Tehran University Medical Journal

Local injection of anesthetic agent in surgical incision in post-operation pain control: a review article

Maryam Esmaeilpour

Today surgery is supposed as the cure for many diseases and the fear of post-operation pain burdens stress over the patients. Postoperative pain can, especially if severe, complicate the patient's condition and may lead to chronic postoperative pain. post-operation pain control is effective in the recovery process, hospitalization period and patients’ satisfaction. Insufficient post-operation pain control increases complications and care costs. Local analgesia is one of the components of multimodal postoperative. analgesic protocol to control pain. Local analgesia technique is a simple, accessible and feasible method for various surgeries. The opioid analgesics to control post-operation pain are associated with some complications such as opium addiction, nausea and vomiting, late return of bowel function and social costs. This review study aims. to review previous studies on the effect of injection of analgesic agents in the surgical incision in post-operation pain control. This is a Narrative review study. to related scientific documentaries a search was conducted in Persian and English using the keywords of local injection of the incision site, wound infiltration with analgesic agents and post-operation pain control in Google scholar, PubMed and Scopus database during the years 2000 to 2020. The obtained articles included systematic reviews, Meta-analyses and randomized clinical trials (RCT). We reviewed studies that had utilized single-dose injection of analgesic agents in surgical incisions at the end of surgery to control post-operation pain. A total of ten studies were reviewed. There were 4 studies in the field of laparoscopic gynecological and non-gynecological surgeries, three studies in the field of laparotomy and three review studies. injection of analgesic agents in the surgical incision to control post-operation pain is easily available and does not necessitate any special skill. On the other hand, it is a safe method without further complications and does not increase the duration of surgery. Regardless of the differences in various studies and the kind of analgesic agents, a general reduction in pain severity and consumption of opioid and non-opioid analgesic agents were observed using the injection of analgesic agents in surgical site incision.

Comparison of the growth hormone, oxandrolone, letrozole and anastrozole’s impact on the height increase in children and adolescents with idiopathic short stature (ISS): a systematic review and meta-analysis

Kourosh Sayehmiri

Background: Short children face many problems throughout their lives. Consumption of growth hormone and the drugs such as Letrozole, Oxandrolone, and Anastrozole can increase the growth of children and adolescents. There is not an overall estimate of the effects of Letrozole, Oxandrolone, and Anastrozole on the growth of children and adolescents with Idiopathic Short Stature (ISS). There are different estimates of the effect of growth hormone and the drugs Letrozole, Oxandrolone, and Anastrozole on growth in children and adolescents with Idiopathic Short Stature. Therefore, the aim of this study was to compare the efficacy of growth hormone, Letrozole, Oxandrolone, Anastrozole, and a combination of growth hormone and aromatase inhibitors on height gain in children and adolescents with idiopathic short stature using meta-analysis method.
Methods: Search was done in databases such as; Scopus, Web of Science(ISI), and PubMed using keywords: Idiopathic, Short Stature, Body Height, Aromatase Inhibitors, Growth hormone, Letrozole, Oxandrolone, Anastrozole. Randomized clinical trial studies ,that have investigated the efficacy of growth hormone and aromatase inhibitors on height gain in children and adolescents with short stature, were selected. Height standard deviation score (HSDS) before intervention and after treatment has been used to measure the rate of height increase in various studies. This study was written based on the PRISMA checklist and the heterogeneity of this study was evaluated using the Q statistic and I² index.

Results: Height increase index (HSDS) was obtained with the use of growth hormone combined with one of the aromatase inhibitors (0.38-3.58=95%CI) (SMD=0.98), with the use of growth hormone (0.62-1.14=95%CI) (SMD=0.88), with the use of Letrozole (0.51-16.51=95%CI) (SMD=0.83), with the use of Oxandrolone (0.99-0.99=95%CI) (SMD=0.56), and with the use of Anastrozole (0.00-0.63=95%CI) (SMD=0.31), which shows that all these drugs have a significant effect on height increase. (P<0.05)
Conclusion: Although the effect of growth hormone on height increase was greater than that of aromatase inhibitors, but according to our results, adding an aromatase inhibitor to growth hormone can increase the effectiveness of it.

A comparison between two groups of diabetic and non-diabetic patients regarding complications during laparoscopic cholecystectomy

Amrollah Salimi

Background: Cholecystectomy is one of the most common abdominal surgeries and its preferred method is laparoscopy. The difficulty of laparoscopic cholecystectomy in diabetic patients is not clear and the preferred method of cholecystectomy in these patients is still under controversy. Therefore, this study was performed to evaluate the difficulty of laparoscopic cholecystectomy in diabetic and non-diabetic patients.
Methods: This retrospective analytical study was performed in Shahid Beheshti Hospital and Forghani Educational and Medical Center from April 2019 to April 2020. Samples were easily selected and 86 people in two groups of diabetic and non-diabetic patients were included in the study. All patient records were reviewed based on inclusion and exclusion criteria for factors such as age, sex, diet, duration of surgery, bleeding, adhesions, and open surgery, and finally, diabetes as a risk factor. It was compared between the two groups. Data were analyzed in SPSS software version 22, an independent t-test was used to analyze quantitative data and the chi-square test was used to analyze qualitative data. In this study, a significance level of less than 0.05 was considered.
Results: Abdominal scar, palpable gallbladder and gallstone were not significantly different between the two groups (P=0.33). But the history of cholecystectomy attacks was significantly different between the two groups (P<0.05). Laboratory values were not significant (P>0.05) . Hard operations in diabetic patients were more than nondiabetic
patients and even two cases of open surgery were seen in the group of diabetic
patients, but there was no significant relationship (P=0.09). Intraoperative bleeding was
statistically significant between the two groups (P=0.02), But adhesion during the
operation was not related (P=0.38).
Conclusion: Finally, our study showed that diabetes can be a predictive risk factor for the difficulty of cholecystectomy.

Prevalence of skin lesions in patients after kidney transplantation referred to Baqiyatallah hospital

Leila Khedmat

Background: Immunosuppressive drugs that are widely used to prevent acute and chronic organ rejections, predispose organ transplant patients to a variety of diseases including skin problems. This study aimed to determine the prevalence of skin lesions and to investigate their association with demographic characteristics in renal transplant patients.
Methods: This cross-sectional study was performed on 100 patients who were referred to the nephrology clinic of Baqiyatallah Hospital, Tehran, Iran and underwent kidney transplantation within a year (from the first working day of the Iranian Hijri calendar in April 2015 until the last working day in March 2016). Patients were referred to a dermatologist in case of any skin lesions. Patients' data were collected in a researcher-made questionnaire and were analyzed using SPSS software, version 18. The p values less than 5% were considered to be significant.

Results: The mean and standard deviation (SD) of the patients' age was 50/4±11/8 years. The average time of incidence of skin lesion after transplantation has been 8/1 ± 5/7 weeks. The most common types of non-melanoma cancers were squamous cell carcinoma (2%) and Kaposi's sarcoma (4%) and there was no significant difference between men and women (p>0.05). Sixty-six percent of the patients had skin infections and the most common skin infections were wart (34%) and tinea versicolor (11%). The relative frequency of skin infections was significantly higher in male patients than in females (p=0.004). Considering all other confounding variables including smoking, hypertension, diabetes and other infectious diseases, the only noteworthy finding was the higher relative frequency of tinea versicolor in diabetic compared with non-diabetic patients (p=0.046).
Conclusion: This study showed that skin complications including various neoplastic (Sarcoma and Carcinoma), infectious (fungal and viral), and other (Acne and Hypertrichosis) diseases are common in patients with kidney transplantation who are taking immunosuppressive drugs. Informing these patients and medical staff about skin problems leads to an early referral of patients and increases their life expectancy and improves their quality of life.

The effects of time management on improvement of educational and therapeutic services in surgical residents of Imam hospital.

Fereidoon Memari

Background: Time management is effective in controlling stress especially for medical residents. Time management in the surgical field and residential education is very important as they are directly involved in treating patients. Proper time management will help decrease work-related stress and increase efficacy, although there is no time management in medical courses. There are few studies in Iran in this field. So, we designed this study to assess the effects of time management on improvement of educational and therapeutic services in surgical residents of Imam Hospital.
Methods: This before–after study was done in Imam hospital between February-March 2015. In this before-after study, 18 surgical residents of Imam Hospital (residents of 1-4 years), were enrolled. Their activities were evaluated in 11 scopes. To evaluate the effects of this self-evaluation, 5 scopes were assessed by the staff. The time during two weeks spent on each item was claimed as a percentage of 336 hours in two weeks. The self-assessment results and their effects on their scores were considered. Data regarding age, sex, and marital status were also gathered. Data were analyzed using SPSS software.

Results: Eighteen residents were enrolled in this study. Ten residents were male (55.6%) and eight were female. Six (33.3%) were married. The mean age was 30±3.7 years. Resting time and emergency room time were significantly higher in the first-year residents while studying time was higher in the fourth-year residents. Second-year residents spend more time in training classes than others. The mean score at the beginning and the end of the study was highest in the forth-year residents and lowest in the first-year residents. All scores at the end of the study were significantly higher than the beginning except clinical judgment. The increase of the mean overall score was significantly higher in the fourth-year group and lowest in the first-year group.
Conclusion: Time management could improve the educational performance of surgical residents.

Evaluation of changes in blood sugar levels in a 14-years cohort study of pre-diabetic patients and its relation with diabetes

Awat Feizi

Background: Examining the course of changes in predictive indicators of future diabetes, such as blood sugar in high-risk individuals including pre-diabetic patients, can provide valuable information about the incidence of diabetes in these individuals. This study aimed to classify people at risk (pre-diabetes) based on the course of changes in their blood sugar and blood lipid and to investigate the incidence of diabetes in these classes on a sample of patients who were referred to the Endocrine and Metabolism Research Center of Isfahan.
Methods: This cohort study was performed based on the information of the Isfahan Diabetes Prevention Plan (IDPs). This project was implemented from April 2004 to March 2018 in the clinics of the Endocrine and Metabolism Research Center of Isfahan. The subjects in this study include 1228 pre-diabetic patients who participated in this project. Demographic and clinical variables of patients including blood sugar and lipid-blood variables were obtained using a questionnaire and laboratory measurements. Also in this study, the number of clinical variables was recorded 3 times. Data analysis was performed using the latent class growth trees model in R software version v4. (R v4.1.0)

Results: The mean (standard deviation) age of participants was 44 (6.86) years. Subjects were classified into two classes of low-risk impaired blood sugar (n=1165) and high-risk impaired blood sugar (n=63) based on the trend of changes in blood sugar levels. Blood sugar levels were reported in the first class (104.28) and the second class (132.41).
Conclusion: In the present study, it was concluded that there is a significant relationship between the incidence of diabetes and the different classes formed based on the course of changes in blood sugar of at-risk individuals. Therefore, by classifying people at risk, the incidence of this disease can be predicted and thus prevented. Also,measures such as managing the blood sugar and lifestyle variables of pre-diabetic patients through nutrition counseling classes and regular periodic tests can be used to reduce the incidence of diabetes in the future is used in people with pre-diabetes who are at high risk for the disease.

Predicting the cause of kidney stones in patients using random forest, support vector machine and neural network

Mohammad Sattari

Background: Today, with the advancement of technology in various fields, the importance of recording data in the field of health is increasing so much that for many diseases around the world, including kidney disease, registration systems have been set up. This is happening in our country and in the future, the number of these systems will increase. The medical data set contains valuable information that will be time-consuming and costly to obtain using laboratory methods, so there is a need for low-cost methods for extracting information. This study focuses on developing a predictive model for classifying the cause of kidney stones in Isfahan using three data mining techniques.
Methods: This cross-sectional research has been done from February 2021 to May 2021. The used medical data set includes information of 353 kidney stone patients in Isfahan. In this study, six target attributes of sodium, phosphate, oxalate, citrate, cysteine and uric acid were identified. The techniques for each of the 6 attributes are used separately. The techniques used in this study were three data mining techniques including random forest (RF), artificial neural network (ANN) and support vector machine (SVM).

Results: The best performance in terms of accuracy is related to support vector machine techniques in uric acid class, support vector machine in oxalate class and neural network in cysteine class. The worst performance is related to the random forest technique in the citrate class. The safest rules with a 66% confidence level are for the citrate and sodium classes, and the least reliable rule with a 50% confidence level is for the oxalate class.

Conclusion: Kidney stones can occur due to various reasons such as low citrate and high calcium oxalate. For example, for citrate, factors such as blood pH (potential of hydrogen), blood sugar and blood pressure are effective. To prevent any of the causes of kidney stones, factors should be controlled.

Severity of COVID-19 in hospitalized elderly at admission, delay in hospitalization, and death from COVID-19

Safieh Mohammadnejhad

Background: Age is a strong risk factor for increasing the risk of severity and death from Covid-19. The risk of hospitalization for Covid-19 disease increases with age. Since the elderly constitute a large proportion of Covid-19 patients, the present study was performed to evaluate the severity of the disease in the hospitalized elderly due to Covid-19 and the delay in hospitalization and death resulting from it, for better disease management.
Methods: The present retrospective cohort study was performed on 444 elderly patients with Covid-19 admitted from 1 April until late October 2020 in Baharloo Hospital in Tehran, Iran. After being diagnosed using the results of RT-PCR and CT scan, patients, were divided into 3 groups: moderate, severe and very severe based on the severity of the disease. Analysis of variance was used to compare quantitative data and a chi-square test was used to examine qualitative variables in disease groups.
Results: From 444 elderly participants in the study, 73% were infected moderately, 15% severely, and 12% had a very severe form. The mean age was 72.90±8.42 and patients with a very severe form of the disease (75.68±8.28) were older. The average time from the onset of symptoms to hospitalization was 7 days. In the elderly with a very severe form of the disease, respiratory dyspnea (P=0.002) and decreased level of consciousness (P<0.0001) were higher. The average hospital stay was 7 days. In very severe form it lasted up to 11 days. ICU mortality and hospitalization were higher in patients with very severe forms of the disease. With the increasing delay in the days of hospitalization, the severity of the disease and mortality has increased.
Conclusion: The study showed that prolonging the onset of symptoms till hospitalization worsens prognosis and also exacerbates the disease and increases mortality in the elderly.

Analytical investigation of ophthalmology complaints referred to legal medicine organization of tehran, Iran

Elham Bazmi

Background: Today, despite the efforts of the medical community and health staff, the rate of dissatisfaction and complaints among patients is increasing and this highlights the importance of evaluating its related factors. The aim of this study was to analytically investigate complaints against ophthalmologists which were referred to the Legal Medicine Organization of Iran in Tehran during 2017-2019.
Methods: In this cross-sectional (analytical-descriptive) study, the demographic data of patients and physicians including age, gender, marital status and academic degree, type of treatment measures leading to complaints, last decision of the medical commission, characteristics of protesting of patients and vote of revision commissions for all the complaints of ophthalmology were recorded and analyzed.
Results: During 3 years, 176 complaints were recorded in the field of ophthalmology. Of these, 90(51.1%) complaints were from medical interventions which took place in university or government hospitals and clinics. Also, 27(15.3%) cases of malpractice were reported, among which negligent was the most common type, with 22 cases (81.5%). The highest number of complaints was for cataract surgery and the most frequent treatments with malpractice of the physicians were cornea transplantation. Although the most protests to the first decision were from the patients, the effectiveness of physicians’ protest was significantly higher (P<0.001).

Conclusion: Nowadays, with advances in treatment methods and technologies in ophthalmology and enhancement in the knowledge of patients about their rights, their expectations from medical staff have changed. The findings of the present study suggest that due to the rise in the number of complaints in ophthalmological treatment while a decrease in malpractice rate, applying intervention actions such as good communication between physicians and patients and patient’s right perception of treatment and possible side effects can lead to less number of complaints. In addition, due to different opinions in consecutive commissions, utilizing a single approach based on new information and evidence seems necessary.

Challenges of teaching medical ethics from the perspective of mentors and students of Tehran university of medical sciences: a brief report

Amir Ahmad Shojaee

Background: The approach of medical ethics training courses at Tehran University of Medical Sciences to change the attitude and promote medical ethics knowledge of learners has challenges. This study aims to identify the challenges in teaching medical ethics at Tehran University of Medical Sciences.
Methods: This is a qualitative study with semi-structured interviews conducted in April 2018 at Tehran University of Medical Sciences. Using purposive sampling, 23 participants were selected from the clinicians and faculty members of medical ethics and medical students. Data were analyzed by the content analysis method.

Results: The challenges of teaching medical ethics from the participant's point of view are classified into three themes: 1- Hidden curriculum 2- Necessity of completing medical ethics education program 3- Executive and managerial macro factors. The results showed that medical ethics training courses are not effective for changing students' behavior and their moral decision-making. There are substantial shortcomings in the current curriculum in terms of content, format, and implementation that make it unresponsive to ethical needs and concerns. Teaching medical ethics should be turned into a longitudinal theme. The duties and missions of the Department of Medical Ethics at the university are not well understood. The Department does not act as a strong executor and supervisor of medical ethics in interaction with higher authorities to pursue the requirements of effective ethics education and to ensure the implementation of ethical codes. There is no effective mechanism for evaluating the ethical performance of activists and students and giving feedback to them. There is insufficient organizational support for students' complaints and reports about the misconduct and unethical behavior of faculty or staff.

Conclusion: The effectiveness and efficiency of medical ethics courses to change the behavior and attitude of learners are not acceptable. Dealing with the existing challenges requires the efforts of the Medical Ethics Department to make maximum use of available resources and interact effectively with other academic departments.

Seyed Abbas Hosseinalipour