Comparison of the effects and side-effects of sedation with propofol versus midazolam plus pethidine in patients undergoing endoscopy in Imam Khomeini Hospital, Ahvaz.

INTRODUCTION: Gastrointestinal endoscopy is an invasive and diagnostic procedure that causes the patients considerable pain, discomfort, and anxiety. Therefore, various types of sedation and analgesia techniques have been used during the procedure. AIM: To compare the effects and side-effects of sedation with propofol versus midazolam plus pethidine in patients undergoing endoscopy. MATERIAL AND METHODS: This is a randomised controlled double-blind clinical trial study conducted on 272 patients undergoing diagnostic and treatment endoscopy and colonoscopy in Imam Khomeini Hospital in Ahvaz between 2017 and 2018. The patients were randomly assigned to two groups. Patients in the first group (n = 136) received propofol with midazolam and ketamine, and the second group (n = 136) received pethidine and midazolam. Study outcome measures included the recovery time, patient satisfaction, quality of sedation, and adverse events. RESULTS: The occurrence of complications was higher in the propofol group (25% vs. 0%; p = 0.0001). No serious adverse events were observed in the study groups. Overall patient satisfaction and quality of sedation assessment scores in the propofol group were significantly better than those seen in the pethidine-midazolam group (p = 0.012 and p = 0.001, respectively). Recovery time was statistically shorter in the propofol-midazolam group (6.05 ±1.62 min) compared to the pethidine-midazolam group (6.72 ±2.21 min) (p = 0.006). CONCLUSIONS: Propofol-midazolam can provide better sedation, patient satisfaction, and recovery than pethidine-midazolam during endoscopy. Therefore, it can be recommended in patients scheduled for diagnostic and treatment endoscopy.

Evaluation of argon plasma coagulation in healing of a solitary rectal ulcer in comparison with conventional therapy: a randomised controlled trial.

INTRODUCTION: Argon plasma coagulation (APC) has been reported to be effective in the treatment of solitary rectal ulcer syndrome (SRUS). However, it has not appeared to be effective in healing ulcers. AIM: This study aimed at assessing the effectiveness of APC in controlling rectal ulcer-induced bleeding, and at examining the ultimate effect of this approach in healing these lesions. MATERIAL AND METHODS: This randomised, controlled trial was conducted on 99 patients with SRUS. Patients were randomly enrolled into two groups of APC therapy (intervention) and conventional therapy (control). The control group (n = 58) received a high-fibre diet, laxatives, behaviour therapy, and sucralfate enemas, and the intervention group (n = 41) were treated with APC plus conventional therapy; in fact they received directed and focused argon gas in addition to a high-fibre diet and laxatives. RESULTS: Responses to treatment in the control group and in the APC-receiving group were 29.3% and 75.6%, respectively. The continuation of ulcer healing after 3 months in the control group was 10.3%, and it was 70.7% in the APC-treated group. There was a significant statistical difference between the two groups (p < 0.004), i.e. bleeding was controlled more frequently in the group receiving APC plus conventional therapies than in the group receiving only the conventional therapies. However, the results showed no statistically significant difference between the two groups in terms of pain relief (p < 0.36). CONCLUSIONS: Argon plasma coagulation not only controlled bleeding in patients with SRUS, but also, in comparison with the conventional methods of treating SRUS, led to healing and continuation of healing of rectal ulcers.

N-acetyl cysteine as an adjunct to standard anti-Helicobacter pylori eradication regimen in patients with dyspepsia: A prospective randomized, open-label trial.

BACKGROUND: Increasing antibiotic resistance of Helicobacter pylori (H. pylori) which is associated with diseases of the upper gastrointestinal tract, has made alternative treatments necessary. This study compares the efficacy of adding N-acetyl cysteine (NAC) to standard regimen for H. pylori eradication. MATERIALS AND METHODS: We conducted a randomized, open-label trial, comparing the efficacy of 14 days of quadruple therapy with Amoxicillin, Bismuth citrate, Omeprazole, Clarithromycin (group A) versus 14 days of above regimen plus NAC (group B) in adult patients with dyspepsia. Primary objective was H. pylori eradication. Compliance and side effects were determined by questionnaires. Our analysis was by intention-to-treat (ITT) and per-protocol. This study is registered with www.IRCT.ir, number: IRCT201201078634N1. RESULT: A total of 121 participants aged 21-76 years with a mean age of 44.5 ± 14.1, and 52.9% female, were randomly allocated a treatment: 60 with 14-day standard therapy and 61 with 14-day standard therapy with NAC. The eradication rate in groups A and B with ITT analyses was 49/60 (81.7%; 95% [confidence intervals] CI = 71.6-91.8%) and 50/61 (82%; 95% CI = 72-91.9%), respectively (P = 0.96). In per-protocol analysis, the rate of H. pylori eradication in groups A and B was 45/54 (83.3%; 95% CI = 73.1-93.6%) and 45/53 (84.9%; 95% CI = 74.9-94.9%), respectively (P = 0.82). Minor well tolerated side effects were reported in 15 (34.9%) and 21 (35.6%) patients of groups A and B, respectively, and only one therapy cessation in group A was created. CONCLUSION: Standard 14-day triple-drug therapy with NAC is not preferable to standard drug regimens for H. pylori infection.

Evaluation of N-acetyl Cysteine for the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Prospective Double Blind Randomized Pilot Study.

BACKGROUND: Acute pancreatitis is the most common serious complication of endoscopic retrograde cholangiopancreatography (ERCP) that can occasionally be fatal. Multiple drugs have been examined for the prevention of this side effect, with generally uncertain results. This study is an effort to prevent this complication by the use of oral N-acetyl cysteine (NAC). METHODS: A total of 100 patients who were candidates for ERCP were divided randomly into two groups. In the NAC (N) group, patients received 1200 mg NAC with 150 cc water orally 2 h before ERCP. In the placebo (P) group, 150 cc water was prescribed as a placebo. We measured serum amylase and lipase levels before and 24 h after ERCP. The prevalence of pancreatitis and duration of admission in each group were determined and compared. RESULTS: In group N there were 5 (10%) cases of pancreatitis, whereas in group P there were 14 (28%) cases, which was significant (risk reduction ratio: 2.8; p=0.02).The average admission time was 1.16±0.55 days in group N and 1.18±0.44 days in group P, which was not significant. CONCLUSION: There were significant differences in the prevalence of acute pancreatitis between the two groups. In addition, the number of need to treat (NNT) consisted of five cases for NAC. With regards to the above results and the safety profile of NAC, it could be used as a therapeutic agent for the prevention of post-ERCP pancreatitis. We recommend that the results of this study be verified by additional clinical trials.

Prevention of post-spinal hypotension using crystalloid, colloid and ephedrine with three different combinations: A double blind randomized study.

BACKGROUND: The benefit of prophylactic combination therapy using crystalloid and colloid preload with ephedrine has not been cleared to prevent maternal hypotension after spinal anesthesia at cesarean delivery. This study evaluated the efficacy of three combinational methods to prevent hypotension following spinal anesthesia. MATERIALS AND METHODS: In this prospective double blind trial, 150 candidates of elective cesarean delivery under spinal anesthesia were randomly allocated to three treatment groups; 1---Ringer's Lactate (RL) solution (15 ml/kg) plus Hemaxel (7 ml/kg) preload, 2---RL solution (15 ml/kg) preload plus ephedrine (15 mg, IV, bolus), 3---Hemaxel (7 ml/kg) preload plus ephedrine (15 mg, IV, bolus). Maternal hemodynamic changes during 60 min after spinal injection, nausea/vomiting, and neonatal condition were compared among the groups. RESULTS: The cumulative incidence of hypotension was 44%, 40%, and 46% in groups 1 to 3, respectively. There were not significant differences in supplementary ephedrine requirement among groups which received or among groups which did not receive prophylactic ephedrine. Groups were not different in the incidence of hypertension and nausea or vomiting. There were no significant differences among groups in Apgar scores at 1 or 5 min and umbilical artery PH. CONCLUSION: Combination of preventive methods decreased the occurrence of hypotension following spinal anesthesia to an acceptable level. Overall, the most effective method was a combination of crystalloid preload with ephedrine.

A randomized comparative trial of combinational methods for preventing post-spinal hypotension at elective cesarean delivery.

BACKGROUND: Various methods have been applied to prevent maternal hypotension after spinal anesthesia for cesarean delivery. We compared the efficacy of three combinational methods in this regard in the current study. METHODS: In this randomized comparative trial, 150 candidates of elective cesarean delivery under spinal anesthesia were assigned to three groups: crystalloid preload and leg bandage, colloid preload and leg bandage, and ephedrine and leg bandage. Maternal hemodynamic changes during 60 minutes after spinal injection and neonatal condition were compared among the groups. RESULTS: The cumulative incidence of hypotension was 54%, 64%, and 36% in groups 1 to 3, respectively (p = 0.018). Spinal injection to hypotension interval was similar among the groups (p = 0.828). Heart rate in group 3 was significantly lower at the most time measures after anesthesia compared with the other two groups (p < 0.05 to <0.001). Regarding neonatal outcomes, the interval between the birth and the first breath was longer and the Apgar score at minute 1 was lower in group 3 compared with the other groups (p < 0.001 and 0.038, respectively) but it was not clinically important. Umbilical cord blood pH was similar among the three groups (p = 0.248). CONCLUSIONS: Among the three studied methods, administration of ephedrine plus bandage of the lower extremities was the most effective one in reducing the incidence of post-spinal hypotension. The groups were not clinically different concerning the effect of treatment on newborn health.

Effect of cisatracurium versus atracurium on intraocular pressure in patients undergoing tracheal intubation for general anesthesia.

BACKGROUND: Increase in intraocular pressure (IOP) following tracheal intubation during general anesthesia can be troublesome. We compared the influence of two muscle relaxants, cisatracurium and atracurium, on IOP in patients undergoing general anesthesia. METHODS: This randomized, double-blind, comparative trial was conducted on 90 candidates for elective non-ophthalmic surgery under general anesthesia. Patients were 18 to 60 years old with the American Society of Anesthesiologists (ASA) class of I or II. Anesthesia was induced with fentanyl (1.5 mg/kg) and sodium thiopental (5 mg/kg). Patients received atracurium (0.5 mg/kg) or cisatracurium (0.15 mg/kg) two minutes prior to tracheal intubation. IOP, systolic (SBP) and diastolic blood pressure (DBP), and heart rate (HR) were measured at baseline (before medication), after medication (before intubation), and 2, 5, and 10 minutes after intubation. RESULTS: In both groups IOP decreased after administration of muscle relaxants (-3.3 ± 3.6 mmHg), then increased 2 minutes after intubation (5.5 ± 4.4 mmHg), but decreased 5 (-3.3 ± 3.3 mmHg) and 10 (-0.5 ± 2.6 mmHg) minutes after intubation. IOP and SBP were significantly higher in the atracurium compared with the cisatracurium group after 2 (p < 0.001 and 0.002, respectively), 5 (p < 0.001 and 0.012, respectively), and 10 (p = 0.02 and 0.048, respectively) minutes after intubation. CONCLUSIONS: Compared with atracurium, administration of cisatracurium can better prevent the increase of IOP following tracheal intubation in general anesthesia. The observed difference might be related to different effects on hemodynamic variables. Application of these results in patients under ophthalmic surgery is warranted.

Prevalence of celiac disease in Iranian children with idiopathic short stature.

AIM: To determine the prevalence of celiac disease (CD) in children with idiopathic short stature (ISS) and the diagnostic value of immunoglobulin (Ig) A G antigliadin antibodies (AGA) and transglutaminase (TTG) antibodies for CD. METHODS: A total of 104 children (49 male, 55 female) with ISS without a specific etiology were studied. Extensive endocrine investigations had shown no abnormalities in any subject. Anthropometric parameters and IgA AGA and IgA TTG antibodies were evaluated in this study group. These antibodies were measured by enzyme-linked immunosorbent assay. All patients were referred for an endoscopic intestinal biopsy. The biopsy samples were classified according to revised Marsh criteria (UEGW 2001). RESULTS: We detected positive IgA TTG antibodies in 36 and IgA AGA in 35 of these patients. Thirty one IgA TTG antibody positive and 28 IgA AGA positive subjects showed histological abnormalities compatible with celiac disease (33.6%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value for IgA AGA were found to be 80%, 88.4%, 77.8% and 89.7%, respectively. Sensitivity, specificity and PPV for IgA TTG antibodies were 88.6%, 94.2% and 88.6%, respectively. CONCLUSION: We conclude that the prevalence of celiac disease is high in patients with ISS and it is important to test all children with ISS for celiac disease by measuring serologic markers and performing an intestinal biopsy.

Hepatis C virus transmission and its risk factors within families of patients infected with hepatitis C virus in southern Iran: Khuzestan.

AIM: To determine whether hepatitis C virus (HCV) infection of index cases increases intrafamilial transmission (sexual and nonsexual contacts) of HCV. METHODS: In a case-control descriptive study we enrolled 300-household contacts of 60 index cases (40 males and 20 females) of HCV infection and 360 pair-matched controls in Ahwaz JundiShapour University Hospitals from August 1, 1998 to September 1, 2003. The control group consisted of first time blood donors referred to the Regional Blood Transfusion Organization. Serum samples and demographic data and a medical history including the existence of risk factors for HCV (after a questionnaire on the risk factors for parenteral exposure) were obtained from each subject. Antibodies to HCV were detected employing a commercially available second-generation enzyme immunoassay (EIA, Abbott II). Positive serum specimens were retested using a second-generation recombinant immunoblot assay (RIBA-2) and a polymerase chain reaction for HCV RNA. Data analysis was carried out for intra-household clustering. RESULTS: Only 4 of 300 (1.33%) cases of household contacts without percutaneous risk factors were positive for HCV Ab while the remaining 296 family contacts were negative for anti-HCV. The mean age of the index cases was 28.4 (Std 15.22) years. The anti-HCV prevalences in parents, spouses, children of the index cases were 0.87% (1/115), 3.39% (2/59)) and 0.79% (1/126), respectively. Among couple partners negative for anti-HCV antibodies, the mean duration of the sexual relationship was 6 years. The two-couple partners positive for anti-HCV antibodies married the index cases for longer than 15 years. The prevalence of positive HCV Ab among household contacts (1.33%) was not significantly higher than that in the controls (1%) (P > 0.06). CONCLUSION: Intrafamilial transmission of HCV is not the significant transmission route and sexual transmission does not seem to play a role in the intrafamilial spread of HCV infection. Intrafamilial transmission of HCV is possible but occurs at a low rate.

Application of fluorescent in situ hybridization (FISH) for the detection of Helicobacter pylori.

BACKGROUND: Peptic ulceration following infection of the stomach with H. Pylori is a common disease. Accurate and rapid detection of the bacteria can lead to the implementation of appropriate treatment and recovery. Chronic infection of the gastric milieu with H. Pylori may lead to gastric carcinoma. Routine detection of this bacterium in peptic ulcer is based on the urease test and culture of peptic biopsies. Unfortunately, the sensitivity and specificity of both tests are not satisfying. Molecular techniques have been successfully applied for the rapid and accurate detection of bacterial agents in clinical samples. This study was undertaken to evaluate the sensitivity and specificity of fluorescent in situ hybridization (FISH) in the detection of H. Pylori in patients suffering from dyspepsia. MATERIAL/METHODS: One hundred gastric biopsy samples taken by endoscopy from the antrum and corpus of the stomach were tested by FISH and compared with the conventional culture method complemented by biochemical tests. RESULTS: FISH detected H. Pylori in 48 clinical samples, while the conventional method detected 42 samples. The sensitivity and specificity of FISH for the detection of H. Pylori were calculated as 98% and 100%, respectively. CONCLUSIONS: The findings of this study suggest that FISH is a highly suitable and rapid method for diagnosing H. Pylori. Especially when the samples are taken from the antrum and the corpus of the stomach, this technique potentially can be applied routinely for the detection of this bacterium in clinical samples.

Seroepidemiology of hepatitis C and its risk factors in Khuzestan Province, south-west of Iran: a case-control study.

AIM: To evaluate possible risk factors for the spread of hepatitis C infection and to analyze the characteristics of the epidemiological and clinical patterns among the patients with hepatitis C infection. METHODS: During a five-year period a cross-sectional study was conducted among HCV positive individuals referred to the Ahwaz JundiShapour University Hospitals (AJSUH) and Hepatitis Clinic from 1 Sept 1999 to 1 Sept 2003. The control group consisted of first time blood donors referred to the Regional Blood Transfusion organization. Enzyme-linked immunosorbent assay and recombinant immunoblot assay anti-hepatitis C virus (HCV) tests were performed for two groups. Positive serum specimens were retested using polymerase chain reaction (PCR) for HCV RNA. Risk factors were evaluated using a questionnaire. Reported risk factors among infected subjects ("HCV-positive") were compared to those of subjects never exposed ("HCV-negative") to HCV. RESULTS: A total of 514 subjects were studied for HCV, of which 254 were HCV-positive and 260 HCV-negative donors comprised the control group. Mean age of the patients was 28.4 (Std 15.22) years. HCV-positive subjects were more likely to be of male gender (63% versus 37%). Transfusion 132 (52%), non-intravenous (n-i.v.) drug abuse and i.v. drug abuse 37 (14.5%), haemodialysis 25 (10%), receiving wounds at war and extramarital sexual activities (2.4%), tattooing (3.6%) were found to be independent risk factors of being HCV-positive. No apparent risk factors could be demonstrated in 29 (11.2%) of the positive cases. CONCLUSION: Our data indicate that a history of transfusion and i.v. drug abuse and haemodialysis are important risk factors for HCV infection in our area and that more careful pretransfusion screening of blood for anti-HCV must be introduced in our blood banks. Improvements in certain lifestyle patterns, and customs in this area may be essential to prevent transmission of the infection.

Celiac disease in South-West of Iran.

AIM: Celiac disease is characterized by life-long gluten intolerance. Clinical features of patients with celiac disease are variable. Studies about the prevalence of celiac disease in our country are scarce and there is no study on the prevalence of celiac disease in southern Iran. In the current study, clinical, laboratory and histo-logical features of 52 patients with celiac disease were evaluated. METHODS: In a cross sectional study we retrospectively studied the characteristics of 52 celiac patients at Ahwaz JundiShapour University Hospitals (AJSUH) from November 1, 1999 to 1st Sep 2004. Intestinal biopsy and serum antigliadin and anti-endomysium antibodies were used for the diagnosis of patients. Mucosal lesions were classified according to the criteria of Marsh. Antigliadin antibodies were measured with a commercial enzyme-linked immunosorbent assay. Anti-endomysium antibodies were analyzed by indirect immunofluorescence with the use of a section of monkey esophagus. Routine hematological and biochemical analyses and measurement of immunoglobulin levels were undertaken. RESULTS: Male: female ratio was 1.08. The mean +/- SD patient age was 21 +/- 4.5 years (range 10-70 years) and the most common symptoms were diarrhea and weight loss (78.8%) followed by fatigue (73.1%), pallor (65.4%), anorexia (40.4%), abdominal distention (32.7%), and failure to thrive (23.1%). Diarrhea and weight loss and fatigue were the most common findings. Iron deficiency anemia was found in 63.2% of patients and this became normal after adoption of a gluten-free diet in all patients. Immunoglobulin A, IgG antigliadin antibodies and IgA anti-endomysium antibodies were found in 33 and 48 cases, 78.8% and 85.4% of patients, respectively. Biopsy of the small intestine revealed that 90.4% of patients had typical lesions according to the Marsh classification. CONCLUSION: Although classical presentation was seen in most of the patients, atypical clinical manifestations of celiac disease should be kept in mind. In particular, patients with uncommon findings, such as short stature, and iron-deficiency anemia, should be screened for celiac disease. Further epidemiological studies in our area in the general population and in high risk groups seem to be indicated.

Risk factors for hepatocellular carcinoma in Southern Iran.

OBJECTIVE: Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. Its etiology and incidence differ according to geographic area. In the present study, we sought to identify risk factors for HCC among a group of patients with HCC in Southern Iran. METHODS: During a 5-year period we retrospectively studied the characteristics of 71 HCC patients at Ahwaz Jundishapur University Hospital, Iran from February 1999 to August 2004. Blood samples and questionnaire data obtained from 71 (45 male and 26 female) incident cases of HCC, were pathologically diagnosed. Sera were tested for hepatitis B surface antigen and antibodies to hepatitis B core antigen, anti-hepatitis C virus and serum ferritin, iron and alfa fetoprotein (AFP), by enzyme immunoassays and cuper study. RESULTS: In 46.5% (33/71) of patients there was a history of chronic liver disease, and in 30 (42%) patients liver cirrhosis was documented. Of the 71 patients, 37 (52.1%) had hepatitis B, 6 (8.5%) had hepatitis C, and 2 (2.8%) had a history of excess alcohol intake. Of the 2 patients with a history of heavy alcohol intake, one had concomitant chronic viral hepatitis infection, and alcohol alone was the etiology of HCC in only one case (1.40%). No etiologic cause was identified in 23 cases (32.4%), there were 2 cases of diabetes mellitus. The value of AFP of >20 ng/ml was found in 29 cases (41%), varying from 24 ng/ml to 364 ng/ml (average 74.6 ng/ml). CONCLUSIONS: In Southern Iran, the predominant etiology of HCC was hepatitis B, hepatitis C, but alcohol and metabolic diseases were only found in rare cases. Cryptogenic cases may be found in one fifth of patients hence, the contribution of virus infection, may have been underestimated in this area, which is based on serological testing only.