma system organizations.