Tehran University Medical Journal

SARS-CoV-2 and COVID-19, evidence from a literature review: review article

Sayed-Hamidreza Mozhgani

SARS-CoV-2 emerging from Wuhan, China is a member of the Coronaviridae family, which has so far infected and killed many people. The SARS-CoV-2 pandemic affected various aspects of life in Iran and Worldwide, and governments have imposed quarantines and travel bans on an unprecedented scale. The virus causes COVID-19, which can spread through close contact with the infected person, contaminated equipment, and suspended air droplets. The most common symptoms of the disease include fever, cough, shortness of breath, gastrointestinal symptoms, and diarrhea. In severe cases, the lung infection can occur, which causes Severe Acute Respiratory Syndrome that leads to ICU admission and even death.
Besides, this infection can cause gastrointestinal, neurological, and renal impairments. Not merely, this new coronavirus has infected many more people worldwide in comparison to MERS and SARS, but also it has killed more people. Patients with underlying diseases such as hypertension, diabetes, respiratory problems, kidney disease, heart disease and Immunodeficiency are at higher risk of infection and potential death. Also, the risk of death and complication increases in older adults, while most of the infected children are asymptomatic. Some infected people may have mild or no symptoms but can still transmit the disease and spread it to others.
To diagnose COVID-19, serology tests, and level of ESR, CRP and other acute-phase reactants are helpful, whereas molecular tests, such as RT-PCR tests, that detect the virus’s genetic material are still the golden standard. Also, CT scan detects lung involvement; Ground-glass opacification, especially in lower lobes and subpleural region, is the most common CT characteristic, although it is not specific for COVID-19. Because the disease is difficult to diagnose, hard to prevent and challenging to treat, it has become a major concern for many countries. This review aims to gather existing information in the fields of virology, molecular pathogenesis, disease symptoms, epidemiology, clinical presentations, diagnosis, treatment, and the spread of the disease. This study also provides evidence-based prevention and treatment strategies for health policymakers, doctors, nurses, and practitioners in the field of public health, including researchers and students.

An investigational study about the conversion risk factors of laparoscopic cholecystectomy to open surgery

Mohsen Eshraghi

Background: Knowing the conversion risk factors of laparoscopic cholecystectomy to open surgery, helps the surgeon to plan for surgery accordingly. This study aimed to determine the risk factors for converting laparoscopic cholecystectomy to open surgery.
Methods: In this analytical study, the case information of 1104 patients who underwent laparoscopic cholecystectomy in Shahid Beheshti Hospital in Qom from April 2013 to April 2017 was evaluated. Inclusion criteria were all cases of acute cholecystitis, chronic cholecystitis, symptomatic gallstones, and biliary pancreatitis who underwent laparoscopic cholecystectomy. The exclusion criteria were patients who underwent laparoscopic cholecystectomy at the same time with other procedures. Data of all patients including age, sex, history of abdominal surgery, emergency or elective surgery, blood transaminase level, blood bilirubin level, white blood cell count, amylase level, and serum alkaline phosphatase were recorded. Finally, potential risk factors were compared between the two groups. Average, standard deviation, frequency and percentage indices were used to describe the data. Independent samples t‐test and Mann-Whitney U test were used for quantitative data analysis and Chi-square test was used for qualitative data analysis. P<0.05 is considered significant.
Results: 1104 patients were studied. 765 patients were female (69.3%) and 339 patients were male (30.7%). In 104 cases, open surgery was performed. The mean age of patients in the method change group was 49.45±8.9 years. Among the studied variables, between sex (P=0.26), age (P=0.056), process of cholecystitis (P=0.65), previous history of abdominal surgery (P=0.62), alanine transaminase (P=0.10) aspartate transaminase (P=0.95) showed no statistically significant relationship with the conversion of laparoscopic surgery to open surgery. However, abnormal ultrasound (P=0.000), emergency surgery (P=0.000), white blood cell count (P=0.008), total bilirubin and alkaline phosphatase (P=0.000) had a statistically significant relationship with the conversion of laparoscopic to open surgery

Conclusion: Due to the high complications and mortality of open cholecystectomy, the detection of these risk factors helps to reduce the rate of open surgery and address these factors before surgery.

Evaluating the relationship between intrauterine insemination outcome and special causes of infertility

Firouzeh Ghaffari

Background: Common treatment for infertile couples is the use of controlled ovulation hyperstimulation (COH) with intrauterine inseminations (IUI). IUI is used in cases such as ovulatory dysfunction, cervical factor infertility, male subfertility, and unexplained infertility. In this study, we evaluated the relationship between IUI outcome and special causes of infertility.
Methods: This was a cross-sectional study and a sampling method was available in this study, from January 2014 to August 2016, 994 cycles in 803 infertile couples referred to Royan Research Institute in Tehran were analyzed. Inclusion criteria were: male factor infertility, combined causes, ovarian disease, and infertility of unknown cause. To evaluate pregnancy, 12-16 days after IUI, it was considered positive if pregnancy test followed by transvaginal ultrasound at week 4 after IUI were positive.
Data were analyzed using SPSS software, version 20. T-test and chi-square were used to compare the case and control groups. Linear-by-linear test was also used to calculate the relationship between female age and clinical and multiple success rates. P<0.05 was considered significant for the results of these tests.

Results: The success rate of pregnancy in all cycles (16.5%) and live birth rate per cycle (14.5%) were calculated. The mean age in the pregnant group was significantly lower than that of the non-pregnant group (P = 0.01). Our findings were: Infertility with unknown cause (290 people, 29.2%), male factor (395 people, 39.7%), ovulation disorders (201 people, 20.2%) [which include: decreased ovarian reserve (1 person) 0.5%), polycystic ovary syndrome (188 patients, 93.5%) and hypothalamic amenorrhea (12 patients, 6%)] and a combination of different factors (108 patients, 10.9%). There was also a significant relationship between the cause of infertility and clinical pregnancies (P<0.001). A Significant decrease in pregnancy success rate was observed with increasing infertility duration (OR=0.8, CI=0.8-0.9, P<0.001).
Conclusion: Women’s age, etiology of infertility, duration of infertility, irregular menstruation, semen volume, and gonadotropin dose were important factors in COH+IUI cycles.

Factors predicting a positive pregnancy screening test at first trimester

Maedeh Rahmanzadeh

Background: For every pregnant woman, it is possible to have a child with chromosomal abnormalities. Although this possibility is not very high, by performing screening tests and considering the mother's background factors, we can largely realize the real extent of this possibility.
Many comorbidities (like high blood pressure, diabetes, and obesity) and high-risk exposures (like alcohol consumption) seem to have an important role in the development of chromosomal abnormalities. This study aimed to determine the predictive factors of a positive first-trimester screening test in the pregnant women.
Methods: This case-control study was done on pregnant women, who were referred to Yas Hospital for their first-trimester screening tests between April 2018 and February 2020. Of those who had positive screening test results, only ones with abnormal biochemical tests, were included in the study regardless of nuchal translucency (NT) examination results and were considered as cases, and the women with normal screening test results were considered as controls.

Results: Totally 960 pregnant women (760 controls and 200 cases) participated in the study. The mean age of the subjects was 31.07±0.17 years old with a minimum age of 17 and a maximum age of 45. The averge age of case group women was 33.57±0.40 years and this was 30.41±0.18 years in control group.
This study indicated that maternal age (P<0.001) and the number of pregnancies in the case group are significantly (P<0.001) higher than the control group. Also, having a history of miscarriage (P<0.001), having a history of infertility (P<0.001), and having hypothyroidism (P=0.030) are significantly more common in the case group. The frequency of intrauterine growth failure (P=0.003) and neonatal hospitalization (P<0.001) were also significantly higher in the case group.
Conclusion: Despite recent advances in the prenatal field, the accuracy of screening tests may still vary depending on maternal age and other existing characteristics. Hence, it seems considering the mother's background characteristics are important just the same as the screening test results.

Studying the effect of vitamin d on the intensity of torsional nystagmus in Benign paroxysmal positional vertigo (BPPV) in Rohani hospital of Babol

Mohsen Monadi

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo and nystagmus in clinics. Vertigo has many causes and the recurrence of vertigo is unknown. Among a lot of factors, vitamin D deficiency is more important. This study was conducted to determine the effect of vitamin D supplementation on torsional nystagmus in BPPV patients. This study wants to show the deficiency of vitamin D leads to the recurrence of BPPV.
Methods: This case-control study was conducted from April 2017 to May 2018. All eligible patients with BPPV were presented to the Audiology clinic of Babol Rouhani hospital consecutively. Diagnosis of BPPV and the presence of nystagmus were confirmed and serum vitamin D was assessed. Dix-halpike maneuver and videonystagmography (VNG) for assessing nystagmus were done and for serologic assessment, ELISA was performed for analyzing the level of hydroxy 25 vitamin D.Vitamin D sufficient patients (more than 20 ng/ml) with BPPV were considered as the control group and vitamin D deficient patients (less than 20 ng/ml) were as the test group.
In all the patients of two groups, torsional nystagmus (vertical, horizontal and oblique) were studied and compared.

Results: Twenty-seven patients in each group have completed the study. The mean age of the control group and test group was 48.2+4.8, 47.8+5.7 and 47.2+4.9 years respectively (P=0.91). Two groups were comparable regarding nystagmus severity. All patients had at least two attacks During the last six months. The mean of serum 25 OHD was 33.81 in the control group and 11.41 in the test group that was statistically significant (P=0.001 for all) and the severity of torsional nystagmus in three axes of horizontal, vertical and oblique in the control group was 4.98, 9.06, 5.40 respectively and 3.32, 8.86, 6.93 in the test group that was statistically significant as compared with the control group (P=0.001).
Conclusion: Findings of this study indicate a relationship between vitamin D deficiency and recurrence of nystagmus in BPPV patients

Development of a persian version of the BREAST-Q and validity and reliability of the reconstruction module for the assessment of the quality of life and patient satisfaction following breast surgery

Amirmohsen Jalaeefar

Background: Breast cancer is the most common cancer in women and its treatment includes various surgeries. Breast-Q is a new patient-reported outcome instrument for breast surgery and it should be validated appropriately for clinical research. This study aimed to develop the Persian version of the Breast-Q and validate the reconstruction module to evaluate the quality of life and satisfaction of Iranian women with a previous history of breast reconstruction.
Methods: This study was descriptive and analytical cross-sectional. The study population consisted of women with a previous history of breast cancer and various breast surgeries referred to the outpatient clinic of Cancer Institute, Imam Khomeini Hospital from September 2017 to October 2019, using convenience sampling. After obtaining permission from the MAPI institute and translating all questionnaires into Persian, the validity, and reliability of the breast reconstruction module were evaluated. To confirm face validity, a questionnaire was given to patients to judge each item. To confirm the content validity of the questionnaire, two qualitative and quantitative methods were used. Content validity ratio (CVR) was calculated based on the expert opinion (Lawshe formula). Waltz & Bausell’s method was used to examine the content validity index (CVI). Finally, a new version of the questionnaire was assessed in 20 women who had undergone TRAM flap breast reconstruction at least 6 months ago.

Results: After translation of the questionnaire into Persian, and face and content validation process, the 116 items of the first questionnaire converted to 72 with an acceptable impact score greater than 1.5 and CVR and CVI. The internal validity of the breast reconstruction module was approved by Cronbach's alpha value of 0.94.
Conclusion: Considering the limitation of the specific questionnaires for various breast surgery procedures, the Breast-Q questionnaire can be an efficient tool for the evaluation of the quality of life and satisfaction in patients. Since the translation of the questionnaire has become valid and reliable, it can be used for future research by other researchers.

Efficacy of chlorhexidine solution on oropharyngeal bacterial colonization in hospitalized patients of intensive care units

Mohsen Soleimani

Background: Infection is a vital problem in intensive care units. Currently, chlorhexidine solution is used to reduce oral colonization. This study aimed to determine the efficacy of chlorhexidine solution on oropharyngeal bacterial colonization in hospitalized patients in the intensive care units.
Methods: This descriptive study (from August 2018 to May 2019) was performed on 60 patients who administered in medical and surgical intensive care units (ICUs) in one of the university hospitals in Semnan city. Patients admitted to (ICUs) were selected according to inclusion criteria. At the time of admission to the intensive care unit, oropharyngeal colonization of patients was assessed. Forty-eight hours after admission and using the chlorhexidine solution 0.2% three times a day, oropharyngeal colonization was assessed again. Data analysis was performed with SPSS software, version. 22 in the significant level of 0.05.

Results: This study showed most of the patients in this study were male (80%) with mean age of 45.23±15.19 years. Most patients were transferred from the emergency department to intensive care units and had endotracheal tubes. At the time of admission to the intensive care unit, 8 patients were infected with E. coli and 6 patients were infected with Klebsiella. The results also showed that the use of chlorhexidine 0.2% had no significant effect on the reduction of micro-organisms in the oropharyngeal area. Forty-eight hours after admission to ICUs, the incidence of E. coli infection increased (P=0.01) but there was no significant increase in the klebsiella infection rate (P=0.25).
Conclusion: This study showed that the use of chlorhexidine solution 0.2% did not affect the reduction of micro-organisms in the oropharyngeal areas of patients. Therefore, oral care protocols that include mechanical movements and toothbrushing should be considered to reduce the occurrence of micro-organisms. This study also found that most patients who were referred to the intensive care unit were contaminated with pathogenic micro-organisms. Therefore, consideration should be given to appropriate strategies to reduce infections in the emergency department.

Survey of marital satisfaction in Iranian working women: brief report

Zohreh Keshavarz

Background: Marital satisfaction is considered to be the feelings and understanding of the couple about their marital relationship and their two-way relationship. Many factors play a role in creating marital satisfaction, and on the other hand, marital satisfaction is one of the concepts that cause sexual health in a person. Sexual health has many dimensions and includes coordination and adaptation of physical, emotional, intellectual, and social aspects of sexual affairs in humans. This study was conducted to assess the marital satisfaction of working women in Iran through meta-analysis.
Methods: In this meta-analytic study, the issue of marital satisfaction amongst Iranian working women which has been published in local articles was evaluated. To find pertaining studies, Magiran, IranDoc, SID, Iranmedex, and Pubmed websites were used. Statistical society in this research consists of all studies in Iran in regard to the relationship between being a working woman and having marital satisfaction that has been accomplished since 2001-2018 and was indexed in one of the scientific informative websites.
To access desired articles we used the English keywords of ‘Sexual dysfunction’, ‘Iran’, ‘Sexual function’, ‘Marital satisfaction’, ‘Working women’ and ‘women’ and their Persian equivalents. After the selection process of articles related to the research objectives, 10 articles were selected and assessed as final samples.

Results: Collected data indicate that the average size of the influence of working on marital satisfaction in research samples was equal to 0.063. Point estimate based on Cohen scale shows low influence level.
Conclusion: The influence of being a working woman on marital satisfaction is not approved. Generally being a working woman can be effective on marital satisfaction at a weak level. However, regarding the impact of women’s work on marital satisfaction, research’s statistical society is also effective and should be considered. On the other hand, the positive impacts of being a working woman has become more significant over time.

Posterior reversible Leukoencephalopathy following thrombotic thrombocytopenic purpura at postpartum period: case report

Atiyeh Vatanchi

Background: Posterior reversible leukoencephalopathy syndrome (PRLS) is a clinical and radiological syndrome of heterogeneous etiologies that are grouped because of the similar findings on neuroimaging studies which may occur at any age. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. The syndrome is more commonly seen in women, RPLS has been described in several medical conditions, with hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressant drugs being the most common conditions. Prompt recognition and treatment are important in preventing the permanent damage that can occur in this otherwise typically reversible condition. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. This report aimed to introduce a case of reversible posterior leukoencephalopathy following postpartum thrombotic thrombocytopenic purpura (TTP).
Case presentation: The patient was a 30-year-old primigravid woman at 33 weeks of pregnancy who was referred to the Ghaem hospital, Mashhad University of Medical Sciences in Mashhad in July 2017 due to high blood pressure, blurred vision, headache and generalized tonic colonic seizure. She did not report in previous history of high blood pressure or seizure before pregnancy. With a diagnosis of eclampsia remote from delivery, she underwent a cesarean section. After delivery, generalized tonic colonic seizure repeated several times and a significant reduction in consciousness level happened. Renal failure also occurred, so she underwent daily plasmapheresis with a diagnosis of TTP. After 35 days, she was discharged with a good general condition.
Conclusion: In predisposing conditions, such as high blood pressure in pregnancy, in the case of clinical suspicion of posterior leukoencephalopathy, any attempt for early diagnosis and appropriate treatment are important factors in reducing the rate of morbidity and mortality.

Cervical Cavernous hemangioma in a patient with postcoital bleeding: case report

Malihe Hasanzadeh

Background: Cervical cavernous hemangioma is an extremely rare, benign lesions, and only a few cases are reported. Cervical cavernous Hemangiomas are characterized by an increase in the number of normal and abnormal veins. The majority of these lesions are superficial, often found in the head and neck area, but may also occur in the inner parts of the body. The occurrence of these lesions in the female reproductive tract, especially the the cervix is extremely rare. This disease should be considered as a differential diagnosis of abnormal uterine bleeding because of the low prevalence and importance of the diagnosis of this uncommon disease. The majority of cervical cavernous hemangiomas have been reported in women of childbearing age. Besides, although most lesions are symptomatic (mostly bleeding), diagnosis is often unlikely. They may cause abnormal vaginal bleeding in the form of menometrorrhagia and postcoital spotting. To date, fewer than 55 cases have been reported. This study aimed to report a rare case of cervical cavernous hemangioma.
Case Report: The patient was a 24-year-old woman who had referred to the outpatient clinic of Ghaem Hospital in September 2016 due to prolonged post coital bleeding after intercourse. At the time of the pelvic examination, posterior lip of cervix was very vascular and there was black color that had extend to the vagina. The patient underwent colposcopy. Following colposcopy, due to severe cervical bleeding, the vagina packed. The patient's bleeding was controlled with the pack after 24 hours. Cervical pathology revealed a cavernous hemangioma.

Conclusion: Cervical cavernous hemangioma is extremely rare. This should be considered in the differential diagnosis of patients with abnormal vaginal bleeding, especially those of childbearing age, and no clinical or radiologic findings such as leiomyoma, adenomyosis, or dysfunctional uterine bleeding. Pelvic examination is the first step in the management of the patient with vaginal bleeding. Increased awareness of this unusual cervical lesion can lead to early diagnosis and conservative treatment approaches. In most cases, hysterectomy is performed, but the patient with mild symptoms can be treated with conservative management. Increased awareness of this unusual cervical lesion can lead to early diagnosis and conservative treatment approaches.

The Impact of COVID-19 on health economics: letter to the editor

Mohammadreza Sheikhy-Chaman

No Abstract No Abstract No Abstract