Diffuse inverted T waves in a young man with structurally normal heart: a case report.

We discuss a young man with episodes of chest pain and dyspnea accompanied with transient T-wave inversion in precordial and inferior leads that repeated several times. Cardiovascular evaluation did not disclose any structural abnormality. Memory T wave following episodes of idiopathic left septal ventricular tachycardia was the reason of these changes and did not repeat after arrhythmia ablation.

The prevalence and prognostic role of vitamin D deficiency in patients with acute coronary syndrome: a single centre study in South-West of Iran.

BACKGROUND: The objectives of this study were estimating the prevalence of vitamin D deficiency in patients with acute coronary syndrome comparing with normal people and evaluating the relationship between vitamin D deficiency and short-term mortality in these patients. METHODS: We considered 106 patients with non-ST elevation myocardial infarction and high-risk unstable angina and 110 patients with ST elevation myocardial infarction as group A. The control group (group B) consisted of 120 individuals without any known cardiovascular diseases or systemic disease. We measured serum 25-hydroxyvitamin D in all cases and classified them according to their serum 25-hydroxyvitamin D levels. Sufficient vitamin D level was considered ≥30 ng/ml. We followed the patients for 30 days after index admission. RESULTS: The prevalence of hypovitaminosis D in group A was much higher than group B. In group A, 72% of patients had serum 25-hydroxyvitamin D level of 20 ng/ml or less. This percentage was only 27.4% in control group. We did not find any significant relationship between vitamin D deficiency and short-term mortality in patients with acute coronary syndrome. CONCLUSION: Our data suggest that vitamin D deficiency was present in most of patients admitted with acute coronary syndrome in Ahvaz.

Randomized Prospective Comparison of Two Protocols for Head-up Tilt Testing in Patients with Normal Heart and Recurrent Unexplained Syncope.

BACKGROUND: This randomized study was aimed to compare the diagnostic value of two head-up tilt testing protocols using sublingual nitroglycerin for provocation in patients with recurrent unexplained syncope and normal heart. METHODS: The patients with normal findings in physical examination, electrocardiography and echocardiography were randomly submitted to one of upright tilt test protocols. The only difference between two protocols was that nitroglycerin was administered after a five minute resting phase in supine position during protocol B. We also considered eighty normal persons as the control group. RESULTS: Out of 290 patients that underwent tilt testing, 132 patients were in group A versus 158 patients in group B. Both groups had an identical distribution of clinical characteristics. Tilt test was positive in 79 patients in group A (25 in passive phase, 54 in active phase) versus 96 patients in group B (43 in passive phase, 53 in active phase). There was no significant difference between results in two groups (P value= 0.127). Forty cases were tested with protocol A and forty underwent tilt testing with protocol B. Tilt test was positive in 4 cases with protocol A versus 3 cases in protocol B. The positive rates of tilt testing with protocol A was 60% while it was 61% in protocol B. The specificity of testing with protocol A was 90% and it was 92.5% in protocol B. CONCLUSIONS: According to our data, adding a period of rest and returning to supine position before nitroglycerin administration had no additional diagnostic yield.

Using TOSCE (Team Objective Structured Clinical Examination) in the second national medical sciences olympiad in Iran.

INTRODUCTION: Second National Medical Sciences Olympiad was done in Shiraz in August 2010 with aim of indentifying scientifically talented individuals, motivating students and orienting extracurricular activities. This Olympiad was done in 3 areas, basic sciences, clinical sciences and management. In clinical sciences, we used TOSCE (Team Objective Structured Clinical Examination). In this article we report the details of this exam and participants' satisfaction. MATERIALS AND METHODS: This Olympiad in Clinical Medical Sciences was held in 2 levels: Individual and team. In the team stage, 9 teams from 9 universities participated. We used TOSCE for measuring clinical competency of teams. Each team consisted of 3 students. We designed 12 stations based on emergency medicine in medical and surgical fields. The time considered for each station was 15 min, after doing this exam the view of students was measured using a valid and reliable questionnaire. RESULTS: Most of the students believed that TOSCE was a useful examination for measuring competency. More than 50% of students reported that success in this exam needs clinical competency, team work and problem solving ability. Nearly, half (48.1%) of students believed that 15 min is not enough for each station and they need more time. CONCLUSION: The results of this study showed that this kind of exam is useful for measuring clinical competency from students' viewpoint.

A Case of Giant Cell Arteritis With a Normal Erythrocyte Sedimentation Rate (ESR) Post ChAdOx1 nCoV-19 Vaccination.

Giant cell arteritis (GCA) has been reported post the coronavirus disease 2019 (COVID-19) vaccination, especially with the mRNA vaccine. A normal erythrocyte sedimentation rate (ESR) is seen in some GCA patients. This report describes a 68-year-old gentleman who presented with a right-sided temporal headache for three weeks, starting three to five days after his second dose of the ChAdOx1 nCoV-19 vaccine, a viral vector vaccine, which was given seven weeks post the first dose. On presentation, he developed blurred vision in the left eye, and it progressed to complete vision loss four days later. He also had episodes of blurred vision in the right eye. The blood test showed a mildly elevated C-reactive protein of 29 mg/L and a normal erythrocyte sedimentation rate (ESR) of 4 mm/hr. Optical coherence tomography showed anterior ischaemic optic neuropathy in the left eye and retinal ischemia in the right eye. Bilateral giant cell arteritis (GCA) was confirmed on temporal artery biopsy. He was treated with methylprednisolone pulse therapy followed by prednisolone. He re-presented with intermittent blurry vision in the right eye three months later. He was treated with methylprednisolone pulse therapy again, followed by prednisolone, aspirin, and tocilizumab. This case describes a patient who developed GCA post ChAdOx1 nCoV-19 vaccination with a normal ESR. Further studies are needed to investigate this relationship as causal or incidental and the likelihood of low-level inflammatory makers in such a situation.

Significance of signal averaged electrocardiography in patients with advanced heart failure and intraventricular conduction delay.

AIMS: Signal averaged electrocardiography is a noninvasive method to evaluate the presence of the potentials that are generated by tissues, activated later than their usual timing in the cardiac cycle. The purpose of this study was to demonstrate the correlation of data obtained via signal averaged electrocardiography and left ventricular dyssynchrony. METHODS: We included the patients with advanced systolic left ventricular dysfunction (ejection fraction

Protective effect of selenium on cisplatin induced nephrotoxicity: A double-blind controlled randomized clinical trial.

BACKGROUND: Renal injury is common following cisplatin infusion. Some agents have been used to attenuate cisplatin nephrotoxicity. However, except hydration, none of them has been proved to be effective. OBJECTIVE: In this study selenium as an antioxidant supplement was tested on cisplatin induced renal injury. PATIENTS AND METHODS: 122 cancerous patients (85 male and 37 female; age range of 14 to 82 years old) were enrolled to receive chemotherapy regimens consisting cisplatin. They were allocated into two groups using a random number list . Investigators, patients and analyzers all, were blinded in allocation by using sealed opaque envelopes. Intervention group received a single 400 mcg selenium tablet and patients in control group took a placebo tablet which was similar with selenium preparation in color, weight, shape and taste. Primary end points were an increase in plasma creatinine above 1.5 mg/dl in men and 1.4mg/dl in women, or increase of plasma creatinine more than 50% from baseline or urine flow rate less than 0.5 ml/kg/h. Creatinine level was measured initially and on the 5th day after cisplatin therapy. RESULTS: There was no difference in cumulative dose of cisplatin between the groups (p=0.54). There were not evidences of acute renal failure (ARF) in cases. While, among placebo group, 7 patients had criteria of acute kidney injury. Conclusions :selenium could probably prevent cisplatin-induced acute kidney injury, when it is added to hydration therapy in cancerous patients.

The prognostic role of serum uric acid level in patients with acute ST elevation myocardial infarction.

OBJECTIVES: The role of uric acid as a prognostic factor in patients with acute ST elevation myocardial infarction is controversial. The purpose of this study was to demonstrate the relationship between serum uric acid level and mortality during admission period and 30-day period after admission. METHODS: We assessed the relation between serum uric acid level and in-hospital and short-term mortality rates in 184 patients admitted with acute ST elevation myocardial infarction. We divided the patients according to their gender and uric acid level measured on admission into four groups: group A1: men with uric acid ⩽7 mg/dl versus group B1: men with uric acid >7 mg/dl and group A2: women with uric acid ⩽5.6 mg/dl versus group B2: women with uric acid >5.6 mg/dl. The patients were followed for 30 days after admission. RESULTS: In-hospital mortality rate in group B1 was higher than group A1 [P value: 0.011, Relative risk: 13.33 (95% confidence interval: 1.55-114.7)]. Short-term all-cause mortality was significantly higher in group B1 patients [P value: 0.037, Relative risk: 3.3 (95% confidence interval: 1.02-10.64)]. Multivariate logistic regression analysis of data showed an odds ratio of 15.23 for in-hospital mortality and odds ratio of 3.76 for short-term mortality in male hyperuricemic patients. CONCLUSIONS: Our data suggest that in the acute phase of ST elevation myocardial infarction, uric acid has a prognostic role for in-hospital and short-term (30-day) mortality in men.

Alterations in antibiotic susceptibility of urinary tract infection pathogens.

BACKGROUND: Urinary tract infection (UTI) is the third most common infection in human. New resisted strains of uropathogens have been developed due to different factors such as widespread use of antibiothics. OBJECTIVES: We conducted this study to assess the recent pattern and susceptibility of uropathogens. MATERIALS AND METHODS: This descriptive cross-sectional study was carried on 32600 ambulatory patients' urine samples from six laboratories from 2008 to 2010 in Ahvaz, Khuzestan. Of those, 3000 positive culture were found. Data including underlying disease, pregnancy, catheterization and drug history were gathered by questionnaire. Susceptibility of pathogens to eight antimicrobial agents was determined. MATERIALS AND METHODS: This descriptive cross-sectional study was carried on 32600 ambulatory patients' urine samples from six laboratories from 2008 to 2010 in Ahvaz, Khuzestan. Of those, 3000 positive culture were found. Data including underlying disease, pregnancy, catheterization and drug history were gathered by questionnaire. Susceptibility of pathogens to eight antimicrobial agents was determined. RESULTS: Mean age of patients was 33.87 ± 3.80 years and 84.9% of them were female. The results showed that, E. coli, Kelebsiella and Enterobacter were the most common pathogens (73.5%, 13.8% and 6.6%, respectively). E. coli was susceptible to Ciprofloxacin, Amikacin, and Nitrofurantoin in 76.9%, 76.4% and 76.1% of cases, respectively. Klebsiella was more susceptible to Ciprofloxacin, Ceftizoxim and Amikacin in 81.1%, 79.9% and 87.7% of positive cultures. Enterobacter was most susceptible to Ciprofloxacin (71.7%), but completely resistant to Ampicillin unexpectedly. CONCLUSIONS: E. coli and other isolates were more sensitive to Gentamicin, Amikacin and Ciprofloxacin compared to the other antibiotics tested and therefore these may be the drugs of choice for the empiric treatment of community-acquired UTI in our region.

The effect of pentoxifylline on reduction of proteinuria among patients with type 2 diabetes under blockade of angiotensin system: a double blind and randomized clinical trial.

Although blockade of renin-angiotensin system have been cited as the first line of therapy for the management of diabetic nephropathy (DN), however in a substantial number of patients, progression of renal disease are not completely halted by these agents. We have conducted a double blinded clinical trial to assess the additive effect of pentoxifylline on reduction of proteinuria among patients with type 2 DM under blockade of angiotensin system. The dosage of PTX used in our trial was at a low dosage of 400mg daily and to our knowledge, we did not found article which evaluated the antiproteinuric effect of pentoxifylline in this dosage. One hundred patients with DN and persistent proteinuria despite treatment with losartan and enalapril in at least 3 months before inclusion in the study were randomly assigned to two groups. Control group (n=50, 26 males and 24 females) received losartan and enalapril, while treatment group (PTX Group) (n=50, 28 males and 22 females) was given losartan, enalapril and pentoxifylline 400mg/day for 6 months. At the beginning of the study there were no significant differences in demographic and clinical characteristics of patients including serum creatinine, HbA1c, blood pressure and urinary protein excretion between two groups (P>.05). In the PTX group, the mean rate of urinary protein excretion have significantly decreased from 616.66mg to 378.24 after 3 months (P=.000) and to 192.05mg after 6 months (P=.000) whereas no significant changes were observed in the control group. The beneficial antiproteinuric effect of PTX was not associated to the degree of metabolic control and a reduction of blood pressure. In addition, at the end of study, the mean clearance of creatinine was significantly higher in PTX group (P=.04). In conclusion, PTX can significantly provide additive antiproteinuric effect and slow the decrease in GFR among patients with type 2 DM under blockade of angiotensin system.

Comparison of alendronate and pamidronate on bone loss in kidney transplant patients for the first 6 months of transplantation.

INTRODUCTION: Osteoporosis develops and progresses in a considerable number of kidney transplant patients. Bisphosphonates, which are used for prevention and treatment of osteoporosis, may accentuate gasterointestinal complications and lead to more nonadherence to treatment. This randomized clinical trial was conducted to compare the effect of pamidronate versus alendronate on early bone mineral density changes in kidney transplant patients. MATERIALS AND METHODS: Forty patients (27 men and 13 women), aged from 20 to 58 years, with low bone mineral density (T score < -2) in the spine, total hip, or femur neck were enrolled. Participants were randomly allocated into 2 groups to receive pamidronate or alendronate. The pamidronate group received intravenous pamidronate, 90 mg, starting from the 3rd week of transplantation for 3 months. The alendronate group started to receive oral alendronate, 70 mg per week for the same period. At baseline and 6 months, bone mineral density was measured by dual-energy x-ray absorptiometry. Gastrointestinal side effects were monitored every month. RESULTS: No significant difference was found in bone density changes of the lumber area between the two groups; however, significantly less reduction in bone mineral density of the femur neck and femur occurred in the pamidronate group. Kidney function and parathyroid hormone levels were similar in the two groups before and after the study. Gastrointestinal side effects were seen in 3 patients of the alendronate group only. CONCLUSIONS: Pamidronate was comparable to alendronate in prevention of early bone loss after kidney transplantation.

QT Dispersion: Does It Change after Percutaneous Coronary Intervention?

BACKGROUND: Myocardial ischemia is one of several causes of prolonged QT dispersion. The aim of this study was to evaluate the effect that percutaneous coronary intervention has on the depolarization and repolarization parameters of surface electrocardiography in patients with chronic stable angina. METHODS: We assessed the effects of full revascularization in patients with chronic stable angina and single-vessel disease who underwent percutaneous coronary intervention. Twelve-lead electrocardiograms were recorded before intervention and 24 hours subsequently. We measured parameters including QRS duration, QT and corrected QT durations, and JT and corrected JT duration in both electrocardiograms and compared the values. RESULTS: There were significant differences between the mean QRS interval (0.086 ± 0.01 sec vs. 0.082 ± 0.01 second; p value = 0.01), mean corrected QT dispersion (0.080 ± 0.04 sec vs. 0.068 ± 0.04 sec; p value = 0.001), and mean corrected JT dispersion (0.074 ± 0.04 sec vs. 0.063 ± 0.04 sec; p value = 0.001) before and after percutaneous coronary intervention. No significant differences were found between the other ECG parameters. CONCLUSION: Our data indicate that the shortening of corrected QT dispersion and corrected JT dispersion in patients undergoing percutaneous coronary intervention is prominent.

Signal-averaged electrocardiography in patients with advanced heart failure: a better indicator of left ventricular enlargement compared with conventional electrocardiography.

BACKGROUND: The signal-averaged electrocardiography is a noninvasive method to evaluate the presence of the potentials generated by tissues activated later than their usual timing in the cardiac cycle. The purpose of this study was to demonstrate the correlation between the filtered QRS duration obtained via the signal-averaged electrocardiography and left ventricular dimensions and volumes and then to compare it with the standard electrocardiography. METHODS: We included patients with advanced systolic left ventricular dysfunction (ejection fraction ≤ 35%). All the patients underwent surface twelve-lead electrocardiography, signal-averaged electrocardiography, and echocardiography. RESULTS: The study included 86 patients with a mean age of 54.66 ± 13.23 years. The mean left ventricular ejection fraction was 18.31 ± 5.49%; the mean QRS duration was 0.14 ± 0.02 sec; and 52% of the patients had left bundle branch block. The mean filtered QRS duration was 145.87 ± 24.89 ms. Our data showed a significant linear relation between the filtered QRS duration and left ventricular end-systolic volume, left ventricular end-diastolic volume, left ventricular end-systolic diameter, and left ventricular end-diastolic diameter; the correlation coefficient was, however, not good. There was no significant correlation between the QRS duration and left ventricular diameters and volumes. CONCLUSION: The filtered QRS duration has a better correlation with left ventricular dimensions and volumes than does the QRS duration in the standard electrocardiography.

An innovative method to assess clinical reasoning skills: Clinical reasoning tests in the second national medical science Olympiad in Iran.

BACKGROUND: Clinical reasoning plays a major role in the ability of doctors to make a diagnosis and reach treatment decisions. This paper describes the use of four clinical reasoning tests in the second National Medical Science Olympiad in Iran: key features (KF), script concordance (SCT), clinical reasoning problems (CRP) and comprehensive integrative puzzles (CIP). The purpose of the study was to design a multi instrument for multiple roles approach in clinical reasoning field based on the theoretical framework, KF was used to measure data gathering, CRP was used to measure hypothesis formation, SCT and CIP were used to measure hypothesis evaluation and investigating the combined use of these tests in the Olympiad. A bank of clinical reasoning test items was developed for emergency medicine by a scientific expert committee representing all the medical schools in the country. These items were pretested by a reference group and the results were analyzed to select items that could be omitted. Then 135 top-ranked medical students from 45 medical universities in Iran participated in the clinical domain of the Olympiad. The reliability of each test was calculated by Cronbach's alpha. Item difficulty and the correlation between each item and the total score were measured. The correlation between the students' final grade and each of the clinical reasoning tests was calculated, as was the correlation between final grades and another measure of knowledge, i.e., the students' grade point average. RESULTS: The combined reliability for all four clinical reasoning tests was 0.91. Of the four clinical reasoning tests we compared, reliability was highest for CIP (0.91). The reliability was 0.83 for KF, 0.78 for SCT and 0.71 for CRP. Most of the tests had an acceptable item difficulty level between 0.2 and 0.8. The correlation between the score for each item and the total test score for each of the four tests was positive. The correlations between scores for each test and total score were highest for KF and CIP. The correlation between scores for each test and grade point average was low to intermediate for all four of the tests. CONCLUSION: The combination of these four clinical reasoning tests is a reliable evaluation tool that can be implemented to assess clinical reasoning skills in talented undergraduate medical students, however these data may not generalizable to whole medical students population. The CIP and KF tests showed the greatest potential to measure clinical reasoning skills. Grade point averages did not necessarily predict performance in the clinical domain of the national competitive examination for medical school students.

Heart and athlete.

Regular participation in intensive physical exercise is associated with electro-morphological changes in the heart. This benign process is called athlete's heart. Athlete's heart resembles few pathologic conditions in some aspects. So differentiation of these conditions is very important which otherwise may lead to a catastrophic event such as sudden death. The most common causes of sudden death in young athletes are cardiomyopathies, congenital coronary anomalies, and ion channelopathies. The appropriate screening strategy to prevent sudden cardiac death in athletes remains a challenging issue. The purpose of this review is to describe the characteristics of athlete's heart and demonstrate how to differentiate it from pathologic conditions that can cause sudden death.