Tehran University Medical Journal

The effect of neonatal bloodletting in the treatment of neonatal jaundice: a review article

Reza Saeidi

Neonatal hyperbilirubinemia occurs in 60-80% newborns in the first few days of birth, in most cases, jaundice is physiologic and usually improves without treatment. Bloodletting is the withdrawal of blood from a patient to prevent or cure illness and disease. Recently the Bloodletting is one of the common treatments for neonatal jaundice. In this review study, we have evaluated medical articles and narrative books (hadiths) for the application of this method in neonatal jaundice. In this systematic review we evaluated PubMed databases, Cochrane, Google Scholar, collaboration library, SID, Magiran, and narrative books (hadiths) with the subject of cupping and Bloodletting were included in the study 1983 and September 2019. In this study, all of articles with the title “Bloodletting“, "cupping" and “Wet cupping”, “Dry cupping”, “Air trapping”, “Scarification”, “Hejamat”, “ear cupping” and the abstracts of the articles presented in the conferences were studied. Then, in the evaluation stage of the articles, all the studies unrelated to the issue were excluded from the research. Also, in this study, all Shia and Sunni hadith sources and the Holy Qur'an were evaluated. The evaluation of hadiths was carried out by Jama Al-Ahadith software, which is a collection of Shia and Sunni hadith books. We assessed 1120 articles related to Bloodletting, none of which were related to neonatal jaundice and Bloodletting. Cupping is a therapeutic method that dates back thousands of years. Bloodletting by scarification was an accepted practice in Ancient Egypt. In Greece, bloodletting was in use in the 5th century BC. "Bleeding" a patient to health was modeled on the process of menstruation. During the Roman Empire, the Greek physician Galen, who subscribed to the teachings of Hippocrates, advocated physician-initiated bloodletting. The popularity of bloodletting was reinforced by the ideas of Galen. In our study in Shiite and Sunni narrations, only two narrations recommended infant Bloodletting after four months just for prevention. According to our finding there is no article or narration that recommended Bloodletting for neonatal jaundice.

A comparative study of the efficacy of coenzyme Q10 and propranolol in prophylaxis of migraine headaches: a double-blinded clinical trial

Elaheh Hoseinpour

Background: Migraine is a recurrent disease which its definitive mechanism is still unknown. Thus mitochondrial dysfunction and neurovascular damage are two hypothetical underlying mechanisms for migraine headaches. The effectiveness of some possibly effective compounds such a CoQ10 has been studied. In this study, we evaluated the efficacy of coenzyme Q10 in migraine headache prophylaxis.
Methods: This study was performed as a double-blinded randomized clinical trial on 112 patients with a diagnosis of migraine who were referred to the Neurology Clinic of Imam Reza Hospital in Kermanshah from March to September 2018. Then the patients were randomly divided into two equal groups (control and intervention). Both groups received propranolol 20 mg twice daily (totally 40 mg/d). The intervention group was treated by CoQ10 60 mg once daily, additionally. Finally, the quantitative and qualitative characteristics of migraine headaches such as nausea and vomiting, photophobia, phonophobia, severity, frequency and duration of attacks were evaluated by Student's t-test, Mann-Whitney U test and Wilcoxon tests.
Results: At the end, it was concluded that CoQ10 supplement of 60 mg daily with propranolol 40 mg daily in patients with migraine headaches improves symptoms more than receiving propranolol 40 mg alone. The results also showed that in the intervention group, nausea and vomiting, photophobia and the severity of headache in patients significantly improved compared to the control group (P values of 0.001, 0.114 and 0.001, respectively). However, the symptoms of phonophobia, frequency and duration of headache attack in the intervention group were not significantly different from the control group (P values were 0.062, 0.853 and 0.106, respectively).
Conclusion: In conclusion considering the main goal of this study, consumption of CoQ10 60 mg daily with propranolol 40 mg daily significantly improves symptoms such as nausea and vomiting, photophobia and severe headache compared to propranolol 40 mg daily. In conclusion, CoQ10 is a suitable choice in patients who do not respond adequately to the standard drug regimen.

Association between sonographic features of thyroid nodules and cellular examination obtained by fine needle aspiration

farhad mohammadi

Background: As we know, thyroid nodules are common, but many of them are benign, and this shows that sampling of nodules is not necessary to diagnose benignity.The aim of this article was to determine the diagnostic accuracy of ultrasound features for diagnosing malignant thyroid nodules in patients referred to Fajr infirmary in Ilam.
Methods: This descriptive-cross-sectional study was conducted on 122 patients referred to Fajr Ilam Clinic in October 2015 to January 2018.Clinical characteristics such as age, gender, BMI and history of underlying thyroid diseases and Hashimoto's thyroiditis were collected with the help of a questionnaire.The dependence of ultrasound characteristics with thyroid malignancy was determined using a multivariate analysis test. This ultrasound feature was compared with the results of fine needle aspiration cytology and the diagnostic accuracy indices were calculated for each ultrasound feature.This article was conducted using statistical tests, chi-square, independent t-test, Mann-Whitney test, and bivariate logistic regression using Spss software.

Results: The study sample included of 30(24.6%) malignant and 92(75.4%) benign nodules. Hypoechogenicity and microcalcification showed statistically significant positive associations with thyroid malignancy (P<0.05).Also, according to Fisher's exact test, 7% and 20% of men had benign and malignant nodules, and 86% and 80% of women had benign and malignant nodules, respectively. But there was no statistically significant difference between the two groups (P>0.05). Hypoechogenicity had 63.3% sensitivity and 67.04% specificity, microcalcification had 60% sensitivity and 65.93% specificity. Having at least one good sonographic feature resulted in the highest sensitivity (86.67%), while the presence of both features had almost perfect specificity (91.3%) and the highest positive likelihood ratio (4.21).
Conclusion: According to the results of this article, the presence of Microcalcification variables and Hypoechogenicity are the most important criteria in predicting thyroid malignancy, and they are Locate in the TI-RADS grading. Therefore, nodules larger than 1 cm in size with the characteristics of microcalcification and homogeneity ultrasound should be the main focus of diagnostic evaluations.

Frequency and risk factors for GI bleeding in children admitted to the PICU of bahrami children's hospital

Kambiz Eftekhari

Background: Gastrointestinal bleeding (GIB) associated with stress is an important complication in critically ill children admitted to the Intensive care unit (ICU), which can lead to serious complications and in some cases death. Only a limited number of studies have been conducted on the risk factors of gastrointestinal bleeding in Pediatric Intensive care unit (PICU), most studies have been conducted in the adults and neonates, therefore, the aim of this study was to evaluate the frequency of risk factors related to gastrointestinal bleeding in children admitted to the PICU.

Methods: This was a cross-sectional study. In this study, in a period of three years from (March 2016 to March 2019), all patients admitted to the PICU of Tehran Bahrami Children's Hospital were examined. The sample size was calculated 380. Demographic information, diagnosis during hospitalization, underlying disease, and initial tests during the first 24 hours of hospitalization were recorded in the checklist. To evaluate the demographic findings between patients with and without UGIB, chi-square and Fisher tests were used. A p-value of less than 0.05 was considered significant.
Results: 462 patients were studied, of which about (58%) were male. The mean age of the samples was 48 months and the average length of hospital stay in PICU was ten days. In general, (21.21%) of patients had gastrointestinal bleeding on the first day and (12.12%) on the second day of hospitalization. Gastrointestinal bleeding occurred in 50 patients (10.82%). Use of ventilator, pulmonary diseases, coagulation and blood diseases were significantly more common in patients with gastrointestinal bleeding than in children without gastrointestinal bleeding. Cardiac, neurological, hepatic, and renal disease were not significantly different in patients with gastrointestinal bleeding compared to children without gastrointestinal bleeding.
Conclusion: The occurrence of gastrointestinal bleeding in critically ill patients admitted to the PICU is a serious risk. The most important risk factor for upper gastrointestinal bleeding is mechanical ventilation. Other risk factors of gastrointestinal bleeding are lung disease, coagulation diseases, hematologic and oncologic disease.

Evaluation of pelvic, spine and sagittal spine parameters in people without chronic low back pain

Sajad Ataei

Background: Chronic low back pain (CLBP) is one of the most common spine disorders, which is seen in 65-80% of people. Knowing the normal patterns of spine and pelvic parameters is very helpful in determining the susceptible subjects for CLBP.
Methods: This study was conducted in healthy people during April 2017 until April 2018 in Golestan hospital of Ahvaz. Inclusion criteria include; Age group 20-65 years, no history of surgery, spine disorders, and having normal radiographs were performed. People who have complained of back pain in the last three months, neuromuscular disease, lumbosacral anomalies, kyphosis and obvious scoliosis, history of spine surgery and vertebral fracture, were excluded. A 36-inch radiology stereotype was prepared in the standing position. Pelvic and spine parameters that were investigated in this research included the following, Pelvic incidence, Pelvic tilt, Sagittal Vertical Axis, T9 Sagittal Angle, Thoracic Kyphosis, Lumbar Lordosis, and Sacral Slope. All data were analyzed with SPSS software, version 24 (SPSS Inc., Chicago, IL, USA).

Results: 50 participants including 27(54%) men and 23(46%) women with an average age of 33±12.5 years and BMI of 25±5.5 kg/m2 were examined. After examining the vertebral and pelvic parameters, it was found that PI is significantly higher in women than in men (P=0.02). It was also found that with increasing age, the amount of Pelvic incidence also increases (P=0.043), so that in people over 60 years of age, the amount of pelvic incidence is significantly higher than other people (P<0.05). Further analyzes showed that BMI has a direct effect on the amount of Thoracic Kyphosis (P=0.03) and Lumbar Lordosis (P=0.04). Thus, the highest amount of Lumbar Lordosis and Thoracic Kyphosis was seen in people with BMI 30-34.9 Kg/m².
Conclusion: The findings of the present study showed that spine and pelvis indices have an important effect on the occurrence of CLBP. Hence, it is highly recommended to check these parameters in asymptomatic people, especially in older people.

Prevalence and risk factors of intestinal metaplasia in patients with dyspepsia

Mehdi Ghobakhlou

Background: Intestinal metaplasia in the stomach is one of the precancerous lesions of gastric tissue. If the lesions are diagnosed early before invasive cancer develops, it is possible to prevent the progression to malignant lesions. Therefore, this study was performed to evaluate the prevalence and risk factors of intestinal metaplasia in patients with dyspepsia.
Methods: This descriptive cross-sectional study was performed on patients who were referred to Shahid Beheshti Hospital in Hamadan, Iran from the beginning of 2019 to the end of 2020. A total of 250 patients over 16 years of age who complained of dyspepsia for at least more than three months were included in the study. Examination was performed for patients along with the completion of a pre-designed questionnaire including demographic information and metaplasia risk factors. Also, endoscopy and biopsy specimen of gastric mucosa were performed for histological examination. Finally, the data were analyzed using SPSS software version 16 with related statistical tests.

Results: There was no significant relationship between job type, level of education, marital status and family history of gastric cancer, smoking, alcohol, high salt, dairy products and high-nitrate diet with the disease. There was a significant relationship between body mass index and the presence of intestinal metaplasia in men (P=0.032). The average age of men with metaplasia was about 13 years older than those without the disease. Also gastric ulcer (84%) and pan gastritis (40.4%) were the most common cases in endoscopic results. The number of female patients with epigastric pain was about 14% higher than male patients. Gastric ulcer was significantly associated with gender, with about 12% more gastric ulcers observed in men than women (P=0.014). Also, no significant relationship was observed between the presence of Helicobacter pylori and the severity of its colonization with intestinal metaplasia. (P=0.230)
Conclusion: In this study, no significant relationship was observed between the presence of Helicobacter pylori and the severity of its colonization simultaneously with intestinal metaplasia. Apart from the two factors of increasing age and type of sex, no serious risk factors for intestinal metaplasia were seen.

Examining the frequency of endoscopic findings in patients with covid-19 with upper gastrointestinal bleeding referred to al-Zahra Hospital of Isfahan

Elham Tabesh

Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan.
Methods: In this cross-sectional study, out of 5800 patients who were admitted to Al-Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings.

Results: Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070).
Conclusion: The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.

The evaluation of the awareness level of patients with hemorrhagic stroke about their hypertension possibility and use of antihypertensive drugs

Mehran Kouchek

Background: Hypertension is an important and controllable risk factor for heart diseases, stroke, renal failure and peripheral vascular disease. The aim of this study was to determine the level of awareness of patients with hemorrhagic stroke to control blood pressure and to provide solutions to improve patients’ awareness.
Methods: This study is a descriptive cross-sectional study that was conducted to evaluate the knowledge of patients with hemorrhagic stroke about the use of antihypertensives. The study population consists of all patients with hemorrhagic stroke, who were admitted to the intensive care unit of Imam Hossein Hospital in Tehran from September 2020 to March 2021. Data related to blood pressure awareness and drug history was completed by the researcher through the method of direct contact with the patients or their relatives. In this study, 17 patients diagnosed with hemorrhagic stroke due to hypertension who were admitted to the intensive care unit of Imam Hossein Hospital in Tehran, were included. The extent of the exact treatment adherence was assessed using the Morisky questionnaire.

Results: In this study, the median of patients age was 67 and 10 (58.82%) of them were women. The median systolic and diastolic blood pressures were 170 and 95 mmHg on admission. 4(23.53%) subjects were not aware of the disease. Out of 13 people who were aware of their hypertension, 11(64.71%) were under the supervision of a physician. However, 7(63.64%) of the subjects, despite being under the supervision of a physician and acceptable drug adherence, did not have controlled blood pressure and expired.
Conclusion: This study is a warning for patients and health care providers to pay more attention to blood pressure control. Furthermore, educating the community as well as medical staff about the importance of timely diagnosis and accurate treatment of hypertension is highly recommended.

Short term effect of low-level laser therapy on tooth stability after orthodontic treatment

Batoolalsadat Mousavi fard

Background: The purpose of this article was comparing the clinical effectiveness of low-level laser therapy (LLLT) in reducing relapse.
Methods: In this clinical trial study 14 patients (11 females and three males) who were under non-extraction treatment (MBT 022 slot) and at the finishing stage of orthodontic treatment at Orthodontics Department of Kerman Dental Faculty from April 2016 to June 2017 participated. Treatment time was two year and the patients at the finishing stage of orthodontic treatment were divided into two groups (RCT code IRCT2017053034061N1). Group 1 (study) were treated with a low-level Gallium aluminum-arsenide diode laser and group 2: control. The exclusion criteria involved patients who consumed medicine that interrupted bone metabolism and those with conditions for which laser therapy could be contraindicated. The laser apparatus emitted a wavelength of 810 nm about 50 seconds and operated with maximum power of 200 MW in continuous wave mode (200 mW, 50 seconds radiation to mesiolingual, mesiobuccal, distolingual and distobuccal surfaces, 35.7 J/cm²). An alginate impression was made from maxillary arch for all patients immediately, four, five and six months after removing the orthodontic archwire and braces and study casts were prepared. The little irregularity index of anterior maxillary arch was measured on the dental casts, with a 0.01 mm precision digital caliper. Intergroup comparisons were performed with Student's t-test and repeated measure ANOVA was perform to compare measurements among groups in different times. The significance level was considered at P<0.05.

Results: There was significant difference among the irregularity index at five and six months after orthodontic treatment between two groups (P<0.05). In the control group except between five and six months after treatment, there was significant difference in irregularity index. The relapse was higher immediately and after four months in the laser group compared to other sequences (P=0.0001).
Conclusion: Sample showed that Low-level laser therapy (LLLT) is a non invasive method for reducing relapse after orthodontic treatment.

Bilateral Y shaped ureter (bifid renal pelvis): a case report

Fahimeh Rajabi

Background: Congenital malformations of the kidney and urinary tracts happen in 3-6 per 1000 live births and these abnormalities are the reason, for (ESRD) in children and also the reason for subsequent kidney problems such as kidney stones, infections and hypertension in adulthood. One of the most common anomalies of the renal system is the double collecting system. Knowledge of anatomical variations and disorders before surgery can make the surgical procedure smoother for the surgeon and prevent unwanted mistakes. Imaging through radiology, computed tomography, and MRI is the best way to diagnose early, follow-up, and planning for surgery, diagnosis of complications and extra kidney abnormalities.

Case Presentation: Our report in this article is about four years old girl who went to the MRA center of Baath Hospital in Sanandaj due to flank pain in December 2019. After abdominal imaging, signs of an abnormality of the double collecting system were revealed. Abdominal and pelvic ultrasound revealed abnormalities of the UVJ, and the distal part of the right urethral duct was approximately 2 mm in size. Also, the anterior-posterior diameter of the right renal pelvis was reported to be 2 mm and the upper calyx of the right kidney was quite dilated. This incomplete integration leads to complete or incomplete forms of the renal collecting system. The prevalence of this anomaly is also mostly unilateral, but our report, in this case, is about bilateral ureters.
Conclusion: We reported a rare case of bilateral Y-shaped bifid ureter, that's in this kind of anomaly 2, pyelocaliceal systems connect at the junction of the ureter to pelvic (bifid pelvis), and this abnormality was accidentally detected on ultrasound and MRI examinations. However, since duplex kidneys are often asymptomatic and therefore mainly diagnosed incidentally in patients, the actual number of patients with symptoms is probably lower.