[Determining the rate of catastrophic health expenditure and its influential factors on families in Yazd province]

Introduction: The high rate of catastrophic health care expenditure is a challenging problem societies face today. Identifying the influential factors on the expenditure is an important measure which should be taken to control them. In this study, the catastrophic health expenditure and its influential factors were examined

Methods: Within the framework of Health Center Province, 400 households were selected in winter 2011. The WHO's health questionnaire was completed for them by the researchers. The incidence of catastrophic health expenditure was evaluated in accordance with the World Health Organization definition and influential factors on the expenditures were investigated by using Stata software 11

Results: It was found that 8.3 Present of the families of Yazd province were exposed to catastrophic health expenditure. The use of inpatient services was shown to have the largest amount in paid-out-of-pocket expenditure and their relationship to incidence of catastrophic health expenditure was found to be significant. It was, moreover, found that the relationships between family sizes, persons below 5 years old in the families, and the use of medical services and diagnosis with catastrophic health expenditure were significant

Conclusion: The variables of medicine, diagnosis, inpatient services and persons below 5 years old in household and family size should be seriously taken into account by policy makers to control Catastrophic Health Expenditure

Learning styles of health services management students at Tehran University of medical sciences

Identifying learning styles among students are very important in order to orient in learning and teaching activities. The aim of this study was to determine the learning styles of students in the ground of health services management in Tehran University of medical sciences in 2010. In this descriptive cross-sectional study, total of health services management students' in Tehran University of medical sciences applied in a census study. The tool which used in this research was VARK learning style questionnaire. Data was analyzed by VARK software that later on designed into Excel and SPSS soft wares. In total, 130 out of 150 students completed returned questionnaire [Response Rate=87%]. Only 33.1% of the students preferred a Uni-modal learning style. Among those students; 10.8% preferred kinesthetics style, 10% preferred read and writing style, 9.2% auditory, and 3.1% preferred visual style. In contrast, the most of students [66.9%] preferred multi-modal [Bi-modal [18.5%], Tri-modal [13.1%], Quad-modal [35.4%]] learning styles. There was no significant association between grade point average, sex and education degree with learning styles. Awareness of existing different learning styles among health services management students' will help to trainers and educators to develop the effective learning approaches and also tailored to students in learning styles. Based on results, it is suggested to apply active learning strategies such as discussion groups, role playing, and simulation and so on to students in this field

[Determination of pneumococcal MIC to antibiotics in pneumococcus strains isolated from Zanjan hospitals]

There are many reports associated with growing increase in incidence of drug resistance in streptococcus pneumoniae strains, complications caused by these organisms during clinical treatment, increasing cost of therapy, and poor prognosis. To determine pneumococcus drug resistance in Zanjan hospitals. This was a cross-sectional study in which all positive cultures for pneumococci were collected from Bouali pulmonary center laboratory and Vali-e-Asr laboratory for determination of MIC. The data were gathered through a questionnaire and further analyzed by chi-square test using SPSS 11.5 for windows package. Of 57 patients, 25 were males and 32 females. The average age of patients was 49.4 with a range of 13-87 years. MIC test for penicillin showed that 24 [42.1%] samples were sensitive, 24 [42.1%] with intermediate susceptibility and 9 [15.8%] resistant. MIC results for ceftriaxone showed higher sensitivity among 52 samples [91/2%] and lower resistance in 5 [8/8%] specimens. All cases were sensitive to vancomycin. There was a significant relationship between underlying diseases and sensitivity to ceftriaxone. Regarding the high resistance of pneumococci to penicillin, it is recommended ceftriaxone to be used as the first line treatment and in case of resistance it should be replaced with vancomycin

[Chronic. hepatitis. B]

Chronic hepatitis B is a major medical problem, distributing all over the world. Affecting more than 400 million people. In highly prevalence places, childhood transmission is the most common form but in low prevalence areas, injection, drug use and familial transmission are the main routes of acquisation of infection. Hepatocellular carcinoma and cirrhosis are significant problems of chronic hepatitis B. Exposure to HBV early in life may progress to hepatocellar carcinoma. The annual number of deaths from HBV infection and related diseases throughout the world is about 1.2 million. The goal of treatment of chronic hepatitis B with Lamivudin or INF-Alpha is sustained suppression of virus replication and liver disease remission. INF, Alpha and Lamivudin have similiar efficacy. The adventage of Lamivudin is that it is less expensive and is well tolerated and adventages of INF. Alpha are the short duration of treatment and absence of resistance but it is expensive and has many side effects. The response rate of INF. Alpha is better than Lamivudin but it is associated with a large number of side effects, sometimes we have to stop or decrease the dose of INF. Viral genotypes and other factors such as pretreatment viral load, fatty liver and liver histiology may alter the response rate. The long-term use of Lamivudin may be with the emergence of YMDD mutations. Treatment of YMDD form of chromic hepatitis B, with combination of Lamivudin and Adefovir dipivoxil, may improve liver function; and YMDD mutations may be over come. The emergence of YMDD mutations reduces the benefit of Lamivudin but does not negate it

[Step by step diagnosis]

A 25 - years- old man was admitted to the hospital because of fever, chills and jaundice after return from Pakistan . On physical examination he had fever [40°C] and BP of 120/70, respiratory rate and pulse rate were 24 and 100 respectively. Heart sounds were normal and there wasn't any pathologic sound in lungs. The sclera was icteric yet there wasn't any signs of anemia _and no adenopathy was found. In abdomen, hepatosplenomegaly was present and right upper quadrant had tenderness on examination, however, there wasn't ascitis and collateral circulation. Laboratory tests performed and revealed leukopenia [3500] and thrombocytopenia [70000] but no anemia, increased liver function tests and bilirubin, though normal PT and PTT. Wright, 2 ME, widal was negative. Sonography of abdomen revealed hepatosplenomegaly, still other findings were normal. Because of high fever blood culture performed and parenteral antibiotic started. For bicytopenia and increased liver function tests, bone marrow aspiration and additional tests, also, carriedout. Markers of viral hepatitis [HAV. HBV. HCV. CMV HBV.HSV] and autoimmune hepatitis were negative and BMA was normal. After five days of admission when the patient was on parenteral ceftriaxone and did not have any fever and felt much better, the result of blood culture reported as salmonella typhi. As a result in patients with fever, jaundice and hepatosplenomegaly it is essential to consider typhoid fever, although the widal test is negative

[Evaluation of deprenyl effect on Bcl-2 protein expression in spinal motoneuron of adult rat following sciatic nerve root avulsion]

Avulsion of sciatic nerve ventral root leads to cell death of motor neurons. Deprenyl has a neuroprotective effect on spinal cord motoneurons. To evaluate the effect of deprenyl on Bcl -2 protein expression in adult rats after ventral root avulsion of sciatic nerve. This was an experimental study performed in Jondishapour University of Medical Sciences [Ahvaz, Iran] in 2005. Twenty four Sprague-Dawley adult male rats were divided into two experimental and control groups and each group further subdivided into three subgroups of 4 members. Rats were anesthetized with ketamin and xylazin injections followed by avulsion of left sciatic nerves. One hour later experimental subgroups were intraperitoneally injected with 0.25 mg/kg of deprenyl and control subgroups received an equal volume of distilled water intraperitoneally. Two intact rats were also considered as sham group. The first injection was performed one hour after avulsion and repeated daily for one, two and six weeks. Later, animals were sacrificed and the spines removed at L1 lumbar segment equal with L4-L6 spine segment. The segments were lysed in lysis buffer and centrifuged. Optical densities of supernatants were measured using a spectrophotometer. The normality of data was confirmed by Npartest. Optic density of Bcl-2 protein in two weeks experimental group [0.55 +/- 0.79] was significantly [p=0.042] higher than two weeks control group [0.424 +/- 0.058]. It seems that Bcl-2 protein expression is increased by deprenyl drug

[Denouement continued/rom page 51 your diagnosis please!]

Aremarkable aspect of the patient's illness is hepatomegaly, splenomegaly right upper abdominal discomfort and jaundice. In lab tests increasing of SGOT and SGPT with high level of alkaline phosphatase and gammaglutamyltranspeptidase with hypergammaglobulinemia, moderate increasing of bilirubine was seen while all the viral hepatitis markers for hepatitis A, Band C were negative. Liver ultrasonography revealed diffuse increase in echogenecity as compared with that of kidneys. C.T scan of liver showed some hepatic lesions that suggested of metastatic lesions. Diffuse increase in echogenecity of the liver of this patient on sonograghy and low density of hepatic parenchyma on C.T scan could be fatty infiltration of the liver. Regardless of the cause, cirrhosis has a similar appearance on imanging study. This patient as mentioned in her medical history did not consume alcohole, but in lab tests we noted her triglyceride and cholesterol were high and because of rheumatiod arthritis she has been on metothorexate since two years ago. On lab tests all the viral hepatitis markers were negative and esophagogasteroduodenal endoscopic examination showed no portal hypertention [no dilatation of esophagal veins in inferior part of esophagus]. Steatosis in most patients with non - alcoholic fatty liver may have appearance of malignant liver. hypercalcemia may be co- existence with cancer of liver in this patient. hypercalcemia may have many causes but what are the clues to the cause of hypercalcemia in this case? hyperparathyroidism, hyperthyroidism, thiaside diuretic consumption, chronic renal failure, Addison's disease and ingestion of excess vit A or vit D may cause hypercalcemia, as in this case; because of Rheumatoid arthritis, she has been prescribed excess dosage of vit 0 Serum protein electrophoresis of this case revealed hypoalbuminemia and hypergammaglobulinemia a phenomena we see too often in chronic liver diseases. In this patient, liver biopsy is the best diagnositic tool and it is usefull to determine kind of treatment and alimentary restrictions. In liver biopsy assay by grading for steatosis and staging for fibrosis you can find the depth of liver lesions. Liver biopsy was done and pathologist data was non-alcoholic steatohepatitis, precirrhotic stage. In non-alcoholic fatty liver with cirrhottic stage, steatosis is diffuse in most patients but, occasionally it is focal in imaging study, both ultrasonography and C.T. Scan may be misinterpreted as showing malignant tumours of liver. In such cases MRI can distinguish space occupying lesions from focal fatty infiltration. But gold standard of diagnosis is liver biopsy. In this patient pathologist data was macro and microvesicular ballooning, PMN cells infiltration around the hepatocytes and fibrosis around the hepatocytes. And bridging fibrosis. Grade II stage III The patient advised for weight loss, avoiding of fatty meals and home Remedies for one year and vitamin E and, B couplex prescribed. Some experts use clofibrate or metformine

35 year old man with fever, weight loss and splenomegaly

A 35 year - old man was referred to an infectious disease specialist because of two weeks; fever, fatigue, 4kg weight loss and an obscure pain of whole body. He had otherwise been well until 1 5 days before. 10 days before; treatment with Procaine Penicillin [800,000 U per 12 hours] and Amoxicillin by a G.P was begun. 5 days later a physician sent him to a lab for routine blood examination and febrile agglutination tests. His physician on physical examination of patient found a palpable spleen and his temperature was 38c, CRP+ + and ESR was 45 mm per h our. In auscultation, heart and lungs were normal. A urine culture was negative.Blood sugar, Creatinine, Cholesterol and Triglycerides were normal. Hematologic lab values were: Hct%40, MCV 82, WBC [Per mm3] 9 100, dif count N=35, L=55, E=O, M=8, B=2, PLT250 000, Blood *chemical *values Creatinine 0.9, Sugar 95, Calcium normal, Liver enzymes; ALT=50, AST=48. And Tuberculin Test positive with 12 mm indurations. The patients' weight had dropped from 75 to 71 Kg. The temperature was 38 c.The pulse rate was 75, respiration rate was 22. The blood pressure was 1 10/70. The urine was positive [++] for protein, Urea Nitrogen 33 mg/dl, Creatinine 1.2mg/dI. Na 139 mmol; K, 4.5mmol/lit; Glucose 119 mg/dl; Bilirubin total 1.7 and direct 0.6; and normal liver enzymes, EKG showed sinusal tachycardia; the other findings were otherwise normal. Chest X-Ray showed no abnormality. Sample of blood was obtained for culture. Temperature was controlled each day and it was maximum 38.3 centigrade. On the next clinical visit of patient,three days later, serum sample obtained on the seventh day of illness was negative for Salmonellosis and Brucellosis and first report of blood culture was negative too. A CT-Scan of lumbo-saccreal portion and Chest x Ray gave no diagnostic information A diagnostic procedure was performed

Step by step clinical diagnosis. A 59 year old man with episodes of jaundice, anemia and repeated transfusions

A 59 Businessman presented to private clinic in Mashhad with one-week history of jaundice, anemia, weakness and vertigo. He reported having had dark urine, loss of appetite and tiredness. This man was a proved Case of PNH since 9 years, and he had been on predniselone 30 mg every other day. When the diagnosis of PNH by Ham test and Sugar test was confirmed and a bone marrow aspiration showed no severe abnormality except Hyperplasic B.M. Because of severe hemolytic anemia he received several times blood transfusion. In many developing countries, one of the primary routes of HCV infection is post blood transfusion. In spite of transfusion of screened blood products. In screening the patient for viral Hepatitis, HBsAg and anti HBC markers were negative but HCV antibody by 3ed generation Elisa assay was positive. A quantitative HCV PCR assay was positive with more than 12 million Virus copies per ml, Liver function tests were high [ALT and SLT]. Ultrasonography of liver showed a fatty liver without symptoms of portal Hypertension and ascitis. Pegasys [Peg interferon alpha -2 alpha Roche] with 180 mcgr. per week started but because of declining platelets, Neutrophyls and Hb after 4 injections, the peg interferon dosage was decreased to 135 mcgr per week and after 20 weeks to 90 mcgr per week. In spite of decreasing peg-interferon dosage, the number of platelets and neutrophils were under normal limit. Because of hemolytic side effect of Ribaverine we did not, prescribe this drug. In another HCV-PCR assay, it was strongly positive and liver enzymes were high, and PT was 19 seconds despite of injection Vit K and infusion of [factors 8 and 9] FFP, Prothrombin time did not change. The patient in a trip to Paris in Necker hospital was evaluated again and a transjugular liver biopsy was done. The report of liver pathologist of Necker Hospital by Metavir scoring was: A[1] F[2] and by Knodell scoring was: 0+1+1+1. So peg interferon discontinued and a complete check up of patient after Peg interferon D.C, evaluated a good condition. Liver enzymes were at normal range, total Bilirubin, less than 3 mg, WBC at a normal range, and no hemorrhagic abnormality. The patient now is in Mashhad with a good condition in spite of HCV-PCR positive. He is on a monthly clinical and laboratory surveillance and probably second liver biopsy should be done after one-year interval

[Congenital cataract with pre-existing posterior capsule defect]

To evaluate the diagnostic signs, intraoperative complications and postoperative outcomes in children with congenital cataract and pre-existing posterior capsule defect [PPCD]. This interventional case series was conducted on 14 eyes of 7 patients who underwent lensectomy-anterior vitrectomy for congenital cataract with PPCD. All children had bilateral cataract. Preoperative diagnostic sign of PPCD detected under maximum pupil dilation in patients without a mature cataract included a well-demarcated horizontal oval defect with white margin and scattered white dots around the defect. The greatest lens opacity was over the defect itself. In patients with mature cataract, PPCD was diagnosed during operation. Bimanual irrigation/aspiration and 2-port anterior vitrectomy was performed in all cases. The patients included in 2 girls and 5 boys with mean age of 11.4 +/- 4.1 month. PPCD was diagnosed preoperatively in 5 patients [10 eyes] and intraoperatinely in 2 patients [4 eyes]. Intraocular lens was implanted in 2 eyes of one patient and 12 eyes were left aphakic. Except for nucleus dislocation into the anterior vitreous in our first case which was successfully removed, no other intraoperative complication occurred. During a mean follow up of 21.1 +/- 7.1 month [18-36 month] the visual axis remained clear in all the eyes. Establishing the diagnosis of PPCD preoperatively with fully dilated pupil and careful surgical planning prevents intraoperative complications and produces satisfactory technical results

[Prediction of visual outcome after penetrating keratoplasty for pseudophakic and aphakic corneal edema]

To evaluate the ability to predict visual outcome after penetrating keratoplasty [PKP] in patients with pseudophakic or aphakic corneal edema [PCE or ACE]. Medical records of 34 patients [34 eyes] who underwent PKP for PCE or ACE during 1994-2004 in Ahvaz were retrospectively analyzed for variables in the history and ocular examination before PKP and visual outcome after PKP. The predictive value of each preoperative variable including age, gender, method of intraocular lens [IOL] implantation, vitreous loss during cataract surgery, time between cataract and PKP surgery, and history of glaucoma or increased intraocular pressure [IOP] before PKP surgery on post-PKP visual outcome was assessed using logistic regression analysis. Odds ratio [OR] with 95% confidence interval [95% CI] was calculated for predictive factors. Mean follow-up was 23.6 months. Best corrected visual acuity [BCVA] of 20/200 or better was achieved in 17 patients [50%]. The strongest predictors of this outcome were time between cataract surgery and PKP [P=0.008, OR=3.50, 95% CI; 0.48-31.18], aphakia [P=0.027, OR=4.29, 95% CI; 0.36-114.8] and no history of glaucoma or increased IOP before PKP [P=0.020, OR=3.75, 95% CI; 0.71-21.41]. In patients with PCE and ACE who are candidates for PKP, time between cataract and PKP less than 20 month, no history of glaucoma or increased IOP before PKP, aphakia versus presence of IOL are associated with a better visual outcome

Your diagnosis please?

A 25-year-old man was evaluated in clinic because of fever, chills, sweats and bicytopenia. 3 months ago, the patient had a trip to south of Iran, where he received vaccines against Hepatitis B and Meningococcus Meningitis and had begun taking Resochine for prophylaxis against Malaria. During his trip he consumed local food and stream water, as drinking water. The patient received many insects' bites. After finishing his trip he returned to Mashhad and discontinued Resochine prophylaxis. This man was well until two months later when he begun having a high fevers [40° C]. Chills sweats, dark urine and mild jaundice. The next day the patient fever was high Nausea developed and had one bout of diarrhea. That evening he came to a private clinic. Physical examination revealed palpable spleen, Mild jaundice. His temperature was 39 C, hematologic tests were performed and Dextrose water serum and antipyretic started. On the next-day hematologic lab data received: Hct 39.5%, WBC 3900 [mm[3]], Neut 74%, Lymphocyte 15%, Monocyte 4%, Eo 1%, Baso 1%, Platelate 105000, ESR 22,Bilirubine 2.7 mg/dl, SGOT 60, SGPT 59, the level of glucose, Creatinine, Amylase were normal, HBV, HCV, HAV Markers were negative. On the next day he was well but on the following day, fever returned and the patient came back to clinic where his temperature was, 40.2°C, on physical examination the findings had not changed. Blood sample was cultured, febrile agglutinin tests, CBC, LFT, Mono test, urinalysis and chest radiograph was done. The patient was unmarried but he denied any illegal sexual contacts. On the third day, examination of patient revealed. Slightly pale sclera without skin rash and lymphoadenopathy, but just a palpable spleen. In lab report, the level of creatinine, glucose, electerolytes SGOT, SGPT, were normal, blood culture remained negative and CBC showed bicytopenia and urine exam was positive for protein, bilirubine, and urobilinogen and the sediment contained no RBC, 5 WBC, and a few bacteria per hpf

Denouement your diagnosis please, continued from page 15

Among the infections, requires the consideration of many entities: acute viral infections like infectious mononucleosis and other viral infections. Such as prodrome of viral hepatitis as initial infection with HIV are considerable, but the patient, had no adenopathies or hepatomegaly, acute salmonella infection is usually recognizable by blood culture in the first week of illness. Patients with SBE present with prolonged fever and usually heart valves symptoms. Unconjugated hyperbilirobinemia raise the possibility of hemolytic anemia like an autoimmune disorder. Autoimmune hemolytic anemia may be induced by drugs or cold reactive antibodies produced by infectious mononucleosis or mycoplasma pneumonia. Microangiopathic hemolytic disorders - DIG, HUS and TTP usually have a more rapidly declining clinical course and they have renal failure and bleeding, none of these finding were found in this case. This patient had a trip to south of Iran two months ago. Each geographical location has specific rates of infections. In south of Iran, malaria is prevalent, malaria is transmitted by the bites of anopheles mosquitoes within minutes after a bite sporozoites invade the liver and after, 8-to-21 days, merozoites enter the blood stream and invade erythrocytes where they pass through trophozoite and schizont stages and produce merozoites again which continue the cycle and expand the infection. The symptoms of malaria are non-specific and once the diagnosis is made, identification of the causative species of plasmodium is necessary for treatment. P. falciparum and P. Vivax account for the majority of infections world- wide. Including south of Iran, P. malaria is very rare and doses not have a hypnozoite phase, but it can present after a long period of latency. Information on the travel history and incubation periods is useful for identifying the probable species but morphologic features observed on the blood smear are definitive. In the management of malaria, to examine a number of parazites on the blood smear to allow correct identification of the species and to rule out possibility of infection with more than one species. In this patient; thick and thin blood smear were examined, over all on blood smear, P. Vivax was found

Your diagnosis please? Young man with hepatitis and negative viral markers

A 19-year-old male youth refered to private clinic for jaundice and fever, starting two weeks J-m ago. There was no history of recent jaundice in his family. And no history of blood transfusion and I.V. drug abusing. The patient was unmarried and according to him, there had been a sexual entercouse 3 months before the oncent of jaundice

On clinical examination the liver was tender and palpable two-centimeter bellow the costal bore. Spleen was palpable too. In palpation of inguinal regions numerous enlarged lymphnodes were touched. These lymphnodes were painless and non-ulcerative and without adhesion to surrounding tissues but cervical and axilarry regions contained no adenopathies. Both of palmar skins were erythematous. Skin and sclera were yellow and the patient complained of malaise, anorexia, hotness and dark urine

Laboratory tests requested and these tests demonstrated; WBC = 8200 with 71%. Neutrophils 25%. Lymphocytes 4%. Monocytes, AST 1210 IU/L, ALT 2110 IU/L, ALP 710 [normal upto 350], PT 18, PTT 52, Bilirubine total 10 mg/dl and direct Bilirubin 6 mg/dl

IgM anti HAV Negative, HBS Ag and IgM anti HBC Negative, anti HCV Negative, IgM anti CMV and IgM anti EBV were negative. There was no history of herbalism and illegal drug abusing and alcohol consumption. Sonography of liver and spleen revealed nothing. Ceruloplasmine level of plasma was normal and there was No neurologic sign and symptoms. Serum protein electrophoreses except mild elevation of gamma globulin was normal. Serologic assays revealed the ethiologic agent

Denouement your diagnosis please, continued from page 33

According to the patient, there had been a sexual encounter 3 months ago and inguinal regions contained numerous enlarged lymphnodes in both sides

But there was no chancre although palmar erythema were seen bilaterally and serum ALP level was high and viral hepatitidis markers were all negative

On further examination for hepatitis, R.P.R titer was requested and it was 1/512 and FTA-abs was positive too. Anti HIV 1,2 assay was negative. Syphilitic hepatitis is a safe disease but in a young sexually active man especially if he engage in anal intercourse with high serum ALP [2.5 times] level with negative viral hepatitidis markers, you should think about syphilitic hepatitis

Liver needle biopsy was done, you sometimes can find T.pallidum in the liver biopsy specimen, but in this patient pathologist was unable to find T. pallidum and just infiltration of inflamatory cells and patchy necrosis without cholestasis was reported by pathologist

Anal intercourse is a risk factor for syphilitic hepatitis but the patient denied any anal intercourse. Antibiotic therapy rapidly improved the condition with reducing serum R.P.R titer

Your Diagnosis, Please? Young Woman with Severe Jaundice and Negative Virologic Markers

A 20 year-old unmarried woman was evaluated in the hospital because of fever and progressive icterus

The patient had been well until 45 days earlier when malaise, anoreia, cervical lymphnodes and weight loss developed

Two weeks before admission laboratory tests were ordered by her phcysician. There was no cough, diarrhea, disuria or rash, but she complained of light stooL dark urine and vomiting

Tests for viral hepatitis A.B and C were negative but aminotransfrases were more than 1000 lu and total bilirubine 6 mg/dl with hematologic tests about normal ranges. There after she vomited as often as 4 times daily. The pulse was 85 beats/minute and respiratory rate 16 beaths/minute

Hetrophil antibadies test was requerted and because of high prothrombine time [19 seconds] and progressive jaundice the patient hospitalized and serum infusion with vitamine KI 10 mg daily was adminstred subcutaneusly. On the second hospital day, laboratory tests were performed and an ultrasonographic examination of the abdomen performed, revealed mild heterogenous echogenecity

No fluid was present in the subhepatic space. On eyes, examination, kayser fleische rings were not found and urine copper was in a normal limit

Reticulocyte count was normal and coomb's test was negative. Plateletes were normal [shape and number] and WBC did not show atipycal lymphocytes

In her medical history she did not state consumption of herbal and illegal drugs, but sugar, creatinine, uric acid, LDL. HDL, and urinalysis were normal and two blood cultures were negative

Anti HIV-1 test was non reactive and febrile agglutination tests were negative too. On the fifth hospital day no petechiae, conjuctival injection were seen. Chest.X.Ray was clear. The liver descended two cm below the righ costal margin and spleen was just felt. The patient was alert and there was no signs and symptoms of hepatic encephalopathy. The patient had no clinical appearances of chronic liver disease like spider angiomas, ascitis and clubbing

A diagnositic procedure was then performed

Denouement your diagnosis please, continued from page 50

Metabolic and genetic hepatitis may be manifested initially as acute hepatitis and wilson disease is more likely to present with chronic liver disease or a neuropsychiatric disorder and a normal urinary copper excretion effectively rules out the diagnosis of acute hepato - lentricular degeneration

In fulminant hepatitis B in less than 5% in the beginning of disease. HBsAg marker may be negative but other HBV infection markers will be positive. Herbalism in Iran especially in liver diseases is a common problem of physicians and swallow of alive, river fishes is an ancient behaviour in managing icteric patients. Fortunately the patient had done none of them

A serum protein electerophoresis performed and revealed high gamma globulin. In a yaung female patient with paranchymal hepatitis and hypergammaglobulinemia with negative viral markers for hepatitis and normal urinary copper excretion, autoimmune liver disorders will be in suspicion

These disorders are chronic but occasionally have no overt manifestation, until an overlap syndrome develops that is indistinguishable from acute hepatitis. The most common of these disorders, is type I autoimmune hepatitis, it is more common in females than in males and its peak incidence is in young peoples. This form of autoimmune hepatitis characterized by hypergammaglobulinemia and a positive test for antinuclear antibodies or antismooth muscle antibodies or both of them. Type II. Characterized by presence of anti-liver-kidney-microsmal antibody and in type III autoimmune hepatitis, antibodies to soluble liver antigen is positive. Type IV autoimmune hepatitis is a-seronegative autoimmune hepatitis and only in liver biopsy diagnosis confirms

In this patient both of antinuclear antibodies and anti-smooth muscle antibodies were positive

Because of bleeding processes with unresponsiveness to vit k and FFP; liver biopsy did not perform and prednisolone plus Imuran started, jaundice and fever disappeared there after, and prothrombine time [pt] became normal

Waste sludge characteristics of a wastewater treatment plant compared with environmental standards

Sludge production is an avoidable problem arising from the treatment of wastewater. The sludge remained after municipal wastewater treatment contains considerable amounts of various contaminants and if is not properly handled and disposed, it may produce extensive health hazards. On the other hand, this sludge has benefits for plants and soils. Thereupon, land application of sludge has received much attention over the traditional incineration and dump in sea. The comprehensive regulations of U.S.EPA title 40 CFR parts 503 include criteria and standards for land application of sludge. One of the most important wastewater treatment plants in Tehran, Iran is Shoosh Plant, which applies its waste sludge in agricultural lands after dewatering in drying beds. In this research, waste sludge from drying beds was examined according to 40 CFR parts 503. Results indicate that the dehydrated sludge has not the characteristics required for final discharge. If the dewatering process in the existing beds of the plant would be modified according to title 40 CFR part 503, the standard of Pathogen Reduction class B would be achieved. Waste sludge of drying bed must be applied in agricultural land with respect to the conditions of application method that is presented in vector attraction reduction. Concentration of this waste sludge is less than ceiling concentration limits identified by title 40 CFR parts 503