Tehran University Medical Journal

Comparative study of the effect of neurotec vs gabapentin on sensory symptoms of patients with diabetic neuropathy

Hadi Gharebaghian

Background: Diabetes is the most common cause of peripheral neuropathy throughout the world and has negative impact on patient's quality of life. There is no cure and to date several drugs have been used for its symptomatic treatment, including antidepressants and antiepileptics. Neurotec is a herbal medicine (combination of wild star anise, nettle and tansy) that can be potentially effective in the treatment of this disorder. Proposed mechanisms include its effects on increasing nerve conduction velocity and repairing peripheral nerves.
Methods: In a single-blind randomized clinical trial from April to September 2018 in Kermanshah of patients referred to Taleghani Hospital Clinic, 100 diabetic patients with sensory complaints, were randomly divided into two groups. The first group received 100 to 300 mg gabapentin (a well-known effective antiepileptic drug) daily and the second group received 100 mg Neurotec daily. At the beginning of the study and at the weeks of 6 and 12, patients were evaluated with DN4 questionnaire and the visual analog scale (VAS) for severity of sensory symptoms including paresthesia and numbness and the results were compared and analyzed. In each serial visit, possible drug side effects were asked from patients and recorded.

Results: Neurotec reduced the feeling of coldness, pain, paresthesia and numbness VAS and DN4 scores (P of 0.01,0.05, 0.05, 0.05, 0.001, 0.05 respectively). Neurotec showed a significant advantage over gabapentin in reducing pain intensity and in other parameters the difference between the two groups was not significant. The only significant complication of Neurotec was dyspepsia that could be minimal in patients who receive the drug after a meal. Conversely in the gabapentin group, dizziness, drowsiness, and vertigo were significantly more common (P>0.05).
Conclusion: Neurotec can be useful for sensory symptoms of diabetic neuropathy. Its effect on symptomatic therapy is comparable to gabapentin or even better for painful diabetic neuropathies. Its proposed mechanism in neuronal repair needs to be evaluated and can be a potential advantage over symptomatic therapies. Neurotic has no serious side effects.

Evaluation of lung transplant patients in Imam Khomeini hospital, Tehran university of medical sciences

Tayebeh Lakzaei

Background: Despite the progress of medical science and organ transplantation, lung transplantation is associated with significant complications and mortality. In Iran, the first lung transplant was performed in 2000 at Imam Khomeini Hospital in Tehran. So far, there has been no assessment of the patients. The main purpose of this study is to investigate the status of lung transplantation status at this center.
Methods: In this retrospective longitudinal study, all lung transplant patients referred to the Lung Transplantation Center of Imam Khomeini Hospital in Tehran from April 2000 to March 2022 were examined. Demographic and clinical data, and information related to their current status, including pulmonary function tests, transplant-related complications, pharmacotherapy, and drug-related adverse events were recorded. Appropriate statistical analysis was applied.

Results: During the study, 20 lung transplants were observed, 20 percent of transplant recipients were women, and 80 percent were men. The mean age of the patients at the time of transplantation was 39.3±11.4 years. The youngest patient at the time of transplantation was 22, and the oldest was 60 years old. The most common indication for transplantation was interstitial lung disease (70%) followed by chronic obstructive respiratory disease. The average forced expiratory volume in one second (FEV1) value of the patients in the first year was about 50%, which gradually decreased to less than 20 percent in the fifth year. The average survival after transplantation was 5.75±4.6 years. The post-transplant one month, three months, one year, three years, and five years survival were 80, 75, 70, 60, and 50 percent, respectively. Chronic lung allograft dysfunction and serious infections are the most common causes of mortality.
Conclusion: The transplant center at Imam Khomeini Hospital is one of the most important lung transplant centers in Iran. The survival status and transplant outcome are comparable with those reported around the world. More attention should be paid to infection control, patient selection, and perioperative care to improve the outcomes of lung transplantation.

Effect of low-dose ketamine versus lidocaine on hemodynamic response to endotracheal intubation in general anesthesia: a prospective, triple-blinded, randomized controlled trial

Behzad Nazemroaya

Background: A smooth endotracheal intubation minimizes hemodynamic changes. We assessed the effect of ketamine and lidocaine on Diastolic blood pressure (DBP) Systolic blood pressure (SBP), heart rate (HR), Mean arterial pressure (MAP) and, oxygen saturation (SpO2) changes after endotracheal intubation compared to a control group.
Methods: In this randomized, triple-blind clinical trial (IRCT20200825048515N56) approved by the Medical Ethics Committee of the Isfahan University of Medical Sciences (IR.MUI.MED.REC.1400.721) 90 patients aged 18-65 years as candidates for surgery under general anesthesia at Alzahra Hospital in Isfahan were included between December 2022 and February 2023. They were randomly allocated to the ketamine hydrochloride (ketamine) (0.5 mg/kg), lidocaine hydrochloride 2% (Lignodic) (0.5 mg/kg), and control groups. The subjects, age, height, weight, gender, Body mass index (BMI) and clinical information, such as mean blood pressure, HR, SBP, DBP, MAP, and, oxygen saturation 1, 3, 5 and 10 minutes following endotracheal intubation, recovery stay and, extubation time were noted and analyzed by repeated measure analysis using SPSS version 28. The significance level in all analyses was considered less than 0.05.
Results: Ninety candidates for electroconvulsive therapy (ECT) were randomly assigned to three groups of 30: one group receiving lidocaine hydrochloride, one receiving ketamine hydrochloride, and the other a control group. Overall, 60 cases (66.7%) were male and 30 cases (33.3%) were female.

Both lidocaine and ketamine effectively reduce hemodynamic changes during endotracheal intubation, but lidocaine potentially has greater benefits in terms of improving oxygenation and reducing heart rate variability, as well as reducing recovery time during anesthesia. No significant difference was detected between the two studied groups regarding diastolic blood pressure, systolic blood pressure, heart rate, mean arterial pressure changes, recovery stay, extubation time, and laryngoscopy grade.
Conclusion: Based on the findings in this study, lidocaine offered more desirable hemodynamic stability than ketamine and resulted in fewer hemodynamic disturbances. Also, in the case of persistent hypertension or tachycardia. This was not observed in any of the groups.

Secondary cancers evaluation inside organs at risk during the prostate cancer radiotherapy: a brief report

Reza Shamsabadi

Background: In prostate cancer radiotherapy, due to the proximity of the prostate to the rectum, it can be affected by high radiation doses. It has been reported that about 70% of secondary cancers after prostate cancer radiotherapy occur in the bladder and rectum, which are exposed to direct radiation. Since prostate cancer radiotherapy may be accompanied by side effects, the aim of this study is to investigate the risk of secondary cancers after the radiotherapy of prostate cancer inside the outfield organs.
Methods: The dose volume histogram data relevant to 39 patients with prostate cancer (who were treated with 3-dimensional conformal radiotherapy technique in 2022 in Tehran) were extracted, and the uniform absorbed dose inside the sensitive tissues was calculated according to the gEUD concept. Then, the risks of secondary malignancies following prostate cancer radiotherapy were calculated using the model introduced by the BEIR report. Accordingly, the lifetime attributable risk values (LAR) were estimated based on the desired organs and patient age at exposure time through the calculation of Excess relative risk (ERR) and Excess absolute risk (EAR) values.

Results: From the obtained results, the gEUD values for the rectum ranged from 51.04 Gy to 74.69 Gy and for the bladder from 27.22 Gy to 75.51 Gy. The maximum calculated risk values for the rectum and bladder were calculated to be 49.85% and 74.91%, respectively. Besides, a significant level of secondary cancer risk within the rectum and bladder was obtained for most of the studied patients. Furthermore, small values of secondary cancer risks were estimated for patients who were irradiated at older ages, and higher ones were obtained for patients who were irradiated at younger ages.
Conclusion: The results showed that there is a higher probability of developing secondary malignancies in the bladder than the rectum. The information obtained in this research can improve the performance of the treatment process, so that information about secondary cancers following radiation therapy for prostate cancer will ultimately help doctors design more effective and optimal treatment designs.

The effectiveness of tDCS on insomnia and mood of female with insomnia

Tahereh Motevalizadeh

Background: Insomnia is the most common sleep disorder that is associated with cortical hyperexcitability. Potentially transcranial direct current stimulation (tDCS) modifies the cortical state related to insomnia. Therefore, we hypothesized that by using tDCS the intensity of insomnia can be reduced, followed by improvement of the mood symptoms.
Methods: This study was an experimental design with a pre-test and post-test with a control group. The statistical sample included 32 females with chronic insomnia that were randomly divided into an experimental group (active stimulation) and a control group (sham stimulation). Transcranial direct current with an intensity of 2 mA was applied for 30 minutes during 12 sessions (three times in the week) in the active stimulation group. In this protocol, anodal stimulation of left Superior temporal gyrus (STG) and cathodal stimulation of right dorsolateral prefrontal cortex (DLPFC) and left secondary motor cortex (SMA). In the control group, sham stimulation was performed for 30 minutes during 12 sessions (three times in the week). The participants were evaluated before and after of the intervention using the Insomnia Severity Index (ISI) and Positive and Negative Affect Scale (PANAS).

Results: The findings of this research showed that the application of transcranial direct current stimulation was effective in reducing the severity of insomnia and improving positive and negative affect (P<0.001, F=19.87). The value of this effect (eta2) in the severity of insomnia, negative mood and positive mood is 0.64, 0.34 and 0.6 respectively.
Conclusion: The results of the present study showed that the implementation of our designed tDCS protocol for the treatment of insomnia, significantly reduced the intensity of insomnia in women with chronic insomnia and improved their mood symptoms.

Evaluation of sensitivity and specificity of filter paper in screening of congenital hypothyroidism

Maryam Razzaghi-Azar

Background: Congenital hypothyroidism (CH) is one of the most preventable causes of mental retardation throughout the world. The aim of this study was to evaluate the sensitivity and specificity of filter paper in screening for congenital hypothyroidism and to determine an appropriate cut-off point for filter TSH for recalling screened neonates.

Methods: In this cross-sectional study (descriptive analytic), the records of 2739 neonates who had been recalled during the CH screening program in the east of Tehran, Iran (health care centers of the Iran University of Medical Sciences), from March 2011 to March 2015, were studied. According to the CH screening program in Iran, the TSH on filter paper>5 is the current cut-off point for recalling the neonates. The data was analyzed with SPSS software, version 21. The ROC curve was used to determine the TSH cut-off point and the sensitivity and specificity of the filter test. The relationship between the filter and serum TSH was also determined. The study was approved by the Ethics Committee of the Iran University of Medical Sciences.
Results: The recall rate was 5.4%. The prevalence of hypothyroidism was 3/1000 neonates (164). The prevalence in males and females was 51.1% and 48.9%, respectively, with no significant difference. The number of recalled neonates diagnosed as patients with congenital hypothyroidism based on the filter TSH level was 5
Conclusion: Based on the findings of the study, considering the kits available in the country and their sensitivity and specificity, the importance of diagnosing infants with congenital hypothyroidism, and the lower cost of filter paper than missing a hypothyroid infant, the current cut-off point is acceptable. However, more studies are needed in different regions of Iran to obtain more accurate results.

Prevalence of congenital cytomegalovirus infection in newborns admitted to the intensive care units in Tehran, Iran

Samileh Noorbakhsh

Background: Cytomegalovirus (CMV) is the most common cause of congenital infections in newborns which can lead to long-term complications in more than half of the cases with symptomatic infection at birth time. Unfortunately, neonates with congenital CMV infection will mostly remain undiagnosed because the golden time for detection is limited to the first 3 weeks of infants' life. This study aimed to determine the prevalence of congenital CMV infection in newborns admitted to intensive care units of hospitals in Tehran, Iran and assess related risk factors associated with the infection.
Methods: In this cross-sectional study from April to October 2017, newborns within the first three weeks of life who were admitted to the neonatal intensive care units (NICUs) of university-affiliated hospitals in Tehran, Iran, were eligible for enrollment. CMV infection in neonates was diagnosed through testing infants' Guthrie cards and detection of viral DNA via an in-house nested-PCR assay. Congenital CMV infection in neonates with positive results was confirmed by testing urine specimens as a sensitive and gold standard sample. Related data (demographic and maternal factors) were collected by questionnaires and analyzed.

Results: Congenital cytomegalovirus infection was diagnosed in 8 of 63 newborns (12.7%). Hearing loss was seen in 2 infected infants. The mean of head circumferences among infected neonates was significantly lower than that observed in uninfected cases. Infants with CMV related symptoms had statistically more chance to have infection (P=0.02). We also found Guthrie cards as a reliable sample with high sensitivity for CMV detection assays.
Conclusion: The current study showed a high rate of symptomatic congenital CMV infection among neonates attending on NICU sections of hospitals in Tehran, Iran. It is of crucial importance to note that based on evidence, diagnosis of infants with congenital CMV infection at early stages could help to decrease the burden of long-term diseases if associated with prompt interventions and reduce the costs of late-ineffective treatment. Therefore, routine screening of newborns for congenital CMV infection via Guthrie cards is suggested.

Comparing the rate of complications of sore throat and hoarseness caused by ETI support method with LMA method in surgical patients under general anesthesia

Farzaneh Boluki Moghaddam

Background: Respiratory support during the patient's anesthesia is done in different ways, such as endotracheal intubation and laryngeal mask. Endotracheal intubation is inevitably used for respiratory support in general anesthesia patients. The use of alternative methods for respiratory support during the process of general anesthesia is one of the most significant ways to control anesthesia complications. The laryngeal mask is placed around the larynx to allow spontaneous and controlled ventilation. Both of the respiratory support methods can cause complications. The purpose of this study is to compare the side effects of sore throat and hoarseness caused by two methods in surgical patients.
Methods: This study was conducted in the period from September to November 2022 on patients who were referred and underwent surgery at Baqiyatallah Hospital. The study is a cohort study that was conducted retrospectively on 60 patients who underwent any surgery with two methods of anesthesia by ETI and LMA. In order to evaluate hoarseness, the standard Voice Handicap Index (VHI-10) questionnaire was used. In order to evaluate the complication of sore throat caused by the respiratory support method, a 4-point pain checklist was used for 24 hours and 14 days after the surgery.

Results: The findings of our study showed that the average amount of sore throat 24 hours after surgery in the LMA and ETI groups was 2.13 and 2.2, respectively, and these values 14 days later were 1.17 and 1.07, respectively. The average level of hoarseness in the 24 hours after surgery in LMA and ETI groups was 2.66 and 3.13, respectively. The statistical comparison of the severity of side effects between the two groups showed that in the LMA method, the amount of sore throat and hoarseness is less than the ETI method, although this reduction does not have a significant difference.
Conclusion: The results of this study showed that the rate of complications of sore throat and hoarseness in the laryngeal mask group is reduced compared to the endotracheal intubation group, although this difference is not significant.

Recurrence and survival in early breast cancer subtypes

Ali Taghizadeh

Background: Breast cancer is the most common type of cancer in many countries, accounting for over 18% of all cancers in females. There are more than one million new cases of breast cancer each year. Most women diagnosed with breast cancer are over the age of 50, but younger women can also get breast cancer. About one in seven women are diagnosed with breast cancer during their lifetime. There's a good chance of recovery if it's detected at an early stage. In Iran, breast cancer is the most common cancer among women, making up 21.4% of all female cancers. The mortality rate of this cancer is 4.33 for every 100,000 people. The purpose of this research is to see how often different kinds of early breast cancer come back and how long people live after being diagnosed.
Methods: This retrospective study evaluated the medical records of 500 breast cancer patients at two hospitals in Mashhad, Iran during April 2006 to March 2016. We used SPSS software, version 16 (SPSS Inc., Chicago, IL, USA) to analyze data. A P value less than 0.05 means that the results are considered statistically significant.

Results: We included 230 women with breast cancer. The average overall survival was 130.7 months, with 83.2% of people surviving for five years and 78.8% surviving for 10 years. The stage of the disease is strongly linked to the recurrence (P=0.000). Additionally, the specific type of disease is also strongly related to disease recurrence (P=0.01) or metastasis (P=0.01). Patients who have the triple-negative subtype had the highest chance of the cancer spreading and recurrence compared to patients with other subtypes.
Conclusion: The different types of breast cancer are strongly linked to the disease recurrence or metastasis. Patients with triple-negative subtypes had the most cases of cancer spreading to other parts of the body and coming back again, compared to other subtypes. Our findings also showed that patients with the triple-negative disease had the worst overall and disease-free survivals.

Oxytocin plus foley catheter versus misoprostol plus foley catheter on cervical preparation in prolonged pregnancies

Masoume MirTeimouri

Background: The success of labor induction depends on the condition of the cervix at the time of delivery. This study examines the effect of labor induction with an intra-cervical Foley catheter and oxytocin compared to a Foley catheter and misoprostol on cervical preparation and delivery rate in the first 24 hours after induction.
Methods: In a randomized clinical study, pregnant women with a singleton pregnancy and a gestational age of more than 40 weeks, with a Bishop score less than 4 and an intact amniotic sac referred to Umm al-Binin Hospital in Mashhad from 2017 to 2018 were included in the study. They were randomly divided into two groups of Foley catheter and oxytocin (1) or Foley catheter and misoprostol (2). In the first group, immediately after placing the Foley catheter; Oxytocin was started with a dose of 2 milliunits per minute, and every 20 minutes, 2 milliunits were added to reach the maximum dose of 30 milliunits per minute (induction method with a low dose). In the second group, after Foley catheter insertion, sublingual misoprostol was prescribed at a dose of 25 micrograms every 4 hours up to a maximum of 6 doses.

Results: 74 pregnant women were randomly evaluated in two groups of 37 people. There is no statistically significant difference in the demographic variables in the two groups. There was a significant difference in the labor rate in the first 24 hours, and it was higher in the oxytocin group (P=0.009). Bishop's score after 24 hours of induction was not significantly different in the two groups. Reaching the active phase was significantly shorter in the oxytocin group. (P=0.01). The time of catheter removal in both groups and the rate of cesarean section and the occurrence of complications were the same in both groups.
Conclusion: The use of oxytocin with a Foley catheter inside the cervix can accelerate the preparation of the cervix and increase the chance of labor in the first 24 hours, but it does not affect labor complications.

Ethical challenges of artificial intelligence in the field of radiology: a letter to editor

Parisa Pishdad