Tehran University Medical Journal

Skin metastases in breast cancer: a review article

Behnaz Varaminian

Skin metastases from breast cancer usually occur in more advanced stages of the disease, but can sometimes be the first clinical manifestation of breast cancer or the first evidence of a previous tumor recurrence. These demonstrations significantly reduce survival. Skin metastases from breast cancer have different manifestations. The most common manifestations are nodules. These nodules are soft, round or oval, mobile, firm, and elastic in texture and can be single or multiple, often flesh-colored, but can also be brown, bluish black, and pink to reddish brown. In the absence of a previous history of cancer, it can be difficult to diagnose the early location of metastatic cancers. However, metastases usually show histopathological similarities to the primary tumor. Soft tissue breast metastases usually have a better prognosis than breast or bone cancer metastases. Also, skin metastases from breast cancer do not necessarily have a poor prognosis as skin metastases from other malignancies. The relative risk of death from skin metastases to other malignancies is more than four times higher than skin metastases from breast cancer. Differential diagnosis includes cutaneous lymphoma, intracranial leukocyte infiltration, and cutaneous metastasis. Metastatic skin lesions are often mistaken for benign lesions. Recognizing them quickly is important to prevent long-term anti-inflammatory treatment that delays proper diagnosis. Therefore, to rule out metastasis, abnormal or nodular lesions should be considered for biopsy in patients with a history of systemic malignancy or suspected malignancy. Cutaneous metastases are usually a sign of widespread disease and may not be treatable in most cases. Treatment options include systemic and/or topical treatments. Extensive skin metastases require systemic treatment. For thicker skin metastases, radiation therapy, surgical or electrochemical resection is indicated as monotherapy or in combination. Oxygen in combination with topical 5% methotrexate (OFAMTX, 5% methotrexate in a carrier solution) is a recently described method that facilitates drug penetration into the epidermis. In the absence of visceral or lymph node metastases, OFAMTX is useful as a local skin treatment. This treatment is an effective and tolerable method for superficial skin metastases. Using local treatment in combination with systemic agents increases the overall effectiveness of treatment on skin metastases.

Ethical considerations in non-heart beating donation: a narrative review article

Keihan Mostafavi

Background: Considering the high death rate of patients on the transplant waiting list, one of the most important ethical challenges of organ transplantation is the lack of transplant organs and different approaches to cover it.
Methods: The ethical issues of organ transplantation have been frequently reviewed recently.
Results: Currently, there are 4 sources for organ transplants, which are: a) organ transplant from animal to human b) transplant from a living donor c) transplant from a brain-dead donor d) transplant from a cardiac-dead donor or donors without a heartbeat, and tissue engineering research continues to prepare a transplantable organ. Each of them has its own limitation and specific consideration. In Iran, organ procurement from brain-dead donors and living donors are the most important sources. Many approaches have been considered to increase the number of procured organs from brain-death cases in the world, but have not yet been able to reduce the gap between supply and demand. Therefore, since the 1980s, the program of organ transplantation from cardiac death (donors with irreversible cardiac arrest) in the world has been reviewed again. Based on the classification of cardiac arrest patients, they are placed in two general categories: uncontrolled and controlled. In a controlled condition, death is predictable, and organ removal is possible by eliminating planned medical interventions and patient support. But in the uncontrolled state, death occurs accidentally, which is more likely to prolong the duration of hot ischemia. Italy's organ donation group has recently introduced type 6 deaths in patients on ECMO, which is mentioned as a semi-controlled group. This group is called donors with abnormal blood flow versus brain-dead donors with normal blood flow. In this study, ethical considerations for organ donation from NHBD were discussed. Regarding the procurement of organs from non-heart beating donors, there are many ethical considerations that include both the donors and the recipients. Considering that the clinical conditions of the brain-dead donors are sometimes very unstable, cardiac arrest may occur before organ harvesting. In these cases, donation after cardiac death is an option.
Conclusion: It is necessary to regulate the ethical considerations for organ procurement from NHBD

The value of biophysical profile and sonographic cerebroplacental ratio (CPR) in predicting childbirth mode and adverse neonatal outcomes

Fariba Nasiraee

Background: Fetal health diagnostic tests are tools to reduce the incidence of adverse outcomes and neonatal death. However, their diagnostic value is still debated in relation to various outcomes. The aim of this study was to evaluate the value of biophysical profile and sonographic cerebroplacental ratio in predicting childbirth mode and adverse neonatal outcomes.
Methods: In this cross-sectional study, 70 pregnant women (37-41 weeks) who were candidates for termination of pregnancy who were referred to Ayatollah Mousavi Hospital in Zanjan from October 2020 to May 2021 were studied. After selecting the mothers based on inclusion criteria, biophysical profile test (BPP) and CPR sonographic index were performed. Then delivery method, infant weight, fifth minute Apgar score, need for resuscitation and hospitalization of infants in NICU were recorded in each case. T-test, Mann-Whitney test and ROC curve in SPSS 22 software were used for statistical analysis. (P≤0.05).

Results: In this study, the mean (SD) gestational age of participants was 38.56±1.11 weeks. Based on the data, there was a statistically significant relationship between CPR and the infant's need for resuscitation and hospitalization in the NICU (P=0.021) and Apgar score (P=0.042). However, there was no statistically significant relationship between CPR and delivery method, gestational age and birth weight. BPP score was not significantly associated with any of the consequences. Based on the results of the ROC curve, CPR with a cut point of 1.59 with a sensitivity of 88.9% and a specificity of 75% is able to predict the need for resuscitation and hospitalization in the NICU, and with a sensitivity of 83% and a specificity of 54.5%, it is able to predict a low Apgar score. However, BPP score did not have a predictive role in any of the studied parameters.
Conclusion: It seems that CPR examination around delivery can be useful in predicting the condition of the baby immediately after birth and preparing the treatment staff for immediate action.

The effect of oral calcium on serum level of vitamin B12 in patients with type 2 diabetes

Mahmoud Parham

Background: Vitamin B12 deficiency is one of the most well-known disorders due to long-term use of metformin due to interference with its absorption.
Methods: This double-blind randomized trial was conducted from June to October 2016 at Shahid Beheshti Hospital in Qom on 60 patients in the age group of 30 to 60 years with a history of type 2 diabetes for one to two years and taking metformin in the amount of one to two grams. Patients were divided into two groups of 30 people. The intervention group received metformin with 1 gram of calcium carbonate daily, and the control group received metformin without calcium. Each of the patients in the intervention group was given 200 calcium carbonate tablets. Vitamin B12 levels of the patients in both groups were measured before the start of the intervention, and they were evaluated in terms of neuropathy according to the Michigan questionnaire. Vitamin B12 of patients and neuropathy in two groups were measured before the intervention and after three months.
Results: There was a difference between the two groups in terms of gender, and no significant difference was observed between the mean ages in the two groups. The mean level of vitamin B12 before receiving calcium in group A (intervention) was lower than group B (control) (P=0.036) and after receiving calcium, the level of vitamin B12 in the intervention group increased (P=0.002). In the control group, the level of vitamin B12 decreased (P=0.030). (P=0.006), and in the control group there was no significant difference in the examination of neuropathy (P=0.2).

Conclusion: Oral calcium daily intake increases vitamin B12 levels in patients with type 2 diabetes and calcium may be able to moderate the decrease in serum vitamin B12 levels induced by metformin in patients with type 2 diabetes.

Short-term prognosis of definitive neonatal infection

Hassan Boskabadi

Background: Neonatal sepsis is a severe systemic bacterial infection that affects on premature neonates prognosis. Therefore, the aim of this study was to evaluate the short-term prognosis of neonate's infection.
Methods: The present study is a cross-sectional study that was performed on 729 neonates suspected of infection, in neonatal ward in Ghaem Hospital of Mashhad since May 2015 to May 2022 by available sampling. The data collection tool was a researcher-made checklist containing neonatal characteristics (gestational age, birth weight, first and fifth minute Apgar score, and neonatal status at discharge) and laboratory information (White Blood Cell, Platelet (PLT), C-reactive Protein, Blood culture, Cerebrospinal fluid culture). Infants with congenital infection, congenital anomaly and positive blood cultures without clinical and laboratory symptoms were excluded from the study. Neonatal prognosis was compared in terms of death or discharge among neonates with and without definitive infection. First, we described the results using statistical tables and graphs, and then, data were analyzed by Kolmogorov-Smirnov, T test and SPSS software, version 26 (IBM SPSS, Armonk, NY, USA). P<0.05 considered as significant.

Results: According to the results of this study, low birth weight and lower gestational age and lower Apgar score increase the risk of neonatal death. About one-fifth of infants died of definitive infection. The cases of death due to infection in the group of deceased infants were about 4 times higher than in the group of discharged infants. About one third of the babies with sepsis and half of the babies with meningitis died. Forty-four percent of infants with early sepsis and 40% of infants with late sepsis died. In cases of neonatal death due to sepsis, the most common gram-negative infectious agent was Acinetobacter and the most common gram-positive infectious agent was Enterococcus.
Conclusion: Neonatal definitive infection worsens their prognosis. So, the risk of neonatal death increases by 5 times. The probability of death in meningitis is more than sepsis and in early sepsis is more than late sepsis and in sepsis due to gram-negative is more than gram-positive.

Assessment of success factors in normal vaginal delivery in late term pregnant women

Shahla Yazdani

Background: The aim of this study was to find the causes of failure of natural childbirth in late-term pregnancy that can be useful for managing childbirth in these pregnant mothers and to design a solution to increase natural childbirth.
Methods: This cross-sectional study was conducted in the community of pregnant women with a late-term pregnancy of more than 41 weeks. The studied sample includes 148 pregnant mothers who were referred to Ayatollah Rouhani Hospital in Babol from March 2018 to February 2020. Mother's age, Body Mass Index, gestational age, number of pregnancies, number of deliveries, length of hospitalization, the state of the cervix and preparation method of the cervix for termination of pregnancy were extracted and recorded from patients' files. Data were compared in two groups of pregnancy termination methods (natural childbirth and cesarean delivery). Statistical analysis was done using SPSS software, version 22 (IBM SPSS, Armonk, NY, USA) and Chi-square test and Student’s t-test statistical tests and logistic regression model fitting. P-value less than 0.05 was considered significant.

Results: In this study, 167 pregnant women with late-term pregnancy were studied. The age of pregnant women is reported with mean of 26.03 and standard deviation 5.98 of years. The high Bishop variable, with odds ratio of 0.44, is a variable protective factor for cesarean delivery (P=0.001). Higher body mass index with odds ratio of 1.09, is also known as a risk factor for cesarean delivery (P=0.01), so that for each unit of increase in Bishop score, the chance of cesarean delivery decreases by 56% and for each unit of increase in body mass index, the chance of cesarean delivery increases by 9%.
Conclusion: This study showed that nearly half of cases of late pregnancies lead to normal delivery. High body mass index reduces the chance of normal delivery in late term pregnancies. But a higher Bishop score can be effective in the success of natural delivery.

Comparison of the effectiveness of intranasal ketamine compared with intravenous ketamine in controlling pain during cataract surgery

Hamidreza Shetabi

Background: To improve the quality of sedation in procedures, different medications are used alone or in combination with each other, but so far, no administration method that is agreed upon by anesthesiologists has been presented. This study aimed to investigate the effectiveness and safety of intranasal ketamine in comparison with intravenous ketamine in cataract surgery.
Methods: This clinical trial was performed from December 2016 to March 2017 in Feyz Hospital, Isfahan. Ninety patients over the age of 18 who were candidates for cataracts surgery were randomly assigned to receive 1 mg/kg ketamine through the nasal route (INk) or intravenously (IVK). Ten minutes before the surgery, ketamine was administered in the INK group and intranasal saline in the IVK group. Two minutes before the start of surgery, normal saline was administered in the INK group and ketamine was administered intravenously in the IVK group. Patients received intravenous midazolam 0.04 mg/kg during prep and drape. The quality of sedation and analgesia, vital signs, patient and doctor satisfaction, and side effects were recorded during the study period. Data were analyzed using of SPSS software, version 23 (IBM SPSS, Armonk, NY, USA).

Results: In this study, 90 people were included in the study, 53 of whom (58.9%) were men. The mean age of the patients was 61.5±10.6. Two groups had a significant difference in terms of gender (P=0.696), age (P=0.960), weight (P=0.212), height (P=0.632), underlying disease (P=0.094), and type of disease (P=0.090). Two groups were not significantly different in terms of mean heart rate (P=0.77), mean arterial blood pressure (P=0.13), mean blood oxygen saturation (P=0.58), patient satisfaction (P=0.470) and surgeon satisfaction (P=0.115), pain intensity (P=0.506), level of sedation level (P=0.477) and side effects (P=0.221).
Conclusion: Intranasal administration of ketamine provides similar sedation and cardiovascular response compared to intravenous administration of ketamine. Administering ketamine intranasally is a non-invasive, safe and effective method with easy application and can be a suitable alternative to intravenous administration.

Comparative study of the sedative effect of ketamine-dexmedetomidine (Ketodex)with ketamine-midazolam(Ketomid) in candidates of fibroptic bronchoscopy

Behzad Nazemroaya

Background: A variety of sedatives like ketamine, propofol, opioids, and benzodiazepines are used during Fibroptic bronchoscopy. The effectiveness of ketamine-dexmedetomidine and ketamine-midazolam on pain level and sedation after Fibroptic bronchoscopy was examined.
Methods: A double-blind, randomized clinical trial was carried out from October 2020 to April 2021 at educational hospitals affiliated with Isfahan University of Medical Sciences. The participants were 60 candidates for fibroptic bronchoscopy who were allocated randomly into two groups of 30 people. Group one (Ketodex) received 1mg/kg ketamine and 1 µg/kg dexmedetomidine for 10 min followed by an infusion of 0.5 µg/kg of dexmedetomidine and 0.5mg/min ketamine. Group two (Ketomed) received 2.5mg of midazolam and 1mg/kg of ketamine for 10min along with infusion of 1 µg/kg/min midazolam and 0.5mg/min of ketamine. The variables under the study were systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), percentage of arterial oxygen saturation (SpO2), heart rate (HR), and level of pain. Furthermore, the sedation score of patients were recorded on the basis
of sedation score is a 5-point scale from 1 to 5. The obtained data were analyzed in SPSS (v.26). To compare the data collected at different occasions and different groups, repeated measure tests and independent t-test were used (P<0.05).

Results: Compared to the Ketomed group, the sedation term in patients in the Ketodex group was longer significantly (P<0.001) with a significantly shorter recovery term (P<0.001). In addition, the differences between the groups were insignificant in terms of diastolic blood pressure, systolic blood pressure, mean arterial pressure, heart rate, and percentage of arterial oxygen saturation (P>0.05). The pain levels were notably lower in patients who received Ketomed compared to Ketomed during 20 min (P=0.04) and 30 min (P=0.001) following the procedure.
Conclusion: The use of Ketodex was associated with a longer sedation duration and significantly shorter stay in the recovery room and lower pain intensity compared to Ketomed, therefore it may be more preferable in bronchoscopy.

The effect of hip joint position on knee joint isokinetic dynamometry indices in football and track and field athletes

Hakimeh Adigozali

Background: Isokinetic dynamometry is a golden standard test to estimate lower extremity sport related injuries in the athlete assessment. Dynamometry is also commonly used to design preventive protocols. The aim of this study was to explore the effects of hip joint positioning in seated and lying positions on knee joint dynamometry indices, including extensor and flexor peak torques in football and track and field athletes.
Methods: Forty four male athletes (including 22 football players and 22 track and field athletes) have participated in this descriptive-analytic study. The sampling method was simple nonrandom sampling. This study was conducted in the Biomechanics laboratory of the Rehabilitation Sciences, Faculty of Tabriz University of Medical Sciences since October 2019 to October 2020. Knee joint dynamometry indices were consisted of concentric and eccentric flexor and extensor peak torques at 60 degrees per second velocity. Optimum length, angle of crossover, and the muscle balance ratios (concentric extensor peak torque/concentric flexor peak torque and eccentric extensor peak torque/concentric flexor peak torque) were also evaluated. All assessments were performed in both seated and lying positions. The indices were compared between football players and track and field athletes.

Results: The interaction effect of group and hip joint was not significant (P<0.05). Further, concentric and eccentric flexor and extensor peak torques and conventional flexor to extensor ratio were higher meaningfully in the seated position compared to the lying (P<0.05). Optimum length was significantly higher in the lying position, but the angle of crossover was higher in the seated position (P<0.05). The hip joint position was not effective on the functional flexor to extensor ratio (P>0.05). Also, dynamometry indices were not different between football and track and field groups (P<0.05).
Conclusion: Findings revealed the effects of hip joint position on strength measurements in football and track and field athletes. This factor should be considered to design strengthening exercises for athletes and also to estimate the sport injury risk.

Relationship between demographic and pathological characteristics on the 5-year survival rate of gastric cancer patients in Tehran province

Ali Mohammad Alizadeh

Background: Gastric cancer (GC) is one of the most common malignancies and is considered as one of the leading causes of cancer deaths worldwide. Despite considerable progress in the disease's control and treatment, the patients' survival rate is relatively low. Different factors can affect the survival rate of GC patients. The current study aims to evaluate the association of demographic and pathological characteristics with the survival rate of GC patients.
Methods: This descriptive-analytical study was conducted on Fifty-six patients with gastric cancer from October 2015 to October 2016, who were referred to the gastroenterology clinic of Imam Khomeini and Rasoul Akram Hospitals in Tehran province and followed up for five consecutive years. The survival rate of the patients was measured using Kaplan-Meier method. Moreover, the Log-rank test and the COX regression model were used to determine the association of the survival rate with the demographic and pathological characteristics, including gender, age, tumor location, tumor type, tumor differentiation, metastasis, tumor staging, and Helicobacter pylori status. Data analysis was performed via SPSS version 22, and a P<0.05 was considered statistically significant.

Results: A total of 56 patients were studied; 73% were men, and 27% were women. Our results showed that gastric cancer is more common in males and older people. Patients' one-year, three-year, and five-year survival rates were 67%, 35%, and 26%, respectively. Also, the survival rate of participants over 60 and in advanced stages of GC was lower than others. The Log-rank test showed that age, tumor type, tumor differentiation, metastasis, and tumor staging could affect the survival rate. However, in the COX regression model, age, metastasis, and tumor staging influenced the survival rate of patients.
Conclusion: The results indicated that the survival rate of gastric cancer patients was relatively low, and the early diagnosis of GC could be a substantial factor in increasing the patients' survival rate. Therefore, an appropriate screening program is necessary to increase the survival rate of GC patients.

A new perspective on the determinants of the concept of aging: a letter to the editor

Rahele Samouei