Tehran University Medical Journal

Evaluation of the diagnostic function of shear wave elastography in the differentiation of malignant and benign breast masses and its relationship with histological factors

Mohammad Momen Gharibvand

Background: Shear wave elastography (SWE) estimates the stiffness of a mass based on the velocity of shear wave propagation by sound waves. Due to higher cell density and angiogenesis, malignant masses have higher stiffness than benign ones.
Methods: The present study was a prospective study and was performed on patients who were referred to Ahvaz Golestan Hospital with breast mass during March 2020 to March 2021. Only patients with 4-5 BI-RAD were evaluated. Patients were graded based on ACR BI-RAD. All patients were subjected to ultrasound and selection of BI-RAD 4-5 patients for evaluation with SWE and sampling for pathology testing. In this study, in order to increase the maximum accuracy and take samples from the main location of the lesion, sampling was done by ultrasound-guided biopsy method. Tumor information was recorded by a specialist doctor after ultrasound and SWE. This information included tumor type, tumor size and grade, presence of metastasis, involvement of lymph nodes, average and maximum elasticity. SWE cutoffs were compared for mean and maximum elasticity to distinguish benign from malignant masses.

Results: In this study, 115 patients were evaluated. 63.5% (73) of the patients had benign mass and 36.5% (42) had malignant ones. There was a significant relationship between tumor size and mean and maximum elasticity (P<0.001 The results showed that the diagnostic accuracy of SWE in identifying malignant masses compared to benign ones was 100%, so that the mean (16.61±8.03 kPa) and maximum (21.14±8.88 kPa) elasticity in benign masses were significantly lower than the mean (32.21±7.59 kPa) and maximum (91.62±8.84 kPa) elasticity of malignant masses (P<0.001). There was also a significant difference between the 4 BI-RAD subgroups, so that in BI-RAD 4a, the lowest mean and maximum elasticity were seen (P<0.001).

Conclusion: The results showed that SWE parameters have sufficient diagnostic accuracy in diagnosing malignant breast masses. Therefore, the use of quantitative SWE parameters in conjunction with ultrasound and BI-RADS classification can avoid unnecessary biopsies.

The effect of body indexes on presence of ocular symptoms in covid-19 patients

Seyed Ahmad Rasoulinejad

Background: During the COVID-19 pandemic, the presence of ocular symptoms was common in COVID-19 patients, which can cause secondary complications in the treatment of ocular diseases. On the other hand, obesity can cause secondary symptoms in infectious diseases by impairing the function of the immune system, which indicates the relationship between involvement of different tissues and dysfunction of the cellular immune system. The aim of this study was to investigate the relationship between body indexes (i.e., age, height, weight, and BMI) and the presence of ocular symptoms in patients with COVID-19.
Methods: In this cross-sectional study (from March 2021 to May 2021), ocular symptoms (including blurred vision, epiphora, photophobia, discharge and exudate, redness, pain, and itching of the eyes) and body indexes (age, height, weight and BMI) were evaluated in 108 patients with COVID-19, who were referred to Ayatollah Rouhani hospital, Babol, Iran. The independent t-test and Kruskal-Wallis statistical tests were used to examine the data relationship in SPSS software.

Results: The results showed that the mean body weight in COVID-19 patients with blurred vision was significantly higher than COVID-19 patients without blurred vision (P=0.003, t=-3.056). The mean height of COVID-19 patients with epiphora was significantly lower than the mean height of COVID-19 patients without epiphora (P=0.018, t=2.398). Also, the BMI of COVID-19 patients with epiphora was 30.00 ±4.07 kg/m², while the BMI of COVID-19 patients without epiphora was 27.68±4.42 kg/m² (P=0.047, t=0.026). In COVID-19 patients with at least one ocular symptom, height was significantly lower than heigh of COVID-19 patients without any ocular symptoms (P=0.001, t=3.397).
Conclusion: Our results indicate the essential role of obesity in the occurrence of eye symptoms in COVID-19 patients. In this study, it was found that blurred vision, epiphora and the presence of at least one eye symptom in COVID-19 patients were significantly associated with the upward trend of BMI (as an index of obesity).

Assessment of mitochondrial DNA copy number in peripheral blood leukocyte of opiate abusers and healthy individuals

Majid Mahmoodi

Background: Based on the studies, variation in the mitochondrial DNA (mtDNA) copy number in peripheral blood leukocytes is associated with increased susceptibility to diseases including cancer. Opiate abusers are at high risk for diseases. In this study, we measured the mtDNA copy number in peripheral blood leukocytes in a group of opiate abusers compared with those in healthy individuals.
Methods: In a case/control study, three groups were selected consisting of 32 opium abusers, 24 heroin addicts and 25 healthy individuals. The amount of 5 ml of whole blood was collected from each individual who participated in the study and stored at -20 centigrade. The sample collection was performed from November 2018 to February 2020. Case groups were recruited from the Methadone maintenance therapy center. Contro group had no history of drug use and cigarette smoking. DNA was extracted from the whole blood samples using the salting out method. The DNA from a mitochondrial gene, dehydrogenase subunit1 (-ND1 gene) and a nuclear gene, human globulin (HGB gene), were quantified by a real-time PCR-based method to measure the relative mtDNA copy number of each group number.
Results: There was no significant difference in demographic characterization between the three study groups, opium abusers, heroin addicts and healthy individuals. We found that opium users had a higher mean of mtDNA copy number than those in the healthy control group (P=0.11). Heroin addicts had also higher mean of mtDNA copy number than those in healthy group (P=0.21). The mean mtDNA copy number in opium abusers was higher than that in heroin addicts (P=0.22), although the difference was not statistically significant.
Conclusion: The results of this study indicated that mtDNA copy number increased in a group of opiate abusers. Considering that alteration of mtDNA copy number is associated with increased susceptibility to several diseases including cancer, further research on mtDNA copy number with a high number of volunteers of opiate addicts may clear the effect of opiate abuse on the human genome.

Comparative study of electrocardiogram changes in patients with brain tumors with midline shift and without midline shift

Mohammad Mahdi Zarezadeh

Background: In addition to heart disease, ECG also changes in non-heart disease, which due to its similarity, can lead to misdiagnosis of heart disease in patients. ECG changes in brain lesions such as ischemic and hemorrhagic strokes, brain traumas, etc. and have been studied in many articles, but the effects of brain midline shift on ECG changes have not been studied. In this study, we want to examine these changes.
Methods: This is a prospective cross-sectional descriptive study. Patients with brain tumors who were referred to Al-Zahra and Kashani hospitals in Isfahan from April 2019 to March 2021 were selected. Patients with a history of heart disease, patients receiving medications that cause ECG changes, patients with ECG changes due to non-cardiac and cerebral causes, and individuals under 15 years of age were not included in the study. Patients whose ECG changes were due to electrolyte disturbances or acute heart problems were also excluded from the study. After obtaining informed consent from patients, a CT scan or brain MRI was taken and patients were divided into two groups with and without midline shift. Then the ECG was taken and ECG changes (T wave, ST segment, QTc Interval, QRS prolongation) were compared in two groups of brain tumors with and without midline shift.
Results: 136 patients were included in the study. Of these, 69 patients were in the without midline shift group and 67 patients were in the midline shift group. In the midline shift group, 3% of patients had ST segment changes and 23.9% had T wave changes, which were 1.4% and 10.1% in the without midline shift group, respectively. The mean QTc Interval in the two groups without and with midline shift was 338.26 (4 28.438) and 388.66 (37.855), respectively, and the mean QRS in the without midline shift group was 86.09 (88.9.88) ms and in the midline shift group was 94.63 (±12.83) ms.
Conclusion: Brain midline shifts can cause QRS widening, QTc interval prolongation, and T-wave changes in patients' ECGs.

Modeling and design of a diagnostic and screening algorithm based on hybrid feature selection-enabled linear support vector machine classification

Negin Manavizadeh

Background: In the current study, a hybrid feature selection approach involving filter and wrapper methods is applied to some bioscience databases with various records, attributes and classes; hence, this strategy enjoys the advantages of both methods such as fast execution, generality, and accuracy. The purpose is diagnosing of the disease status and estimating of the patient survival.
Methods: Feature selection algorithms have been modeled in Matlab R2021a during April and May 2022 in the framework of statistical pattern recognition. First, the features are ranked based on normalized mutual information, as a metric of relevance and redundancy of features, and accordingly, an optimum feature subset with the highest accuracy of classification is selected. Two feature selection algorithms, i.e., inclusion of features enhancing the classification accuracy and exclusion of irrelevant features are applied to the interest datasets, subsequent to the mini-batch k-means clustering of records.

Results: At the end of the execution of both feature selection methods, evaluation metrics including accuracy, precision, recall, and F1 score are measured and compared. Both proposed feature selection approaches for the molecular biology, hepatitis C virus (HCV), and E. coli bacteria datasets result in the precision and recall scores more than 98 percent, meaning that there are few false positives and false negatives in the linear support vector machine (LSVM) classification. Regarding the HCV dataset, selection of nine relevant features among the thirteen present ones using the feature exclusion method yields the classification accuracy and F1 score of 98.92 percent and 99.02 percent, respectively. The feature inclusion approach also results in an accuracy of 98.78 percent with a slight discrepancy.
Conclusion: The results reveal superior strength of the feature selection methods used here for life science datasets with higher-order features such as protein/gene expression database. The potentials to generalize to other classifiers and automatically specify the optimal number of features during the feature selection procedure make these approaches flexible in many data mining applications for the life sciences.

Assessment of the effectiveness of local anesthesia before thyroid fine needle biopsy considering the size of the nodule

Mohammadreza Sasani

Background: Fine needle aspiration biopsy (FNAB) is usually used to distinguish the malignant and benign nodules. Applying a biopsy needle evokes a sense of fear and pain in the patients. Although some studies refute the usefulness of local anesthesia (LA) prior to fine needle aspiration biopsy, it is still debatable. This prospective cross-sectional study intended to evaluate the effect of LA prior to fine needle aspiration biopsy on pain and anxiety considering nodule size.
Methods: Amongst the patients who were referred to Shiraz Shahid Fagihi Hospital for Thyroid fine needle aspiration biopsy from August 2017 to January 2018, 114 patients participated in this study. LA was performed for 41 patients, and 73 underwent the thyroid nodule fine needle aspiration biopsy without LA. Patients' pain and anxiety were scored using the visual-analog-score and Spielberger anxiety scale. The nodules were categorized into five groups. Pain and anxiety of patients were compared considering their nodule sizes to assess the effects of LA in the reduction of pain and anxiety considering the nodule size.

Results: The patients undergoing LA had a mean age of 44.69 years old and average body mass index (BMI) of 26.7, the patients who performed thyroid nodule fine needle aspiration biopsy without LA had a mean age of 48.17 years old with an average BMI of 26.0. The patients with the maximum nodule size of<10 mm, experienced more pain during the fine needle aspiration biopsy without LA, but there was no significant difference between the S/T-anxiety of these patients. There was no significant difference between the pain and anxiety scores of the patients with larger nodules.
Conclusion: The more pain experienced by the patients with the smallest nodules can be attributed to the need for more needle manipulation due to the small nodule size and less precision while piercing the needle into the nodule. Thus, it can be suggested that in patients with a small nodule size, less than 10mm, usage of LA prior to fine needle aspiration biopsy can reduce the pain significantly.

Frequency of cardiopulmonary resuscitation levels in the neonates delivered in Moheb Yas hospital of Tehran

Kambiz Eftekhari

Background: The neonate's Cardiopulmonary resuscitation (CPR) is the most important and common emergency condition in the delivery room. Approximately 10% of newborns are unable to initiate effective breathing and require assistance. The aim of this study was to evaluate the frequency of CPR levels of the neonates delivered during a year in Moheb Yas Hospital who were resuscitated.
Methods: This was a retrospective cross-sectional descriptive study. The sampling method in this study was census. In this study, all the live neonates born during the year (April, 2010 to April, 2011) in Moheb Yas Hospital who were resuscitated, were enrolled in the study. The information of these infants was recorded in separate checklists. This checklist included the following information: mother's age, gestational age, gender of the baby, method of the delivery, multiple births, complications of the placenta and umbilical cord, amount of amniotic fluid, fetal presentation, meconium excretion, fetal heart rate pattern, Apgar of the baby, resuscitation levels, underlying diseases of the mother, maternal diseases during pregnancy, drug use by the mother and premature rupture of the amniotic sac. Finally, the data were analyzed by SPSS software. P-values less than 0.05 were considered statistically significant.

Results: There were 2,176 live births during the study. Of these infants , a total of 322 neonates (15.27%) underwent CPR. 51.8% were male. The mean gestational age was 36.08 weeks. The first minute Apgar was less than 5, between 5-7, and above 8 respectively in 10.5%, 33.4%, and 56% of neonates. About 42% of neonates needed initial resuscitation (warming, drying, and respiratory stimulation). 48% required respiratory ventilation with bag and mask, 5% endotracheal tube, 2.7% cardiac massage, and 1.3% needed medication. In 96.7% of cases, the CPR team was ready for resuscitation before delivery.
Conclusion: If resuscitation is performed in a timely and appropriate manner, very few of these infants will need advanced resuscitation. On the other hand, the high need for resuscitation by bags and masks can be secondary to the educational nature of this hospital.

Evaluation of risk factors of recurrence of hodgkin's lymphoma using random survival forest and comparison with cox regression model

Amal Saki Malehi

Background: In many studies, Cox regression was used to assess the important factors that affect the survival of cancer patients based on demographic and clinical variables. The aim of this study was to determine the factors affecting the survival of patients with Hodgkin's lymphoma using the random survival forest (RSF) method and compare it with the Cox model.
Methods: In this retrospective cohort study, all patients with Hodgkin's lymphoma who were referred to the Oncology and Hematology Center of Ahvaz Shafa Hospital from March 2000 to February 2010 were included. The survival time was calculated from diagnosis to the first recurrence event date (based on month). To assess the process of the disease, demographic characteristics and disease-related variables (including disease stage, chemotherapy, site of lymph involvement, etc.) were extracted from the records of 387 patients with Hodgkin's lymphoma. To investigate the prognostic factors that affect the recurrence of disease the Cox model and RSF were implemented. Moreover, their performance based on the C-index, IBS, and predictor error rate of the two models were compared Data analysis was implemented by using R4.0.3 software (survival and RandomForestSRC packages).

Results: The results of the Cox model showed that LDH (P=0.001) and classical lymphoma classification (P<0.001) were associated with an increased risk of relapse in patients. However, the results of the RSF model showed that the important variables affecting the recurrence of disease were the stage of disease, chemotherapy, classical lymphoma classification, and hemoglobin, respectively. Also, the RSF model showed a higher (c-index=84.9) than the Cox model (c-index=57.6). Furthermore, the RSF model revealed a lower error rate predictor (0.09) and IBS index (0.175) than the Cox model. So, RSF has performed better than the Cox model in determining prognostic factors based on the suitability indicators of the model.
Conclusion: The RSF has high accuracy than the Cox model when there is a high number of predictors and there is collinearity. It can also identify the important variables that affect the patient's survival.

Successful cesarean section in a woman with coronavirus and scleroderma: a case report

Payman Rezagholi

Background: The incidence of adverse perinatal outcomes including increased risk of miscarriage, preeclampsia, preterm birth and stillbirth is higher in pregnant women with coronavirus. Pregnant women who are infected with the coronavirus have placentas that are abnormal compared to the placentas of healthy women. Examples of these adverse effects have been observed before and include reduced fetal growth, pre-eclampsia, premature birth and stillbirth. Scleroderma is an uncommon connective tissue disease and its most obvious manifestation is skin fibrosis. Patients may also have involvement of visceral organs, as a result, their digestive system, kidney and heart are affected. Scleroderma also exacerbates miscarriage, fetal growth retardation, intrauterine fetal death, and preterm delivery. Pregnant women with these problems need special measures, so this study was performed to report a successful cesarean section in a woman with coronavirus and scleroderma.
Case presentation: The patient was a 31-year-old pregnant woman with a gestational age of 29 weeks who presented to Sanandaj Besat Hospital in November 2021 with symptoms of shortness of breath and dyspnea. HRCT-positive, PCR-positive, bilateral pleural effusion, and pulmonary dilatation corona were diagnosed. Due to 3 liters of vaginal bleeding and diagnosis of Décollement 60% and severe preeclampsia underwent emergency cesarean section. The live baby was born weighing 1300 g with Apgar 7. During surgery, he received 3 units of FFB and 3 units of Cryoprecipitate. Microcalcifications and fibrin thrombi were reported in the pathology of intermittent nodules. The diagnosis and treatment of this patient has significant points that are mentioned below.

Conclusion: Complications of pregnancy and childbirth in pregnant women infected with Corona virus include an increase in premature birth and an increase in the rate of cesarean section. Pregnancy in women with scleroderma at the right time and careful delivery monitoring will increase the probability of successful pregnancy outcome and all patients need counseling.

Investigating the antibiotic resistance pattern of MRSA isolates from blood and wound samples of patients admitted in a number of Tehran university of medical sciences hospitals: a brief report

Monireh Rahimkhani,

Background: Considering the frequency of MRSA strains in hospitals and medical centers as well as in different communities, it seems necessary and important to observe the use of appropriate drugs in order to reduce antibiotic resistance and reduce the economic costs of treatment. This study aimed to investigate the antibiotic resistance pattern of MRSA isolated from blood and wound samples of patients. The study patients were hospitalized in different departments in a number of Tehran University of Medical Sciences hospitals.
Methods: In this descriptive cross-sectional study from September 2021 to February 2022, the blood and wound samples of the patients were collected and referred to laboratory. Staphylococcus aureus had identified by phenotypic and biotypic tests. MRSA isolates were screened by showing resistance to Cefoxitin by disc diffusion method and finally confirmed by examining the mecA gene by PCR. The microbial resistance pattern of MRSA was also measured by disk diffusion method and resistance to Vancomycin was confirmed by E.test.

Results: 41 isolates from 87 Staphylococcus aureus samples were confirmed as MRSA by present the mecA gene. The mecA gene was detected in all MRSA by PCR method. The antibiotic resistance pattern showed the highest sensitivity to Vancomycin and Linezolid with 100% sensitivity and the highest resistance to three antibiotics Erythromycin, Ceftriaxone and Cloxacillin with 97.57%by disk diffusion method. The most MRSA strains were isolated from the ICU department with 13 cases and the least MRSA strains were isolated from the two NICU and pediatric departments with one case.The majority of the population infected with MRSA belonged to the age group of 40-65 years.
Conclusion: The prevalence of microbial resistance with high dispersion was obtained among MRSA strains isolated from clinical samples; which indicates a significant increase in resistant strains and requires a quick and timely diagnosis to prescribe the appropriate antibiotic.

Knowledge, attitude and performance of physicians towards clinical practice guidelines: a letter to the editor

Alireza Olyaeemanesh