Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Kidney Transplantation in Iran1839742ENBehzadEinollahiDepartment of Internal Medicine/
Nephrology Division Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.Journal Article20150302Kidney transplantation in patients with end stage renal disease is preferred to dialysis because transplantation provides a better quality of life andimproved survival. However, the gap between the supply and demand for a renal allograft is widening and the waiting time is increasing. Iranian protocol, a controlled transplant program supported by the government for living unrelated donors, was initiated for solving the problem of organ shortage. Although this system might experience challenges, clearly it has advantages over other organ procurement systems primarily that thousands in need do not die while waiting for a compatible donor.In the present review I discuss the history of renal transplantation in Iran, "Iranian model" protocol, the situation of Iran’s kidney transplantation from either living or deceased donors compared with the Middle East countries, and our experiences of unrelated renal transplantation.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302The Effect of Alendronate on Symptoms of Knee Osteoarthritis: A Randomized Controlled Trial91539743ENMohammad HassanJokarRheumatic Diseases Research Center,
Mashhad University for Medical Sciences, Mashhad, Iran.ZahraMirfeiziKamranKeyvanpajohJournal Article20150302Background: Knee osteoarthritis is a common degenerative joint disorder and a major cause of pain and disability. Recent studies have suggested that bisphosphonates such as alendronate may have a role in the treatment of osteoarthritis. The purpose of the present study was to investigate the potential effect of alendronate on the symptoms of knee osteoarthritis. Methods: Thirty nine patients with mild to moderate knee osteoarthritis were enrolled in a randomized, double-blind, placebo-controlled trial with parallel-group design. The patients received either placebo or alendronate pills (70mg, weekly) in a blinded fashion for six months. Symptoms of osteoarthritis were scored by Western Ontario and McMaster Universities (WOMAC) osteoarthritis index at enrollment and at weeks 4, 12, and 24.Results: In both groups there was a significant improvement in total WOMAC score and WOMAC subscales scores of pain, stiffness, and function at 4, 12, and 24 weeks of treatment. Maximum improvement occurred at week 4. There was no statistically significant difference between the two groups regarding their total WOMAC score and its subscales at the end of weeks 4, 12, or 24 (P=0.94). Conclusion: Alendronate does not reduce symptoms of mild to moderate knee osteoarthritis.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Continuous Adequate Iodine Supplementation in Fars Province: The 2007 Goiter and Urinary Iodine Excretion Survey in School Children162039747ENAtiehAmouzegarResearch Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.HosseinDelshadMehranMehraeinLadanMehranMaryamSafarkhaniFereidounAziziJournal Article20150302Background: The iodine deficiency elimination program that began two decades ago resulted in Iran becoming an iodine deficiency disorders free country in the Middle East region. The present study was performed to evaluate the adequacy of iodine supplementation after 17 years of universal salt iodization in Fars province. Methods: In a cross-sectional study, 1200 schoolchildren (480 girls and 720 boys) aged 8 to10 years, were randomly selected from Fars province and evaluated in 2007. Goiter prevalence, urinary iodine excretion, and iodine content of household salts were measured and the data were compared with those obtained in 1996 and 2001. Results: Total prevalence of goiter was 1.3% (CI: 0.53-2.47) and no grade 2 goiter was found. One-tenth of the children enrolled for goiter assessment, were randomly selected for urinary iodine measurement. The median urinary iodine in these 120 schoolchildren was 159.4 µg/L (85.6-252.3), with 14.8% having urinary iodine excretion less than 50 µg/L. 98% of households were using purified iodized salt. 70% of households had appropriate salt storage and none of the household salts contained less than 15 µg iodide. Conclusion: Goiter prevalence has significantly decreased in the Fars province, 17 years after universal salt iodization. The median urinary iodine of schoolchildren was adequate as that reported in 1996 and 2001, indicating a well established sustainable iodine deficiency elimination program in the provinceShiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302The Effect of Subcutaneous Dexamethasone Added to Bupivacaine on Postcesarean Pain: A Randomized Controlled Trial212639751ENMitraJabalameliHamidSaryazdiOmolbaninMassahipourJournal Article20150302Background: Previous studies have shown a prolonged blockade of nerves using bupivacaine-dexamethasone microspheres. The goal of this study was to assess the effect of subcutaneous dexamethasone added to bupivacaine on post cesarean pain. Methods: After randomization, 75 healthy parturients were allocated into three groups and received the following treatments: group A: bupivacaine 0.25% (20 ml, subcutaneously [s.c]) plus dexamethasone 16 mg (4 ml, s.c) plus normal saline (4 ml, intravenously [i.v]); group B: bupivacaine 0.25% (20 ml, s.c) plus dexamethasone 16 mg (4 ml, i.v) plus normal saline (4 ml, i.v); group C: bupivacaine 0.25% (20 ml, s.c) plus normal saline (4 ml, s.c) plus normal saline (4 ml, i.v). The visual analog scale (VAS), meperidine consumption, and time to first meperidine consumption were evaluated in the recovery room, 6, 12, 24, 48, and 72 hours postoperatively. Results: The mean VAS in group A was less than groups B and C at 12, 24 , 48 and 72 hours after surgery (A< C< B respectively). The decrease in VAS was statistically significant between groups A, B and B, C (P=0.009 and P=0.015 respectively). The mean VAS in group A was significantly less than group C at 48 and 72 hours postoperatively (P=0.020 and P=0.024 respectively). Meperidine consumption was lower in group A compared with B and C groups, however it was not statistically significant (P=0.25 and P=0.11 respectively). Conclusion: The addition of subcutaneous dexamethasone to bupivacaine prolonged the analgesia during 48-72 hours postoperatively. It may be an option for longer pain relief after cesarean section.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Geriatric Disability and Associated Risk Factors: A Community Based Study in a Rural Area of West Bengal, India273239753ENPankaj KumarMandalDepartment of Community Medicine,
Kolkata, India.DebadattaChakrabartyPramitGhoshNirmalyaMannaSarmilaMallikChitaChatterjeeJadab ChandraSardarManabendraSauAmal Kumar SinhaRoyJournal Article20150302Background: Similar to developed countries, aging is increased in India. Because of the epidemiology and demographic transition phase, chronic diseases and disabilities along with health costs are increasing day by day. As social factors and chronic diseases are the major reasons for geriatric disability, the present study was done with the following objectives: to assess and compare the socio-demographic characteristics among the disabled and non-disabled geriatric population, and to find out the association between socio-demographic and chronic diseases with functional disability among the study population. Methods: A cross-sectional study was done in a rural community of West Bengal, India. House to house visit, clinical examination, observation, and interview were done with a pre-designed, pre-tested proforma. Epi Info and SPSS software were used for statistical analysis. Results: A total of 458 people had chronic conditions and the prevalence of disability was 17.47%. Among the socio-demographic variables, age, female sex, marital status, literacy status, and family composition and among the chronic diseases, tuberculosis, chronic obstructive pulmonary diseases, ischemic heart disease, osteoarthritis, neuropathy, acid peptic disorder, prostatic hypertrophy, and osteoporosis were found as risk factors of disability in binary logistic regression analysis. 71.2% of the disabilities were explained by these risk factors. Conclusion: The data highlighted the different risk factors associated with disability. No single measure rather multi-dimensional approach should be the model for the prevention of disability.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Analysis of TP53 Codon 72 Polymorphism in Mucinous and Non-Mucinous Colorectal Adenocarcinoma in Isfahan, Iran333939754ENMehdiNikbahkt DastjerdiDepartment of Anatomical Sciences,
School of Medicine,
Isfahan University of Medical Sciences,
Isfahan, Iran.Journal Article20150302Background: The tumor suppressor gene TP53 (alias p53) located on chromosome 17 is involved in various cancers. Case-control studies have shown that p53 codon 72 polymorphism modulates the prognosis and susceptibility to various malignancies. We undertook the present study to explore a possible association between mucinous and non-mucinous adenocarcinomas with different genotypes or alleles at codon 72 of TP53. Methods: The genotype distribution and allelic frequencies for p53 polymorphism was assessed in 46 and 134 specimens from patients with colorectal mucinous and non-mucinous adenocarcinomas, respectively, by using allele-specific PCR. Results: The PCR products were 177bp for proline allele and 141bp for arginine allele. In the mucinous samples, the genotype distribution for p53 polymorphism showed 63%, 23.9%, and 13.1% for the Arg/Arg, Arg/Pro, and Pro/Pro genotypes, respectively. In the non-mucinous specimens 32.1% of the cases were Arg/Arg, 48.5% Arg/Pro, and 19.4% pro/pro. A significant difference between the two types of adenocarcinomas for the Arg 72 Arg genotype compared with (grouped) Arg 72 Arg and Pro 72 Pro genotypes was noted [OR=3.61 (1.76-7.27), P<0.001]. The arginine allele was found more often in patients with mucinous adenocarcinoma [OR=1.85 (1.07-3.19), P<0.03]. A higher portion of Dukes stage C was noted in the mucinous specimens (P<0.02) and also mucinous specimens were seen more often at advanced TNM stages (P=0.01). Conclusion: The Arg/Arg genotype at p53 codon 72 is more prevalent in mucinous colorectal carcinoma and the arginine allele may contribute to mucinous carcinogenesis. The proline allele was associated with higher Duke's staging in non-mucinous adenocarcinoma.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Possible Causes of Ileal Injury in Two Models of Microbial Sepsis and Protective Effect of Phytic Acid404739755ENRashaRashad AhmedDepartment of Zoology,
Faculty of Science,
Beni-Suef University,
Beni-Suef, Egypt.HossamEbaidJournal Article20150302Background: Sepsis related-multiple organ dysfunction is associated with ileum injury. We aimed to determine the causes of ileal injury in two models of microbial sepsis resulted from infection with Aeromonas hydrophila or its endotoxin. We also evaluated the protective effect of phytic acid. Methods: Thin sections of ileum from 60 Swiss male mice in control, bacteria-infected or lipopolysaccharides (LPS) and bacteria-infected or LPS-infected co-administered with phytic acid were subjected to histopathological and TdT-mediated dUTP nick-end labeling (TUNEL) assay for apoptotic cells detection while ultra thin sections were stained with uranyl acetate and lead citrate for cytological changes examination. Also, ileum images were exposed to the image analysis software to determine some related morphometric measures. Results: Necrosis and apoptosis were observed in ileum injury in both examined sepsis models. The ileum injury was more severe in LPS model. Phytic acid showed the ability to attenuate ileum injury in Aeromonas hydrophila and its endotoxin models of sepsis after four weeks administration where its supplementation significantly minimized the histopathological and cytological complications and morphometric alterations resulted from the injury. Conclusion: The protective effects of phytic acid may be caused by increased mucous secretion, decreased apoptotic index, attenuating the inflammatory and lymphocytic cells count or increasing the renewal of the crypt cells and villous epithelial cells proliferation.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Hemolysis Induced by Glucose-6-Phosphate Dehydrogenase Deficiency and Its Association with Sex in Children485239756ENEsmaeelSadeghiDepartment of Pediatrics,
Namazee Hospital,
Shiraz, Iran.PerikalaVijayananda KumarMansourHaghshenasHamedJalaeianJournal Article20150302Background: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzyme disorder in human. The aim of this study was to determine the prevalence of G6PD deficiency among children and evaluate its association with ABO/Rh blood groups. Method: Blood samples of 3401 asymptomatic children were analyzed and compared with 317 children who were admitted to hospital because of hemolysis resulted from G6PD deficiency. Results: Among asymptomatic children 375 (11%) were G6PD deficient. Male to female ratio for this group was 4.2:1 and for the hemolytic group was 2.5:1 (P=0.004). Two hundred and sixty-seven (84.2%) of the patients with hemolysis were younger than 2 years, with the peak age of hemolysis between 2 and 3 years (27.7%). The overall rate of hemolysis caused by G6PD deficiency was 12.3% during the 3 consecutive months of fresh Fava bean consumption. Blood groups O+, A+, and B+ together constituted 87.1%, 87.7%, and 84% of the blood groups among normal children, asymptomatic G6PD deficient subjects, and those with G6PD deficiency related hemolysis respectively (P=0.367). Seven percent of the normal children and asymptomatic G6PD deficient subjects were Rh- vs 9.7 % of G6PD deficient children with hemolysis (P=0.16). Conclusion: The prevalence of G6PD deficiency among the children was 11%. Male to female ratio was greater in non- hemolytic vs hemolytic group so that the female share was higher in hemolytic group than in the other two groups (P=0.004).The distribution of ABO blood groups was similar among asymptomatic non-G6PD deficient, asymptomatic G6PD-deficient, and G6PD-deficient children with hemolysis. The distribution of Rh- types among the G6PD-deficient children with hemolysis and the other two groups was similar (9.7% vs 7%, P=0.16).Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Surgical Complications of Cochlear Implantation535639744ENBasirHashemiAkbarBayatTayebeKazemeiDepartment of Otolaryngology,
Khalili Hospital,
Shiraz University of Medical Sci-ences,
Shiraz, Iran.Journal Article20150302Cochlear implantation is a method used for the treatment of patients with profound hearing loss. This procedure may the accompanied by some major or minor complications. We evaluated the surgical complications of cochlear implantation in Fars province (south of Iran). A total of 150 patients with cochlear implantation were enrolled in the present study. Most of the patients were pre-lingual children and most of our devices were nucleus prosthesis. We had three device failures and four major complications, including one misplaced electrode, one case of meningitis, one case of foreign body reaction to suture and one case with extensive hematoma. These complications were managed successfully by surgical intervention or re-implantation. Facial nerve damage or wound breakdown was not seen. Minor complications including small hematoma, edema, stitch infection and dizziness were found in 15 cases, which were managed medically. In our center, the rate of minor complications was comparable to other centers in the world. But the rate of major surgical complications was lower than other centers.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Late Sleeping Affects Sleep Duration and Body Mass Index in Adolescents576039748ENRajesh G.KathrotiaDepartment of Physiology, P.D.U.
Medical College, Rajkot,
Gujarat, India.Pinkesh V.RaoSwapnil J.ParalikarChinmay J.ShahElvy R.OommenJournal Article20150302During adolescence, there is a tendency to sleep late and sleep less because of altered psychosocial and life-style changes. Recent studies have demonstrated the link between sleeping less and gaining weight in children, adolescents, and adults. We studied the effect of late sleeping and sleeping less on body mass index (BMI) in medical college freshmen. All participants were adolescents (104 male and 38 female adolescents, mean age 17.77±0.79 years). After obtaining informed consent, they filled out a questionnaire about their sleeping habits. Height and weight were measured after a brief history taking and clinical examination. BMI increased significantly with decrease in total sleep duration and with delayed bedtime. Late sleeping individuals (after midnight) had significantly less sleep duration (6.78 hours v 7.74 hours, P<0.001), more day time sleepiness (85.2% v 69.3%, P=0.033) and more gap between dinner time and going to sleep (234.16 min v 155.45 min, P<0.001). Increased BMI in late sleepers may be explained by low physical activity during the day caused by excess sleepiness and increased calorie intake with a gap of 5-6 hours between dinner and sleep. Sleep habits of late sleeping and sleeping less contribute to increase BMI in adolescents.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Sweet Syndrome Accompanying Inflammatory Bowel Disease in a Child616439745ENAnahitaSanaei DashtiPediatric Infection Research Center (PIRC), Mofid Children Hospital,
Shaheed Beheshti University of Medical Sciences, Tehran, Iran.EsmaeelSadeghiPerikala VijayanandaKumarJournal Article20150302Acute neutrophilic dermatosis, first described in 1964 by Robert Douglas Sweet, is characterized by sudden onset fever, neutrophilic leukocytosis, and well demarcated erythematous papules, nodules, and plaques with dense neutrophilic infiltrates on histologic evaluation.Here is a report of a 7-year-old girl who presented with high grade fever, and discrete erythematous papular skin eruptions, which gradually increased in number and involved the face, trunk, extremities, palms, soles, hard palate, and palatal tonsils. The skin eruptions evolved to pustules and after coalescing caused large crusted plaques, with mild tenderness but without any pruritus. White blood cells were 36900/ml with 92% neutrophils. Skin biopsy test was compatible with acute febrile neutrophilic dermatosis, so prednisolone (1 mg/kg/day) was started that led to a rapid defervescence and significant improvement of dermatosis. After a few days, the patient presented with fever and arthritis of right elbow, both ankles, and wrists, so she was re-admitted. She also developed bloody diarrhea during the hospital stay. Colonoscopy and intestinal biopsy were performed, which confirmed the diagnosis of ulcerative colitis. Prednisolone, sulfasalazine, and naproxen were prescribed. The fever and diarrhea stopped after a few days and joint swelling decreased. She was discharged 2 weeks after the admission with a rather good general condition. Inflammatory bowel disease can be one of the several conditions accompanying sweet syndrome.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Thoracobiliary Fistula of Calcified Hydatid Cyst of the Liver656839749ENMohsenSokoutiDepartments of Thoracic Surgery,
Imam Reza Hospital,
Tabriz University of Medical Sciences,
Faculty of Medicine,
Tabriz, Iran.VahidMontazeriAshrafFackrjuJournal Article20150302Thoracobiliary fistula is a rare complication of hydatid cyst disease of the liver especially in calcified form. Given the rarity and high mortality of such fistula, it is not surprising that there is no consensus about surgical treatment of this condition. In the present paper we report two cases of thoracobiliary fistula of complicated calcified hydatid cyst of the liver. A 64-year-old man with cough and biliary sputum and a 66-year-old man with cough and right biliary pleural effusion (pleurobiliary fistula). The patients underwent left hepatectomy with cholecystectomy and T-tube choledochal drainage in one patient and successful decortication of the lung, and cystectomy with excision of calcified pericystectomy of the liver in another patient. Pathologic examinations revealed calcified hydatid cysts of the liver. Because of poor prognosis of thoracobiliary fistula, radical surgical intervention is recommended.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Limb Loss Caused by Thrombosis led to the Diagnosis of Ulcerative Colitis697139752ENSeyed Mohammad VahidHosseiniDepartment of Pediatric Surgery,
Shiraz University of Medical Sciences,
Shiraz, Iran.Hamid RezaForoutanBabakSabetMohammadNasibiSeyed AbbasBananiJournal Article20150302Arterial thrombosis associated with ulcerative colitis usually occurs in the postoperative period with a good response to anticoagulant therapy and embolectomy. Our patient was a 14-year-old girl with ulcerative colitis who presented with bilateral pulsless extremities, which did not respond to medical treatment and embolectomy. Subsequent colectomy did not save her limbs. The repeated thrombosis caused gangrene of extremities in the below knee region leading to bilateral amputation. Thrombosis can be the first presentation of ulcerative colitis.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302Drug Therapy for Small Abdominal Aortic Aneurysm727339746ENRamachandranMeenakshisundaramDepartment of Institute of Internal Medicine,
Madras Medical College, Chennai.
Chennai, India.DiptiAgarwalPonniahThirumalaikolundusubramanianJournal Article20150302Dear Editor,Abdominal aortic aneurysm is often asymptomatic, less recognized, and causes considerable mortality and morbidity, if missed. The incidence varies from country to country and the occurrence is influenced by modifiable (smoking, coronary heart disease, hypertension, dyslipidemia, and prolonged steroid therapy) and non-modifiable risk factors (increasing age, male gender, and positive family history). Most of the patients with such aneurysm do not exhibit symptoms and the diagnosis is made accidentally during routine medical investigations, abdominal ultrasonography, or by an astute surgeon during an abdominal procedure. Sometimes the diagnosis is made in an emergency room, if the attending resident/doctor is aware of it. Despite good diagnosis and effective management, the outcomes of complicated cases are poor and the treatment cost is prohibitive. Hence, we reviewed the literature to find out the pathogenesis of such aneurysms and the usefulness of available drugs in its prevention.The pathogenesis for the development of abdominal aortic aneurysm is considered under four headings namely, tissue mechanisms, enzymes related, cellular aspects, and infection-inflammation induced. However, one or a combination of these mechanisms might be involved in its pathogenesis. Tissue mechanisms include proliferation of vascular smooth muscles, angiotensin-II mediated atherosclerosis, rupture of plaques, and abnormal matrix by degradation and suppression of tissue repair through C-junction N-terminal kinase.1-3 Enzymes such as elastase induce changes in vessel wall layer and remodeling.1 Human T-lymphocytes activation through activator protein-1,4 mediates changes at cellular level. Angiotensin converting enzyme (ACE) inhibitors,1,2 or angiotensin–II receptor blockers,4 can inhibit the vessel wall changes, and statins,5 can revert atherosclerotic plaques. Statins inhibit aneurysm development by reducing atherogenic lipoproteins and C-reactive proteins. In experimental models, Janus N Kinase inhibitor (SP 600125),3 was shown to slow down the degradation and suppression of tissue repair in vessel walls through C-Junction N-terminal kinase. Gadowski and co-workers demonstrated that beta blockers reduced the expansion of un-ruptured abdominal aortic aneurysm,6 however, another study did not confirm this notion.7 Hence, further evaluation of the usefulness of beta blockers in such aneurysms need to be conducted.Among drugs currently used in clinical medicine, ACE inhibitors,1,2 or angiotensin–II receptor blockers were evaluated in abdominal aortic aneurysm.4 These medications were found to be beneficial by preventing the development and/or retarding the progression of the aneurysm. In addition, patients on long-term steroid therapy should be monitored for abdominal aortic aneurysm and changed over to suitable alternatives, wherever possible. Progression of such aneurysm can be enhanced by secondary infection with Chlamydia pneumoniae, because the bacterium promotes the atherosclerosis in the aortic wall.8 Hence, the macrolides (Roxithromycin 300mg daily for 4 weeks) may reduce the infection/inflammation-induced changes in vessel walls.9 Additionally, matrix metalloproteinase (MMP) is closely linked to the aneurysm in animal models and human studies.10 Hence, MMP inhibitors such as tetracyclines, statins, and ACE inhibitors have shown to reduce the expansion of such aneurysms. Tetracyclines suppresses aortic wall MMP activity, elastin degradation, and aneurysm development in elastase-induced abdominal aortic aneurysm in a rat model.11It should be considered that treatment of small abdominal aortic aneurysm (less than 5-5.5 cm) before rupture substantially lowers the mortality and reduces the cost of treatment. However, mechanical intervention is the only treatment shown to be effective in preventing rupture and aneurysm related death. It is reserved for aneurysms ≥5.5 cm in men and ≥5 cm in women, and/or aneurysm of rapid expansion. Because the drug therapy has a preventive effect, regular use of the drugs by susceptible population is likely to lower the onset, progression, or complications of the aneurysm in the years to come.Smoking is the most important and modifiable risk factor contributes to the development of abdominal aortic aneurysm. Clinicians should aim to modify the modifiable risk factors by recommending a healthy life style by considering factors such as diet, regular physical exercise, smoking cessation, and treating co-morbid illnesses including hypertension and dyslipidemia. Likewise, patients at risk of such aneurysm should be screened by ultrasonography in the elder age groups at regular intervals and motivated for regular follow-up.Shiraz University of Medical SciencesIranian Journal of Medical Sciences0253-071635120150302The Responsibility of the Institutional Review Board in Good Clinical Practice: First, Do No Harm747739750ENFarrokhHabibzadehDirector, Medical Education and Research Center, National Iranian Oil Health Organization, Shiraz, Iran0000-0001-5360-2900Ali AkbarMohammadiDepartment of Surgery, Shiraz Burn Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.0000-0002-5769-9508Journal Article20150302Dear Editor,I read with interest the article on outpatient management of burn wounds published in a recent issue of the IJMS.1 There are many questions that arise which are worth mentioning. Under the methodology section, no description was provided on how patients were randomized into the two treatment arms and, therefore, it is not possible to assess how confounding variables were controlled. Based on the data presented in table 3 of the article, the pain score before dressing was significantly lower in the “amnion group” than the “control group”. This might reflect degrees of bias in assigning patients to the study groups. Consequently, as expected, the pain score measured after dressing and the dose of analgesics consumed were lower in the “amnion group” than in the “control group” (table 3 of the article).Another point to be mentioned is that according to Article 32 of the Declaration of Helsinki code of ethics,2 “the benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best current proven intervention.” While numerous brands of synthetic dressings have been readily available in Shiraz, where the principal investigator practices, it is not clear why the researchers treated the control group with silver sulfadiazine ointment.Under the methodology section, it is also not clear how the amniotic membrane was processed; it is stated that “the amniotic membranes were placed in a sterile pot containing normal saline and 80 mg gentamicin,” but the volume of normal saline is not mentioned. Did the authors think that an undetermined dose of gentamicin could eradicate all possible infectious organisms? “VDRL, HIV, and HCV and HBS antigens” were tested; the membranes were also cultured for identifying probable bacteriologic contamination. Did all these efforts eliminate the likelihood of transmission of infectious diseases?As the authors, themselves, state in the very first paragraph of the Discussion, dressing with the amniotic membrane was introduced almost a century ago, but for concerns about the transmission of infections, it soon became obsolete in most developed countries. Nonetheless, based on its physiologic properties, synthetic dressings have been manufactured and used widely. The authors do not explain why their patients who were treated with amniotic membrane developed a “relatively high fever” for a few days soon after application of the membrane. As authors mentioned, amniotic membrane does not cause serious inflammatory response; so what was the cause of that fever? Have these patients been followed up for a reasonable period of time to identify whether they developed any health problem? Although it is mentioned that all the participants provided informed consents to take part in this study, because of marked differences between the knowledge of physicians and patients, it is not acceptable to put the patients’ health in danger. Note that Ravishanker, whose work had probably influenced the authors of this article, used long-term glycerol preserved amniotic membranes for dressing since glycerol has antibacterial and antiviral properties.3 Furthermore, Ravishanker used the membranes only for dressing of superficial wounds.Finally, I believe that the Ethical Committee of Shiraz University of Medical Sciences is the most responsible body in this study for approving conduction of such an appalling and sketchy clinical trial. Over the past decade, we have witnessed an increasing trend in the number of scientific and biomedical publications from Iran.4 Thanks to incorporation of many Iranian journals in major indexing systems, most of our publications are now readily accessible to the entire world. The world community judges us by our work. Doing a misconduct,5 publishing a plagiarized article,6 or conducting a poor research will seriously jeopardize this national movement.7 I, for one, believe that all the bodies supervising research activities in our country should be more cautious in managing this critical situation.The Authors’ Reply Dear Editor,I carefully read the letter about our manuscript that you sent to me.1 There were questions about our work, which I have answered below;1- Randomization was done using random allocation software.22- I think there was a misunderstanding about table 3. Pain score before dressing means average score before all dressings in both groups, which was interpreted by Dr. Habibzadeh as the pain measured at the beginning of the study. Obviously when the time between dressings becomes longer, patients have less pain, and this is one of the advantages of amnion dressing.3- Dr. Habibzadeh states that according to the article 32 of the Declaration of Helsinki code of ethics, a new intervention must be tested against the best current proven interventions. According to all textbooks related to “Burn”, the most effective and common treatment of burn in all burn centers is silver sulfadiazine.3-5 And almost always, in all controlled clinical trials in burn patients in the world, the control group receives silver sulfadiazine.6,7 On the other hand, all brands of synthetic dressing have many advantages and disadvantages. And no synthetic dressing has been suggested as the standard treatment in burn patients. Synthetic and biological dressings are alternatives to antimicrobial dressing.5 Also, synthetic dressings are very expensive and are used in selected patients and rare circumstances, even in developed countries. For example; Integra (Integra lifeSciences corporation, USA) costs about 4500 US dollars for covering one percent of body surface area. It means that in a patient with 50% burn in his/her body surface area only one dressing with Integra would cost 225000 US dollars. With Acticoat (Smith&Nephew Healthcare Pvt.Ltd, USA), the cost is 2500 US dollars and with Biobrane (Smith&Nephew Healthcare Pvt.Ltd, USA) it is about 10000 US dollars.4- Each amniotic membrane in our study was placed in 100 ml of normal saline and 80 mg of gentamycin. There are many preservation methods for amniotic membrane.8 According to new studies, all preservation methods of amniotic membrane might have strong influences on cell viability. For example, glycerol preservation method leads to immediate cell death.8 Therefore, we used a new and easy method (saline preservation method) with consideration of all precautions; by selection of placenta from HCV, HIV, HBS, and VDRL negative mothers,7,8 with electivecaesareandeliveries.9 Additionally, we checked HCV, HIV, HBS, and VDRL of umbilical cord and performed bacteriologic study and used only the sterile membranes. Therefore, it is obvious that we did not put the patients’ health in danger.Dr. Habibzadeh wishes to know why fever developed in our patients who were treated with amniotic membrane. Hyperthermia is a component of the physiological response to burn. Hyperthermia (≥38.50) is routinely present following thermal injury, and is a poor indicator of infection.10,11 In our study, many patients in the amniotic membrane group had a slightly higher fever during the first days of treatment, which may be related to accumulation of burn discharge caused by the delay in changing the dressings. However, this fever was not associated with any other clinical manifestations and disappeared after dressing change without any other interventions, and the patients were discharged uneventfully.5- Dr. Habibzadeh believes that the amniotic membrane is a discarded treatment for burn and only has a historic value. However, this is a wrong idea. Human amniotic membrane is known to be an effective dressing since John Staige Davis used it in 1910. But, since then, in spite of some concerns about the transmission of infections, extensive studies on amniotic membrane performed worldwide have proved it to be an excellent biological dressing with almost all the qualities of an ideal dressing.12,13 Nowadays, in addition to wide use in ophthalmology,14,15 amniotic membrane is widely applied in a variety of clinical applications, including intra-abdominaland reconstructive surgery, as well as dressing for burns and chroniculcers,16-22 reconstruction of artificial vagina,23 head and neck surgery,24 prevention of tissue adhesion in surgical procedures of the abdomen and pelvis,25,26 insulin-producing cells,27 and graft fixator.28Amniotic membrane dressing has been a routine practice in our center since 3 years ago and in this period we have treated a considerable number of patients and had no health problem in their follow-up.The last paragraph of Dr. Habibzadeh’s letter is very strange. I believe that we passed all usual ethical and scientific stages to conduct our study, and that the Ethical Committee in Shiraz University performed its duty very well. Calling this clinical trial, which helps us to solve many problems in our burn patients as an appalling trial and using sentences such as plagiarized article or poor research about this study and calling it jeopardous for Iranian national scientific movement is very illogical and without scientific value. So, I think, silence is the best answer to such discriminations.Finally, sorry to say that I think this letter has been written under the influence of some commercial medical companies that their benefits have been threatened by such studies.