Attitudes of medical students and staff toward organ donation in cases of brain death: a survey at Shiraz University of Medical Sciences.

CONTEXT: Organ transplant is one of the most important management strategies for end-of-life patients. The demand for organs in patients awaiting transplant is increasing, and many of these patients die before a donor is found. OBJECTIVE: To determine the attitudes of medical students and staff at clinical institutions affiliated with a large medical university in the Eastern Mediterranean region toward organ donation in cases of brain death. PARTICIPANTS: A total of 500 medical students, physicians, and nurses recruited at hospitals and medical centers affiliated with Shiraz University of Medical Sciences in Shiraz, Iran.Design and Setting-Information about participants' demographic characteristics, knowledge of organ donation, and willingness to donate their own organs after death was collected by using self-administered questionnaires. RESULTS: Most participants (78%) had favorable attitudes toward donating their own organs after brain death. However, only about 25% of them carried an organ donation card. In addition to public media, the main sources of information about organ donation after brain death were their professors and textbooks. An association in charge of improving public awareness and facilitating the process of registration and issuance of donation cards appears to be necessary.

Intestinal pseudo-obstruction as an unusual gastrointestinal presentation in pediatric human immunodeficiency virus infection.

Intestinal pseudo-obstruction is a condition in which the intestine's ability to push food through is reduced. It often leads to the dilation of the various parts of the bowel. It can be idiopathic or inherited from a parent, or caused by another disease. We report a rare case of human immunodeficiency virus (HIV) infection in a 3-year-old boy who referred with acute abdominal pain, and was later diagnosed as having intestinal pseudo-obstruction caused by HIV. The underlying causes of intestinal pseudo-obstruction should be taken into account. HIV induced pseudo-obstruction may be considered in the differential diagnosis of pediatric intestinal pseudo-obstruction in order to provide a timely diagnosis and optimal care of children with HIV.

Clinical characteristics of pediatric esophagitis in southern iran; a single-center experience.

BACKGROUND: We sought to determine the clinical characteristics of pediatric esophagitis in southern Iran. METHODS: This cross-sectional study was conducted over a 4-year period, from 2005 to 2009, in Nemazee Hospital, a tertiary healthcare center in Shiraz, southern Iran. We consecutively included all pediatric patients (<18 years) who underwent endoscopy in our center and had pathology-confirmed diagnosis of esophagitis. Data regarding the patients' demographic characteristics, comorbidities, and clinical findings were recorded using a questionnaire. All the patients underwent upper gastrointestinal endoscopy and biopsy of the esophagus, and the findings were recorded in the questionnaire. RESULTS: We studied 125 children, comprising 61 (48.8%) girls and 64 (51.2%) boys at a mean age of 6.6±5.5 years. Repeated vomiting was the prominent symptom in our series, with it being reported by 75 (60%) patients, followed by fever in 35 (28%). Erythema (33.6%), esophageal ulcer (11.2%), and whitish patch (8.0%) were the most common endoscopic findings, while reflux esophagitis (32.8%), chronic (6.4%) and acute esophagitis (5.6%), and candida esophagitis (5.6%) were the most common histological diagnoses. Only one (0.8%) patient was diagnosed as having eosinophilic esophagitis, aspergillosis, and graft-versus-host disease. CONCLUSION: Reflux was the most common cause of esophagitis in the pediatric population of southern Iran. Contrary to previous reports, the prevalence of eosinophilic esophagitis was far less than that estimated, while the prevalence of opportunistic infections was higher secondary to post-liver transplantation immunosuppression.

Do Serological Tests Eliminate the Need for Endoscopic Biopsy for the Diagnosis of Symptomatic Patients with Celiac Disease? A Retrospective Study with Review of Literature.

Background: Celiac disease is one of the most common genetic allergies worldwide. The prevalence of celiac disease in Iran is similar to or even higher than the global prevalence. Celiac disease is a chronic inflammatory disease that affects the small intestine. Affected patients are allergic to gluten protein that exists in some grains, such as wheat and barley. Methods: Serological endomysial IgA antibody (EMA-AB) and tissue transglutaminase IgA antibody (TTG-IgA) tests were performed on 114 patients aged the ages of 0-18 years with histopathological findings of celiac disease. The results of these tests were compared to the results of the histopathological study of the duodenal biopsy. Results: Based on the receiver operating characteristic (ROC) curve and a calculation of the TTG-IgA test's sensitivity and specificity, the best diagnostic limit for the TTG-IgA test is 144, which has the best sensitivity and specificity. At this value (cut-off), the test's sensitivity was 62%, and the specificity was 93.7%. For the endomysial test, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 80%, 93%, 90%, and 75%, respectively. Conclusion: The diagnostic accuracy of the endomysial test is better than that of the TTG-IgA test in general for diagnosing patients with celiac disease. In the TTG-IgA test, false-positive cases are high due to a cut-off of 20, reducing the test's specificity. In these false-positive cases, the endomysial test helps in better diagnosis.

Diagnostic Value of Immunoglobulin G Anti-Deamidated Gliadin Peptide Antibody for Diagnosis of Pediatric Celiac Disease: A Study from Shiraz, Iran.

Purpose: Screening serologic tests are important tools for the diagnosis of celiac disease (CD). Immunoglobulin (Ig)G anti-deamidated gliadin peptide (anti-DGP) is a relatively new autoantibody thought to have good diagnostic accuracy, comparable to that of anti-tissue transglutaminase (anti-tTG) antibody. Methods: Pediatric patients (n=86) with a clinical suspicion of CD were included. Duodenal biopsy, anti-tTG, and IgG anti-DGP antibody tests were performed. The patients were divided into CD and control groups based on the pathological evaluation of duodenal biopsies. The diagnostic accuracy of serological tests was determined. Results: IgA anti-tTG and IgG anti-DGP antibodies were positive in 86.3% and 95.4% of patients, respectively. The sensitivity, specificity, and diagnostic accuracy of the IgA anti-tTG test were 86.3%, 50.0%, and 68.6%, respectively, and those of the IgG anti-DGP test were 95.4%, 85.7%, and 90.7%, respectively. The area under the receiver operating characteristic (ROC) curve was 0.84 (95% confidence interval [CI], 0.74-0.91) for IgA anti-tTG test and 0.93 (95% CI, 0.86-0.97) for IgG anti-DGP test. The comparison of IgA anti-tTG and IgG anti-DGP ROC curves showed a higher sensitivity and specificity of the IgG anti-DGP test. Conclusion: IgG anti-DGP is a reliable serological test for CD diagnosis in children. High tTG and DGP titers in the serum are suggestive of severe duodenal atrophy. The combined use of IgA anti-tTG and IgG anti-DGP tests for the initial screening of CD can improve diagnostic sensitivity.

Triangular cord sign in detection of biliary atresia: is it a valuable sign?

BACKGROUND: Early detection of biliary atresia (BA) has a vital role in prevention of liver cirrhosis in these patients. There are some evidences that triangular cord (TC) sign, i.e., triangular structure located cranial to the portal vein bifurcation on ultrasonographic examination, is suggestive of BA in suspected cases. The aim of this study is to evaluate and compare the sensitivity, specificity, and accuracy of TC sign with other methods of diagnosis such as hepatobiliary scan. METHODS: Fifty-eight infants referred to pediatric gastroenterology ward with diagnosis of infantile cholestasis from March 2004 to March 2008 were evaluated to find the cause of cholestasis. Diagnosis was made by means of history, clinical examination, hepatobiliary scan, and liver biopsy. Ultrasonographic examination was focused on presence of TC sign in patients. If the diagnosis was in favor of BA, patient was sent for direct cholangiography as a gold-standard test for confirmation of the diagnosis. The sensitivity, specificity, and accuracy of the tests were compared with golden standard. RESULTS: Among 58 infants with infantile cholestasis, BA was diagnosed and confirmed in 10 infants (17.2%). Hepatobiliary scintigraphy had 80% sensitivity, 72.9% specificity, and 74.1% accuracy. TC sign had 70% sensitivity, 95.8% specificity, and 91.3% accuracy. CONCLUSION: TC sign is more accurate than hepatobiliary scan and has acceptable sensitivity and specificity for diagnosis of BA.

Low-risk planned caesarean versus planned vaginal delivery at term: early and late infantile outcomes.

BACKGROUND: Understanding the impact of delivery mode on neonatal morbidity becomes essential in the context of rising Caesarian delivery rates. AIMS: We aimed to compare the selected outcomes in neonates born by low-risk planned Caesarian delivery versus planned normal vaginal delivery (NVD). METHODS: This prospective cohort study examined early, and late neonatal complications among 1071 neonates born through low-risk planned Caesarian delivery and 1367 neonates born through planned NVD, in Fars, Islamic Republic of Iran, during 2012-2014. RESULTS: Gestational age of neonates born through Caesarian delivery was significantly lower than their counterparts in NVD group. Accordingly, babies' birth weights were 3166 (±442.4) grams in Caesarian delivery group and 3213 (±454.8) grams in NVD group. Normal skin colour at birth was more prevalent in the Caesarian delivery group compared to the NVD group (85% vs. 81.3%, P = 0.04). No significant differences were detected between the two groups regarding birth trauma, birth height and head circumference, and developing infection, icterus and convulsion during neonatal period. Also, height and weight at two years of age did not significantly differ in both groups. CONCLUSION: The results of this study show that neonates born by Caesarian delivery and NVD had the same early and late outcomes.

Prediction of Early Liver Failure in Pediatric Patients Admitted to Intensive Care Unit.

BACKGROUND Hepatic dysfunction has been associated with poor prognosis in critically ill patients. We aimed to investigate the incidence of early liver dysfunction and its association with probable predictive variables in a group of Iranian patients. METHODS The study was conducted on 149 pediatric patients referred to the pediatric intensive care unit (PICU), Shiraz University of Medical Sciences, Shiraz, Iran between April and October 2016. Serum levels of liver aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, and international normalized ratio (INR) were recorded in 24, 48, and 96 hours after admission. RESULTS On the first day of admission, direct bilirubin was the least (9.1%) and abnormal alkaline phosphatase level was the most (66.9%) common abnormalities. Abnormal levels of all tests except alkaline phosphatase were predictive of increased rate of mortality. In univariable logistic regression, abnormal aminotransferases (ALT and AST), INR, total bilirubin, and direct bilirubin had significant relationship with patients' mortality after 24, 48, and 96 hours. In multivariable logistic regression only ALT and INR in the first 24 hours had significant relationship with mortality in final model. Although univariate logistic regression revealed a significant relationship between AST and ALT levels with PICU length of stay, no significant relationship was observed between these variables and PICU length of stay (except AST in the first 24 hours) in multivariable analysis. CONCLUSION Increase in liver enzymes may predict mortality and increased PICU length of stay in critically ill children.

Association between Helicobacter pylori Infection and Iron Deficiency Anemia in School-aged Iranian Children.

OBJECTIVES: To find the relationship between Helicobacter pylori infection and iron deficiency anemia in school-aged children. METHODS: 71 children with dyspepsia, epigastric and vague abdominal pain attending a tertiary medical center in Iran underwent upper gastrointestinal endoscopy and were investigated for H. Pylori infection. Hemoglobin, mean corpuscular volume (MCV), serum ferritin, total iron binding capacity (TIBC) and serum iron levels were compared between children with or without H. pylori infection. RESULTS: H. pylori infection was detected in 42 (59.1%) patients. Proportion of children with iron deficiency anemia was not statistically different between two groups (26.2% vs. 14.3%; P=0.48). While hemoglobin was significantly lower in children with H. pylori infection (P=0.01), there were no significant differences in serum level of ferritin, iron, mean corpuscular volume and total iron binding capacity. CONCLUSIONS: Presence of H. pylori does not seem to play an important role in the pathophysiology and development of iron deficiency anemia in school-aged Iranian population.

Blood Lead Level in Children with Neurological Disorders.

OBJECTIVE: We aimed to investigate the blood lead level (BLL) in children with neurologic disorders of unknown causes and compare with normal children. MATERIALS & METHODS: In this prospective case-control study, 68 patients aged 1 to 18 yr with neurologic disorders of unknown causes, were referred to pediatric neurology clinics and wards, Shiraz, Iran selected during a 12 months period from Sep 2013. They were compared with 1:1 ratio, age, and sex-matched healthy children. BLL was checked from all participants using 3 cc heparinized venous blood sample. Level of ≥5 mcg/dl was considered toxic dose. RESULTS: Totally, 136 children (68 cases and 68 controls) with mean ages of 5.20±4.12 and 4.18±3.86 yr, respectively, were enrolled. Mean BLL was higher in case group than in controls but the difference was not significant (P=0.84), though they were less than toxic levels in both. In addition, the difference in mean BLLs was not significant in terms of living place, sex, and age. Totally, 17.7% of the study sample had BLL ≥5 mcg/dl. The frequency of BLL ≥5 mcg/dl was significantly higher in case group (P=0.024) with an odds ratio 2.9 times higher (95% CI: 1.066-7.60). CONCLUSION: Strategies in public health must focus on practicing primary and secondary preventions of lead exposure in children.

Complications of blind versus ultrasound-guided percutaneous liver biopsy in children.

BACKGROUND AND STUDY AIMS: Liver biopsy is a well-established procedure in the diagnosis and follow-up of liver diseases. Complications of liver biopsy are rare but potentially lethal. The aim of this study was to evaluate the complications of percutaneous liver biopsy and to compare the complications of blind and ultrasound-guided percutaneous liver biopsy in paediatric wards of Nemazee Hospital of Shiraz in the south of Iran. PATIENT AND METHOD: To complete the questionnaire, registered information of liver biopsies due to different causes in paediatric patients between 2008 and 2012 was retrospectively reviewed. All children aged between 0 and 18years, who underwent liver biopsy (due to any indication), participated in this study. RESULTS: Liver biopsies were obtained from 210 patients. Seven of 210 cases were excluded due to unreliable data. A total of 209 liver biopsies were done in the rest of the cases (n=203). Of all cases of liver biopsies, 22 (10.5%) experienced complications after biopsy. Pain (n=7) was the most frequent complication in 22 cases of liver biopsy. Mortality rate was one (0.5%) due to rupture of subcapsular haematoma. In terms of complication (p=0.592), there was no significant difference statistically between patients with blind liver biopsy (n=16) and patients with ultrasound-guided liver biopsy (n=6). CONCLUSION: In terms of complications, there was no significant difference when the patients were evaluated with and without ultrasound-guided biopsy.

Prevalence of celiac disease in children with idiopathic dilated cardiomyopathy.

OBJECTIVE: This study aimed to evaluate the prevalence of celiac disease (CD) in the patients with dilated cardiomyopathy (DCM). Simultaneous presentation of these two diseases has been recently reported in some studies; however, few researches have been done on children. The sooner CD is diagnosed, the better the prognosis will be, especially in the patients with a chronic disease like DCM. METHODS: In this study, 82 cases were screened for CD by measuring the level of anti-body against transglutaminase (anti tTG). These cases included 41 patients with DCM labeled according to clinical evaluation and echocardiography and 41 healthy children who had been referred for routine checkup. All the patients were between 1 and 18 years old. The expired patients and those with previous diagnosis of CD were excluded from the study. Besides, the patients with positive antibody results underwent intestinal biopsy to match the serology findings with histopathology of CD in the intestine. Finally, the data were analyzed by the SPSS statistical software (v. 16) and through t-test and Pearson correlation coefficient. FINDINGS: According to the findings, 1/41 (2.5%) DCM cases had positive tTG antibody level and negative intestinal biopsy which is classified as potential CD in the children with DCM. In addition, 7/41 (17%) patients had borderline anti body level. A direct correlation was observed between age and anti tTG level. CONCLUSION: It is beneficial to assess CD in DCM children with unknown cause.

Etiology of lower gastrointestinal bleeding in children:a single center experience from southern iran.

BACKGROUND: This study aimed to determine the common etiologies and characteristics of lower gastrointestinal (GI) bleeding in children from Southern Iran. METHODS: This five-year prospective cross-sectional study was performed from March 2006 to March 2011 in Nemazee Hospital. All pediatric patients (<18 years of age) who referred to our center with gross lower GI bleeding or two consecutive positive occult blood tests with at least a one-week interval were included in the study. Patients were categorized as neonates, infants, children and adolescents and the findings were reported separately in each group. Each patient underwent a colonoscopy and several mucosal biopsies were taken. Demographic and clinical information as well as colonoscopy and pathology findings were reported. RESULTS: Overall, we included 363 pediatric patients with a mean age of 71.9±58.4 months (range: 1-216 months). There were 215 (59.2%) boys and 148 (40.8%) girls. The most common colonoscopy findings were sigmoid colon polyp in 91 (25.1%) patients followed by descending colon petechia in 78 (21.5%) patients, whitish rectal lesions in 45 (12.4%) patients, and sigmoid and rectal ulcers in 37 (10.2%) patients. Biopsy samples were non-specific in 96 (26.4%) patients. The most common pathological findings were juvenile polyp in 84 (23.1%) followed by lymphoid nodular hyperplasia in 55 (15.2%) and solitary rectal ulcers in 25 (6.9%) patients. CONCLUSION: We found that lower GI bleeding was more common among 2-10 year-old children and was rarely encountered in neonates. Hematochezia was the most common form of presentation followed by bloody diarrhea and occult blood. The most common colonoscopy finding was sigmoid colon polyp and the most common pathological finding was juvenile polyp.

Tacrolimus related hypertrophic cardiomyopathy in liver transplant recipients.

BACKGROUND: Recently there are a number of reports on the cardiotoxicity of tacrolimus in post-transplant patients. There is no protocol for cardiovascular evaluation in these patients. This study was performed to evaluate the cardiotoxicity of tacrolimus in liver transplant recipients. METHODS: We evaluated 63 post-liver transplant patients who received tacrolimus. They were evaluated for cardiovascular complications by physical examination, electrocardiographic and echocardiographic examinations within three and six months following liver transplantation. Serum tacrolimus levels were checked by ELISA. For comparison, we selected 50 post-liver transplant patients who received no tacrolimus and evaluated them for cardiovascular function identically. RESULTS: Among 63 patients, 42 were male (66.7%) and 21 were female (33.3%); 70% of the patients were adults, and 19 (30%) were within the pediatric age group. The cardiovascular examinations, electrocardiogram and echocardiography of all patients three months post-transplantation were normal except for two children who developed tacrolimus related cardiac complications. Both had high serum tacrolimus levels. No adults developed cardiovascular complications. In the control group, the results of the cardiovascular evaluations were normal in all cases. CONCLUSION: The cardiovascular toxicity of tacrolimus, such as hypertrophic cardiomyopathy, may be observed in pediatric patients. Therefore, we recommend routine regular cardiovascular evaluation of children after liver transplantation.