Co-existence of cutaneous leishmaniasis with pleural effusion: a case report from Iran

Herein, a 12-year-old Afghan boy with chronic cutaneous leishmaniasis on the face and verrucous lesions on the body and pleural effusion suspected of having co-existent tuberculosis has been presented. The cutaneous lesions were appeared for five years before his admission. Leishman-Donovan bodies were seen in H and E [Hematoxylin and eosin] slide of skin lesion specimens. The pathogenic species was proved to be Leishmania tropica using Polymerase Chain Reaction [PCR] method. Purified Protein Derivative [PPD] and Leishmanin Skin Test [LST] were strongly positive. The patient was treated with systemic and intralesional meglumine antimoniate [Glucantime] for cutaneous leishmaniasis and then with anti-tuberculosis drugs for pleural effusion. Afterwards, pleural effusion was disappeared and cutaneous leishmaniasis cured

Cutaneous leishmaniasis in suspected patients referred to the center for research and training in skin diseases and Leprosy, Tehran, Iran from 2008 to 2011

Cutaneous leishmaniasis [CL] is a major health problem in many parts of Iran, although diagnosis of CL especially in the endemic area is easy, but treatment and management of the disease is a global dilemma. Diagnosis of CL in non-endemic area is not as simple as in endemic foci. In this study, the status and the proportions of CL induced by Leishmania major and L. tropica among CL suspected patients referred to the Center for Research and Training in Skin Diseases and Leprosy, [CRTSDL] during 2008 to 2011 are described. CL patients with suspected lesions were clinically examined. History of trip to zoonotic CL and/or anthroponotic CL endemic areas and the characteristics of their lesion[s] were recorded. Diagnosis of the lesion was done using direct smear microscopy, culture and conventional polymerase chain reaction [PCR]. A total of 404 [M=256, F=148] patients with 776 lesions were recruited and parasitologically examined. The results showed that 255 of the patients with 613 lesions; patients with lesion[s] induced by L. major=147 [M=63, 43%, F=84, 57%] and lesion[s] induced by L. tropica=108 [M=35, 32%, F=73, 68%]. History of travel to endemic area was not always correlated with isolated Leishmania species. Although travel history to endemic area is an important factor to be considered for diagnosis, but parasitological confirmation is necessary initiation of treatment

Dermatology: a public health perspective

Dermatology is a branch of medicine which is related to the diagnosis, treatment and prevention of the diseases and disorders that affect the skin and its appendages including hair, nail, sweat glands and mucosal surfaces of mouth and external genitalia. There are about 3000 clinical entities in the field of dermatology, which are very diverse in terms of their etiologies. Although some of these diseases are really prevalent and some others of them have high incidence rates and acknowledging that because of their visibility in many cases they are associated with stress, anxiety and impairment of patients' quality of lives, their resultant burden of disease at individual, familial and social levels are usually ignored. Herein, we provide some examples of the adverse public health and health economics effects of different dermatological diseases and disorders in different countries and populations. We also provide some reasons for this negligence and suggest some strategies to tackle this problem

Safety and efficacy of tacrolimus 0.03% ointment in the treatment of atopic dermatitis: a randomized, double-blind, placebo controlled clinical trial

Atopic dermatitis [AD] is a chronic, relapsing, pruritic skin disease more common in infancy and childhood. Emollients, topical corticosteroids, and avoidance of irritating factors are the mainstay of its treatment, but fear of side effects has limited the use of topical corticosteroids. The objective of this study was to evaluate the safety and efficacy of topical tacrolimus 0.03% ointment in the treatment of AD. In this randomized, double-blind, clinical trial, 76 patients with AD older than 2 years were randomly allocated in two groups and treated with either tacrolimus 0.03% ointment [Abu-Rayhan Co., Iran] or placebo, twice a day for 6 weeks. Responses to treatment were compared every 2 weeks using SCORAD. Twenty-nine patients in tacrolimus group and 26 in placebo group completed the trial. The reduction in SCORAD after 2 and 4 weeks in tacrolimus group was significantly higher than placebo group [P<0.05]. The frequency of treatment-induced pruritus and burning sensation was similar in both groups but erythema was more observed in the placebo group [P<0.05]. Tacrolimus 0.03% ointment is more effective than placebo in the treatment of AD

Blood pressure screening in school-aged children in Tehran

Hypertension is one of the most common diseases in the world and a major risk factor for cardiovascular, renal, and neurologic diseases. It seems that hypertension and overweight in children are a growing epidemic. The aim of this study was to investigate the prevalence of hypertension in school-aged children in Tehran. In a cross-sectional study, blood pressure and anthropometric measurements were performed on school-aged children in Tehran from 2008 to 2009. Children aged 7 to 11 years from 5 public schools in Tehran were included. Blood pressure, weight, and height measurement were performed at the school. At each screening, 3 seated blood pressure, weight, and height measurements were made and at least after 3 minutes of rest and choosing proper cuff, blood pressure was measured by a pediatric nephrologist and a pediatric assistant. A total of 425 school-aged children were included. Twenty-four percent of the primary school children had hypertension and 12% were shown to be overweight. Hypertension was more common in students of the north of Tehran in comparison to other geographic parts of Tehran. There was a significant difference in the prevalence of hypertension between girl students of north of Tehran and girls of the other parts of Tehran. We concluded that hypertension is a common problem in school-aged children. Our study re-emphasized the need for prevention and control of high blood pressure in children to manage the global diseases burden due to hypertension

Ultrasonographic measurement of subarachnoid space and frontal horn width in healthy Iranian infants

Ultrasonography is among the most general evaluating methods for central nervous system [CNS] assessment, especially for detecting extra axial collection via anterior fontanel. There are few studies showing values of this technique in normal developing infants for detection of subarachnoid space width. Association between age and sex and cerebrospinal fluid [CSF] spaces are controversial. Therefore, we conducted this study to evaluate the relationship between subarachnoid space and sex and age in Iranian infants. We used ultrasonography with a 7.5 MHZ linear probe to evaluate 74 healthy infants who were referred to our departments for other reason.s sinocortical width [SCW], craniocortical width [CCW], interhemispheric width [IHW] and frontal horn width [FHW] were evaluated. Data was collected an analyzed using STAT 9.1 software. Fifty four percent of the patients were male and 45% were female. Mean age of cases was 71 days. Mean SCW was 2.8 +/- 1.33 mm [5% and 95% were 1.1 and 5.8]. Mean CCW was 2.52 +/- 1.37mm [5% and 95% were 1.2-5.8]. Mean CCW was 2.52 +/- 1.37 mm [5% and 95% were 1.1 and 5.2mm, respectively] and mean IHW was 4.39 +/- 2mm [5% and 95% were 1.7 and 8mm, respectively]. Mean FHW was 2.9 +/- 1.09 mm in females and 3.52 +/- 1.34mm in males [5% and 95% were 1.4 and 5mm in females and 1.7 and 5.8 mm in males, respectively]. There was no significant difference in subarachnoid space width between boys and girls except for FHW which was wider in males than females. All spaces diameter correlated with age and were wider in older infants. Although our sample size was rather small for accurate conclusion, we found a normal range which was wider than western countries but similar studies conducted in China. Delayed maturation of arachnoid villi is one of the most important reasons of subarachnoid space widening in infants younger than one year which seems occur later in Iranian infants

[Comparison of efficacy of intralesional injection of meglumine anti-moniate once-weekly with twice-weekly in the treatment of anthroponotic cutaneous leishmaniasis in Mashhad: a randomized clinical trial]

Cutaneous leishmaniasis [CL] is endemic in Iran, where it is one of the most important health problems. Both anthroponotic CL [ACL] caused by L. tropica and zoonnotic CL [ZCL] caused by L. major are reported. Antimoniate derivatives as the standard therapy for CL need multiple injections and are not easy to tolerate for the patients. This study was conducted in Mashhad to compare the efficacy of weekly versus twice a week intralesional injections of meglumine antimoniate [MA] in the treatment of ACL. This randomized controlled trial was performed during 2006 to 2008 in Mashhad, Iran. Using computerized sequence of random numbers, participants were randomly allocated in the two arms of the study: one receiving weekly and the other receiving twice-a-week intralesional injections of MA. The lesion size, induration and healing rate were assessed, recorded and compared. Healing was defined as complete re-epithelialisation and disappearance of duration. A total of 252 suspected CL patients with 372 lesions were screened. 82 parasitologically proven cases with 121 lesions caused by L. tropica were included and 74 patients with 113 lesions completed the study. At 12[th] week after initiation of treatment, complete healing was observed in 38 out of 44 lesions [86.4%] in the group which received weekly intralesional MA injection. The median time-to-heal in this group was 36 days [95% confidence interval [CI]: 32.0-39.9]. Complete healing was recorded in 60 out of 69 lesions [86.9%] in the group which received twice a week intralesional injections of MA with a median time-to-heal of 25 days [95% CI:20.9-29.1]. While no significant difference was observed between the two groups in terms of complete healing rate [P=0.999], time-to-heal was significantly different between the 2 groups [P=0.003]. It seems that the effectiveness of twice-weekly intralesional injections of MA is similar to once-weekly regimen while the former regimen causes more rapid healing of lesions

[Evaluation of diagnostic test accuracy studies]

In the recent years, advances in different fields of technology have been resulted in a dramatic increase in the diagnostic methods and tests in different branches of clinical medicine with a consequent increase in the number of scientific methods in the diagnosis or prevention of diseases. dermatology is not an exception, Since, evidence-based medicine emphasizes on the appropriate use of the current best clinical research evidence in the diagnosis or treatment of each individual patient acknowledging his/her values, the capability of dermatologists in appraisal and application of the publications, which reports the results of diagnostic test review on basic issues in diagnostic test accuracy studies, principles of critical appraisal of these studies, from an evidence-based viewpoint, will be discussed. General strategies for evaluation of validity, applicability and quality assessment of a diagnostic test study will be provided

[Comparison of the efficacy of weekly vs. twice a week intralesional injections of meglumine antimoniate in the treatment of anthroponotic cutaneous leishmaniasis: a randomized clinical trial]

Treatment of cutaneous leishmaniasis, especially when caused by L. tropica, is challenging. Meglumine antimoniate [Glucantime[R]] is used as the standard treatment, but multiple injectiond are necessary. The objective of this study was to compare the efficacy of weekly intralesional injections with twice weekly injections of Glucantime for the treatment of anthroponotic cutaneous leishmaniasis [ACL]. This randomized open clinical trial was conducted, in Bam, Kerman province, Iran. 96 eligible patients according to inclusion and exclusion criteria who were willing to participate were included. The included patients were randomly assigned into two groups, one group treated with weekly intralesional injections of Glucantime[R] and the other group treated with intralesional Glucantime[R] twice a week. Type and size of each lesion [induration, ulcer and scar] were recorded weekly. Complete healing was defined as complete re-epithelialization and absence of induration in all lesions and was considered as the primary outcome measure. A total of 48 patients completed the study; complete cure was seen in 24 of 27 [89%] patients who received weekly intralesional MA with a mean duration of healing equals to 70 +/- 10 days. Complete cure was seen in 24 of 31 [77%] patients who received intralesional MA twice a week, the mean duration of healing in the latter group was 58 +/- 5 days. There was no significant difference between the two groups [P=0.23]. It seems that the efficacy of intralesional injections of Glucantime[R] once a week is similar to efficacy of twice a week Glucantime[R] injections

[ review on evidence-based medicine]

Physicians' daily need for valid information about diseases, their limited time for finding this information, the inadequacy of traditional sources [E.g. textbooks] to address this matter, the disparity between physicians diagnostic skills and clinical judgment [Which increase with experience] and their up to date knowledge and clinical performance [Which decline by time], as well as dramatic development in the field of information technology that provides easy access to an uncountable number of data resources, all have resulted in the consideration of evidence-based medicine [EBM] as an appropriate approach to solve these problems. EBM is defined as: [The conscientious, explicit, and judicious use of current best evidence in making clinical decisions about the care of individual patients]. The full-blown practice of EBM comprises five steps: Step 1] Asking a well-built clinical question; step 2] Tracking down the best evidence which answer that question; step 3] Critically appraising that evidence for its validity, importance, and applicability; step 4] Integrating the critical appraisal with the clinical expertise and with the patients unique values and circumstances; and step 5] Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them for next time

Evaluation of clinical trials

In a number of important clinical issues such as evaluation of the efficacy or effectiveness of therapeutic or preventive interventions as well as for comparing the harms of interventions, randomized controlled trials [RCTs] provide the highest levels of evidence, either directly or indirectly. It is obvious that critical appraisal of these studies to assess their validity and precision is of paramount importance. The aim of this review is to provide the readership an outline about different types of RCTs, the importance of proper appraisal of RCTs, an overview of the most important factors that have an influence on the validity of an RCT and a strategy for systematic evaluation of those factors, and to introduce some useful methods for improving design, implementation and reporting of RCTs as well as some tools that are used for the evaluation of these studies. It is expected that after reading this review, the reader obtains some knowledge about different phases and types of RCTs, as well as being enabled to evaluate the four major factors: randomization sequence generation, randomization concealment, blinding and intention to treat analysis that affect the validity of an RCT

Uses of intravenous immunoglobulines

Adjuvant high dose IVIgs are being used increasingly in a range of immune-mediated and auto-immune diseases. Although numerous immunomodulatory mechanisms have been suggested, the exact mechanisms of action are poorly understood. The efficacy of IVIg in certain diseases has been proven in clinical trials, in so far as IVIg is approved as the therapy of choice for Kawasaki syndrome and idiopathic thrombocytopenic purpura. IVIg treatment has been shown to be safe, without many drug-related adverse effects, including systemic immunosuppression, that are related to corticosteroids and other immunosuppressive agents. Current dermatologic uses of IVIg are increasing, which calls for adequately controlled clinical trials. This review evaluates the current published data on the use of IVIg therapy in the treatment of autoimmune diseases and discusses current opinion concerning its potential immunomodulating mechanisms, the industrial preparation and safety features of this biologic agent

[ comparison between the efficacy of intralesional injection of 2% Zinc Sulfate solution with Glucantime in the treatment of acute old world cutaneous Leishmaniasis: a randomized, double-blind, controlled clinical trial]

Several treatment modalities have been used for cutaneous leishmaniasis[CL] with various results. In vitro and in vivo studies have shown inhibitory effects of zinc sulfate [ZnSO4] on Leishmania parasites. To compare the efficacy of intralesional injections of 2% ZnSO4 solution with meglumineantimonate[Glucantime] in the treatment of acute Old World CL. Seventy-two patients with CL with a duration of less than 8 weeks were recruited in a randomized, double-blind, clinical trial in Isfahan province - an area endemic for Leishmania major - after giving written informed consent. They were treated with 6 weekly intralesional injections of either 2% sterile ZnSO4 solution or Glucantime prepared in identical vials. The primary outcome measure was complete re-epithelialization of CL lesions. Among 36 patients with 53 lesions treated with ZnSO4 and 36 patients with 53 lesions treated with Glucantime, 13 patients with 19 lesions and 22 patients with 31 lesions completed the trial, respectively. Inadequacy of treatment was the main reason for drop-out in 12 [33.3%] and 2 [5.5%] patients in ZnSO4 and Glucantime groups, respectively [P < 0.05]. Complete re-epithelialization was observed in 2 [10.5%] and 19 [61.3%] lesions 1 week after the end of treatment in the ZnSO4 and Glucantime groups, respectively [P < 0.05]. A six-week course of weekly intralesional injections of 2% ZnSO4 solution was less effective than Glucantime in the treatment of acute Old World CL