Tehran University Medical Journal

Vagus nerve stimulation in the treatment of nervous system disease: a review article

Seyedeh Masoumeh Seyedhosseini Tamijani

The vagus nerve (VN), the longest cranial nerve and an essential part of the parasympathetic system, connects the central nervous system to respiratory, cardiovascular, immune, gastrointestinal, and endocrine systems and is involved in the maintenance of homeostasis by controlling these systems. Vagus nerve stimulation (VNS) is related to any method that would stimulate the vagal nerve via electrical stimulation. VNS is a Food and Drug Administration (FDA)-approved treatment for medication-resistant depression, drug-resistant epilepsy, and migraine. However, VNS has also been studied for various other conditions, such as Alzheimer's disease and tinnitus, by targeting the VN in the neck and ear. Currently, there are two methods for VNS: a) invasive-VNS (iVNS), which requires surgical implantation of a pulse generator under the anterior chest wall, that is linked through a wire to an electrode cuff that wraps around a cervical vagus nerve, b) non-invasive transcutaneous VNS which is separated into cervical transcutaneous vagal nerve stimulation (ctVNS) and auricular transcutaneous vagal nerve stimulation (atVNS). The non-invasive transcutaneous VNS techniques are well tolerated and have no significant side effects, making them effective in clinical research for brain diseases. Because with these newer methods, the electrical stimulation is carried out through the skin.
The results of this study were collected using the advanced search in Scientific Information Database (SID), Google Scholar, PubMed, and Scopus between 2011 to 2021. Out of 671 articles surveyed, we used 53 articles in the study after the evaluation. Medical Subject Headings (MeSH) and Keyword Searching was carried out through the MeSH database. VNS has been shown to alter neural activity in multiple areas of the brain related to the regulation of the affective states. However, the precise mechanism of VNS action on the clinical consequences is still unknown. This study aimed to review the therapeutic effect of both methods of VNS in neuropsychiatric and neurological disorders such as depression, migraine, seizure, tinnitus and Alzheimer's disease and discuss several hypotheses on the mechanism of VNS, as a new approach, in the treatment of such disorders. It considers that a brain-mapping approach is needed to discover the therapeutic mechanisms of VNS in brain diseases.

Evaluating conservative treatments to reduce coccydynia symptoms: a systematic review

Masumeh bagherzadehcham.m@iums.ac.ir

Background: There are many conservative interventions to reduce the symptoms of coccydynia, but it is not clear which treatment can be more effective. The aim of this review study was to evaluate the types of conservative interventions and the effectiveness of each of them in reducing coccydynia symptoms.
Methods: This systematic review was carried out based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) instruction. A search for research studies published up to October 2021 was conducted in Neuromusculoskeletal Research Center, Firoozgar General Hospital, Iran University of Medical Sciences, Tehran, Iran, using Scopus, Science Direct, Web of Knowledge and Cochrane without data constraints. The search was carried out in October 2021 and continued for seven months. The quality of the articles was evaluated using the Physiotherapy Evidence Database scale (PEDro). All prospective randomized clinical trial studies in which participants suffered from coccydynia and were treated with nonsurgical treatments were included.

Results: 945 articles were found in the primary search of the databases. After eliminating 493 repetitive papers, 452 studies remained which were screened by the two researchers of this study in terms of the title and abstract. 40 studies were selected for full-text evaluation. Finally, 12 articles were included in the review study. Two papers used extracorporeal shockwave, two papers used impar ganglion block, three papers manual therapy, and four studies injection. The remaining four studies used iontophoresis with ketoprofen, biofeedback therapy, acupuncture, and physiotherapy with Kinesio taping.
Conclusion: Treatment with extracorporeal shock wave and impar ganglion block significantly improve tailbone pain and show more permanent effects on patients' symptoms. Manual therapies are mostly used in cases where the tailbone is stable. It seems that achieving the desired response requires more than six sessions, which is not pleasant for patients. Injections, especially those performed under fluoroscopic guidance, require high skill in addition to being unpleasant and painful. However, this procedure is done in one session, so there is no need for the next visit.

Evaluation of clinical and laboratory symptoms of children with idiopathic arthritis treated with methylprednisolone pulse

Mamak Shariat

Background: Juvenile idiopathic arthritis is the most common rheumatic disease in children, which includes a group of disorders that all have a common clinical manifestation of arthritis. The aim of this study was evaluation of the clinical and laboratory symptoms of children with idiopathic arthritis who treated with intravenous methylprednisolone pulse.
Methods: This study is a descriptive cross-sectional study of 20 years in Imam Khomeini Hospital from 1993 to 2013. Information of 202 hospitalized patients diagnosed with JIA who had files, containing demographic, clinical and laboratory data were recorded. The software 17spss was used for data statistically analyzed.
Results: The mean age of patients was 6.98±3.65 years. After treatment in all age and sex groups, the mean of Hb and HCT increased significantly and WBC and PLT decreased significantly. Mean CRP and ESR decreased significantly. Mean alkaline phosphatase was significantly reduced in boys. There were no significant changes in AST and ALT. At Ca and K levels, the decrease was significant. There was significant increase in Na. Ca level in boys and K level in girls decreased and Na level in boys increased significantly. Serum sodium also increased significantly in the group over ten years, potassium in the group of five to ten years and calcium in the group up to 5 years and over ten years decreased significantly. FBS did not change significantly. Blood pressure increased significantly. In this study, the highest joint involvement related to knee joint that was 89.7% and the lowest joint involvement related to neck joint that was 7.4%, which ultimately improved significantly By 76.7% in response to treatment.
Conclusion: Due to its availability, improving patient function and reducing clinical symptoms, this treatment is recommended. However, the need for further studies and consultation of other specialists, including cardiovascular counseling, seems necessary.

Evaluation of the therapeutic effect of coenzyme Q10 in patients with generalized vitiligo

Saeed Karimi Motaleb

Background: Vitiligo is a skin autoimmune disease that affects 0.1% to more than 8% of people in the world. About 50% of patients develop the disease before the age of 20. In this disease, melanocytes are destroyed in the skin, mucous membranes and retina. As a result, white spots appear on different parts of the body. Studies have suggested the role of oxidative stress in vitiligo. Coenzyme Q10 is a specific lipophilic antioxidant. The aim of this study was to evaluate the therapeutic effect of coenzyme Q10 in patients with generalized vitiligo.
Methods: This study was a randomized, double-blind, clinical trial of patients with generalized vitiligo who had been referred to the dermatology clinics of Vali-e-Asr Hospital and Imam Reza Clinic in May-August 2016. The sampling method was random. Patients were treated with standard treatment, and the case groups in addition to standard treatment with tablets containing coenzyme Q10. Patients were evaluated for response at the first visit, 1 and 3 months after the start of treatment.

Results: The mean age of 50 patients was 26.2±4.3 years. The diameter of the largest depigmented patch decreased in both intervention (P=0.000) and control (P=0.001) groups during 3 months of treatment. The difference in the frequency of patients in the grade of repigmentation was significant at the end of the third month compared to the end of the first month of treatment in both intervention (P=0.01) and control (P=0.02) groups. At the end of the third month, the frequency of patients in both intervention group with 21 patients (76%) and the control group with 18 patients (72%) were more in grades 1 and 2, while at the end of the first month, the frequency of patients in both intervention groups with 23 patients (92%) and control with 23 patients (92%) was more in grades 0 and 1.
Conclusion: Adjuvant therapy with oral coenzyme Q10 has no effect on improving depigment patch in vitiligo.

Automatic segmentation of glioma tumors from BraTS 2018 challenge dataset using a 2D U-Net network

Iraj Abedi

Background: Glioma is the most common primary brain tumor, and early detection of tumors is important in the treatment planning for the patient. The precise segmentation of the tumor and intratumoral areas on the MRI by a radiologist is the first step in the diagnosis, which, in addition to the consuming time, can also receive different diagnoses from different physicians. The aim of this study was to provide an automated method for segmenting the tumor and intratumoral areas.
Methods: This is a fundamental-applied study that was conducted from May 2020 to September 2021 using multimodal MRI images of 285 patients with glioma tumors from the BraTS 2018 Database. This database was collected from 19 different MRI imaging centers, including multimodal MRI images of 210 HGG patients, and 75 LGG patients. In this study, a 2D U-Net architecture was designed with a patch-based method for training, which comprises an encoding path for feature extraction and a symmetrical decoding path. The training of this network was performed in three separate stages, using data from high-grade gliomas (HGG), and low-grade gliomas (LGG), and combining two groups of 210, 75, and 220 patients, respectively.

Results: The proposed model estimated the Dice Similarity Coefficient (DSC) results in HGG datasets 0.85, 0.85, 0.77, LGG datasets 0.80, 0.66, 0.51, and the combination of the two groups 0.88, 0.79, 0.77 for regions the whole tumor, tumor core, and enhancing region in the training dataset, respectively. The results related to Hussdorf Distance (HD) for HGG datasets were 8.24, 9.92, 4.43, LGG datasets 11.5, 11.31, 2.23, and the combination of the two groups 7.20, 8.82, 4.43 for regions the whole tumor, tumor core, and enhancing region in the training dataset, respectively.
Conclusion: Using the U-Net network can help physicians in the accurate segmentation of the tumor and its various areas, as well as increase the survival rate of these patients and improve their quality of life through accurate diagnosis and early treatment.

Costs of services covered by the global payment system in Tehran University of Medical Sciences

Maryam Radin Manesh

Background: In Iran, a combination of three methods of budget payment, fee for service and case-based payment (known as the global payment system) is used to reimburse the cost of hospital services. The aim of this study was to investigate the costs of 90 services of the Global Hospital Reimbursement System at Tehran University of Medical Sciences.
Methods: This descriptive cross-sectional applied study was performed from March 2017 to March 2019 in the hospitals of Tehran University of Medical Sciences. The billing and record data of all patients whose services were reimbursed on a global payment system basis were extracted from hospital information systems. Data were analyzed using descriptive statistics (frequency mean. std deviation, maximum & minimum) in SPSS 21 and Excel 2016.
Results: During two years in TUMS, the costs of services provided to 143,866 patients have been reimbursed based on the global payment system., which had a cost of 2300 billion rials. 80% of the total services and costs were related to 10 services. 78.46% of the cases were related to two specialized groups of ophthalmology and obstetrics and gynecology. 83.17% of the total costs of services reimbursed globally at the TUMS were related to these two specialized groups. The average cost per service was about 16 million Rials, but varied greatly for different services, ranging from about 1.8 million Rials to 67 million Rials. On average, for a global service, the share of each of the cost subgroups of diagnostic services, hoteling and nursing services, medicine and consumables, operating room and surgery, physician's visit and consultation, respectively 3.1%, 11.6%, 21.4%, 49.9% and 13.9%.

Conclusion: Managers need to focus on high-frequency and high-cost services to reduce the cost and financial losses for services that are under the global payment system. Depending on the specific cost pattern of each service, the strategies adopted to control the costs of that service should also be different.

Evaluation of effective factors in the success of resuscitation of patients with in-hospital cardiopulmonary arrest

Aref Javari

Background: Previous studies have shown that several factors affect the outcome of cardiopulmonary resuscitation. In this study, we have evaluated the factors associated with the outcome of resuscitation in in-hospital cardiopulmonary arrest patients (IHCA) 002E.
Methods: This cross-sectional non-probability study was performed on patients with in-hospital cardiopulmonary arrest between 2015 and 2020 in the emergency department (ED) of Al-Zahra Hospital, Isfahan, Iran. Data were then collected from medical records to describe patient characteristics, arrest profile, and survival details. Factors associated with the dependent variable were examined Logistic regression.
Results: Among 848 in-hospital cardiopulmonary arrests, 18 patients (2.1%) survived and were discharged from the hospital. The mean age of patients was 62.74±21.17 years, 583 (68.8%) were male, and 265 (31.2%) were female. The mean age of patients with successful resuscitation and those with unsuccessful resuscitation was 62.33±21.79 (6 to 116 years) and 61.58±21.20 (1 month to 108 years) years, respectively. The rate of unsuccessful resuscitation increased with increasing age (P=0.04). Also, the rate of unsuccessful resuscitation increased if there was an underlying disease (P=0.01). In frequency analysis of resuscitation services, emergency medicine with 633 (57.3%) resuscitation is in the first place in the number of resuscitations, of which 22.9% of them have been successful (ROSC). In the anesthesia service, of 2 resuscitations performed, both were successful. In the general surgery service, 36.5% of 63 resuscitations were successful, and the success rate for the neurosurgery service was 32.4% of 102 resuscitations. Analyzing the duration of successful and unsuccessful resuscitation has great importance. In successful resuscitation, the average time was 18.98 minutes and in unsuccessful resuscitation was 39.20 minutes. Also, the maximum and minimum time for successful resuscitations was 63 and 1 minutes. The maximum and minimum time for unsuccessful resuscitations was recorded as 60 and 10 minutes.

Conclusion: The results showed that several factors were influential in cardiopulmonary resuscitation. Increasing age and underlying disease reduced the success of cardiopulmonary resuscitation.

Evaluation of the one-year effectiveness and side effects of rituximab in patients with multiple sclerosis in Kermanshah

Nazanin Razazian

Background: Multiple sclerosis (MS) is an inflammatory disease affecting the central nervous system. Rituximab (Zytux) is a type of monoclonal antibody against B cells with CD20 antigen that reduces B cells. The present study examined the one-year effectiveness and side effects of Rituximab.
Methods: This quasi-experimental clinical trial was conducted from September 2018 to September 2019 in Imam Reza Hospital in Kermanshah. 44 eligible patients were selected by the available sampling method and entered the study after evaluation in terms of inclusion and exclusion criteria. Patients were treated with rituximab for one year. At the beginning of the study and at the end of the year, the disability score based on the Expanded Disability Status Scale (EDSS) and active lesions based on MRI for patients were evaluated. Also, the patients were followed up in terms of relapse and medication side effects throughout the year. This study was performed with the support of Kermanshah University of Medical Sciences. Informed consent was obtained from all participants. The data were analyzed by SPSS-25 software.

Results: 44 patients with MS including 29 (65.9%) female and 15 (34.1%) male were studied. 22 patients had RRMS and 22 patients had progressive-relapsing MS (PRMS). In patients with RRMS, the EDSS score at the end of the study was significantly reduced compared to the beginning of the study (P=0.010) but in PRMS patients EDSS was increased but this increase was not significant (P=0.148). In both RRMS and PRMS patients, the number of MRI lesions at the end of the study was lower than the beginning of the study and this decrease was not significant (P>0.05). More Immediate side effects occurred in RRMS patients (13.6% vs. 4.5%) and more delayed side effects were observed in PRMS patients (54.5% vs. 36.3%).
Conclusion: rituximab caused a greater reduction in EDSS in the treatment of RRMS than PRMS and its use had few side effects.

Comparing the diagnostic accuracy of bedside ultrasound with wound exploration in diagnosis of nerve and tendon injuries in upper extremities: a brief report

Marzieh Khademi

Background: Trauma is one of the most common causes of death in all ages. Considering the prevalence of trauma in the general population, and its costs and complications, it is important to use aiding tools to accelerate the diagnosis in order to act in time. The aim of this study was to evaluate the efficacy of ultrasound in diagnosing nerve and tendon injuries in the upper extremities.
Methods: This study is a cross-sectional study, which was carried out at the emergency department of the Besat Hospital, Tehran from march 2018 to march 2019. The statistical population was all patients who had been referred with deep lacerations in upper extremities and had injuries in the superficial or deep compartments (nerves/ tendons). For all the patients who met the inclusion criteria, bedside sonography with 11 Mhz Linear probe was performed by the researcher and under the supervision of the radiologist. The results were compared with the results from local exploration of the wounds. Local exploration of the wounds was also done under the surgeon's supervision. After completing the sample size and data collection, SPSS software, version 22 (IBM SPSS, Armonk, NY, USA) was used for statistical analysis

Results: In this study, from 144 patients with penetrating trauma in the upper extremities, 56 patients were suspected with nerve injuries and 50 patients were suspected with tendon injuries. After evaluation with an ultrasound probe, 21 out of 23 cases suspected of nerve injuries were confirmed by local exploration. Local exploration confirmed that 27 out of 28 cases were suspected of tendon injuries. The accuracy of ultrasound in the assessment of nerve damage was estimated at 99.64% and in tendon damage at 92%, and the sensitivity of ultrasound in the diagnosis of nerve damage was 91.30% and in the diagnosis of tendon damage was 96.42%.
Conclusion: By the results of this research it can be concluded, that ultrasound leads to a faster diagnosis. It provides a wider field of view, can reduce possible secondary injuries and increases the accuracy of the diagnosis.

Aggressive angiomyxoma of the vulva: a case report

Maryam Esmaeilpour

Background: Aggressive angiomyxoma is a rare mesenchymal tumor with extensive local invasion. It often presents with a lump in the perineal area and pelvic. Since it often does not involve adjacent organs such as the urethra and anus, does not cause obstructive symptoms. Its incidence is 6 times higher in women than men. This tumor grows slowly and has a slight tendency to metastasize. However, the rate of local recurrence is high. MRI is the most widely used diagnostic method. Ultrasound and CT scan are also used for diagnosis. Due to the rarity of this tumor, it is difficult to diagnose before surgery and pathology assessment. Due to the penetrating nature of the tumor and the lack of a clear capsule, incomplete surgical resection is common. Local recurrence is common even after complete mass resection. Therefore, patients need a long follow-up. The main treatment is surgery but non-surgical interventions such as hormonal therapy, radiotherapy, arterial embolization, etc. have been associated with variable success rates.

Case Presentation: A 54-year-old female patient presented with a vulvar mass in February 2021. The patient mentioned that the mass had existed for ten years and had increased in size in the last two years. After discussion on the tumor board, she underwent surgery. The pathology of the mass was reported to be aggressive angiomyxoma. The patient was treated with a GNRH agonist after surgery. The patient is currently under follow-up and has not had a recurrence so far (March 2020).
Conclusion: Aggressive angiomyxoma is a rare mesenchymal tumor. It has extensive local invasion and a high recurrence rate, but distant metastasis is rare. Estrogen receptors or Progesterone receptors are commonly positive in aggressive angiomyxoma. The best treatment for aggressive angiomyxoma remains unknown. Extensive local resection of the tumor has been reported as an important therapeutic measure. In cases of mass recurrence, reoperation and hormone therapy have been effective. It is important for gynecologists to consider this tumor as a differential diagnosis when dealing with vulvar masses.