Tehran University Medical Journal

Retinoblastoma treatment over time: a review article

Babak Masoomian

Retinoblastoma is the most common primary malignant ocular malignancy in children. The management and treatment of retinoblastoma is a very complex process and requires attention to different aspects, such as the stage of the disease based on the International classification of retinoblastoma (ICRB) or International intraocular retinoblastoma classification (IIRC), the genetic status of the tumor and mutations, psycho-social factors of the family and society, cultural beliefs, and available economic resources. From the identification of this malignancy until the beginning of the 20th century (before the introduction of radiation therapy as one of the treatment options), enucleation was the only treatment option for this disease. In addition to not controlling metastatic and extensive features of the disease and increasing the chance of death in these cases, enucleation causes many adverse psychological and aesthetic complications in patients, and especially children, who are the main population affected by this disease. Tremendous progress has been made since the 20th century to identify and invent new methods to preserve the eyes and less invasive treatments (globe salvage treatments), and the set of efforts led to the inventing of new treatment methods such as radiation therapy, systemic chemotherapy, local treatments such as cryotherapy and thermotherapy, intra-arterial chemotherapy and intraocular chemotherapy. In summary, the set of treatments from the beginning until now has gone towards increasing survival, reducing the rate of enucleation and providing more targeted and less invasive treatments. Despite these advances, early diagnosis is the most important prerequisite for better outcomes. However, early detection is influenced by socioeconomic factors and is a major challenge, especially in low- and middle-income countries. In fact, the provision of advanced medical care in high-income areas has provided excellent survival, globe, and vision-saving rates. Unfortunately, these results do not hold true for medical systems in low- and middle-income areas, leading to poor patient outcomes. In this article, we briefly introduce various retinoblastoma treatment methods from the beginning of detection until now, and we assess the evolution of the treatment of this disease from the beginning until now, which has reduced the need for enucleation as a treatment for this disease.

Effects of intravenous infusion of lidocaine and dexmedetomidine on immediate complications after tonsillectomy surgery in children

Behzad Nazemroaya

Background: Tonsils are lymphoid tissues of the body's defense system that surround the pharynx and prevent the entry of microbes through inhalation. Tonsillectomy is the final treatment for enlarged tonsils and is one of the most common procedures in the ear, throat and nose. To prevent and improve postoperative complications, various methods are used, including lidocaine and dexmedetomidine injections. The aim of this study was to compare the effects of intravenous infusions of lidocaine and dexmedetomidine on the rate and severity of immediate complications after tonsillectomy surgery.
Methods: This study was conducted as a prospective, triple-blind, randomized clinical trial on 96 patients who were candidates for tonsillectomy under general anesthesia at Al-Zahra Hospital, Isfahan, Iran. The patients had informed consents and met the conditions to enter the study. 30 minutes before induction of anesthesia, patients were randomly assigned to one of three groups receiving lidocaine, dexmedetomidine, or placebo. All patients were examined for intraoperative bleeding, laryngospasm in the first 2 hours after the operation, and laryngitis in the first 24 hours after the operation. SPSS version 26 software was used for statistical analysis.

Results: The findings of this research indicated that at 45, 75 and, 90 minutes after recovery, the mean score of pain and at 15-90 minutes in terms of anxiety was significantly different from the rest in at least one of the three groups (P<0.05). Systolic blood pressure (SBP) and arterial oxygen blood pressure in minutes 30 to 90, as well as Diastolic blood pressure (DBP) in minutes 60, 75 and 90, showed a significant difference between the three studied groups (P<0.05). There was no significant difference between the incidences of laryngospasm in the groups. However, there was a significant difference between the incidences of bronchospasm in all three groups. In terms of factors such as cough and nausea, no significant differences were observed in the studied groups. However, the average amount of bleeding in surgery, the recovery time and, the first time to tolerate liquids and solids in at least one group were significantly different from the others.
Conclusion: Overall, both dexmedetomidine and lidocaine are effective in reducing heart rate, SBP, Per Os (PO), and bleeding, and also increase arterial oxygen pressure, while respiratory rate, laryngospasm, bronchospasm, cough, nausea and extubation time were not significantly different between the three study groups.

Epidemiological investigation and clinical findings of various types of vasculitis in children of eastern Iran

Abdolreza Malek

Background: Vasculitis is a heterogeneous group of diseases that means an inflammatory process in blood vessels. Diagnosing vasculitis in children is challenging due to the variety of symptoms. Classification of childhood vasculitis is usually based on clinical phenotypes, size of affected vessels (small, medium, or large), and pathology of inflammatory infiltrates. The aim of this study is to investigate the epidemiological information on types of vasculitis and their clinical symptoms in children in eastern Iran.
Methods: This 3-year descriptive cross-sectional study was performed on all male and female patients with any vasculitis referred to the outpatient clinic and rheumatology department of Akbar Children's Hospital from the beginning of September 2017 to the end of September 2020. Has been. This study was based on information obtained from the checklist (information from the inpatient and outpatient records and information in the HIS). Checklist information included age, gender, drug history, history of surgery, clinical symptoms in different systems, season of disease onset, etc.
Results: Out of 263 children, 135 (51.33%) had Henoch-Schonlein and 100 (38/02%) of them had Kawasaki. The numbers of Behcet, Takayasu and Churg-Strauss patients were 20, three and two, respectively. In most subgroups, female patients were more common than male patients. Kawasaki and Takayasu had the lowest and highest age of onset, respectively. The most common seasons of appearance for Henoch-Schonlein and Kawasaki were autumn and summer respectively. In most subgroups, skin rashes are the most common clinical symptom, with, the most common types being petechiae and purpura.

Conclusion: In the present study, the most common type of vasculitis diagnosed in children in eastern Iran was reported by Henoch-Schonlein and Kawasaki respectively, which was completely different from the most common types of vasculitis in adulthood and indicated the importance of age in diagnosing the type of vasculitis. The necessity of clinical suspicion of these two diseases in children with skin rashes, along with matching with other clinical findings, is undeniable.

Assessment of STIR and contrast-enhanced MRI sequences in detection of diabetic foot osteomyelitis

Somayeh Zamani

Background: MRI is the imaging modality of choice for the detection of diabetic pedal osteomyelitis. The aim of this study is to compare the STIR sequence, as the most important fluid-sensitive sequence, with contrast-enhanced images for diagnosing diabetic pedal osteomyelitis.
Methods: Medical images were compared. Moreover, the effect of adding T1W image findings to the STIR sequence was evaluated. This cross sectional study was collected and analyzed at Namazi Hospital, Shiraz University of Medical Sciences, from 20 March 2016 to 22 September 2017.
Results: The final diagnosis of osteomyelitis was confirmed for 47 bones (78%). 13 bones (22%) didn't have osteomyelitis. The specificity of contrast-enhanced and STIR sequences was 92.3% and 53.8%, respectively; whereas the sensitivity of the two sequences was similar (100%). Records of 48 diabetic patients suspected of having pedal osteomyelitis referred to one of the university hospitals, who underwent foot MRI with and without contrast injection, were assessed. Overall, 48 Patient MRIs and 60 separate bony parts were evaluated. Diagnoses were confirmed by clinical correlation. Finally, sensitivity, specificity and diagnostic accuracy of STIR sequence and contrast-enhanced images were compared. Moreover, the effect of addition of T1W image findings to STIR sequence was evaluated.
Conclusion: This study was performed to suggest a pulse sequence that doesn’t need contrast media injection for diagnosing diabetic pedal osteomyelitis since the previous studies showed that gadolinium-based contrast media shouldn’t be applied in patients with renal failure (glomerular filtration rate<30 ml/min/1.73m². According to the results STIR images had the same sensitivity as T1 post-contrast images; therefore, it can be concluded that contrast media injection can be avoided using this pulse sequence. The specificity of the STIR pulse sequence was lower than that of post-contrast images which was due to the lower ability of this pulse sequence to detect secondary symptoms of osteomyelitis such as cortex disruption, sinus path, and abscess. Using the T1 pre-contrast images, specificity and diagnostic accuracy increased. Finally, it can be concluded that MRI without contrast including STIR and pre-contrast T1W images is a reliable modality for the detection of osteomyelitis in suspected diabetic patients who are more prone to renal disorders.

Investigating the factors affecting post-laparoscopic cholecystectomy pain in patients referred to mashhad medical sciences of islamic azad university hospitals in 2021-2022

Yasamin Kaheni

Background: Due to the prevalence of laparoscopic cholecystectomy, controlling common problems after this surgery is essential. This study aimed to determine the factors affecting pain after laparoscopic cholecystectomy.
Methods: In this cross-sectional study, 222 patients over 18 years old with symptomatic gallstones who underwent laparoscopic cholecystectomy from March 2021 to February 2022 in Mashhad Medical Sciences of Islamic Azad University Hospitals, were included. The amount of analgesic received after surgery was the same for all patients (Acetaminophen 1 gram intravenously every 8 hours and diclofenac 100 mg rectal every 8 hours). Demographic information of patients, body mass index, history of abdominal surgery, duration of surgery, carbon dioxide pressure, type of surgery (elective or emergency), number of surgical incisions, and pain intensity six and 24 hours after surgery (using a visual analog scale) were collected, and finally, the findings were statistically analyzed by SPSS version 26.

Results: Out of 222 patients, 179 cases were women (80.6%), and their average age and body mass index were 44.68±12.27 years and 27.08±4.7 kg/m², respectively. In our study, 110 people (49.5%) had a history of abdominal surgery, of which cesarean section was the most common delete. Pain six and 24 hours after the operation was more common in women than in men, and surgery with three incisions was more painful than surgery with four incisions (P<0.05). In patients with a history of surgery, the pain was greater in six hours after surgery (P<0.05). Pain 24 hours after the operation in patients with gas pressure less than or equal to 14mmHg was greater than in patients with gas pressure greater than 14 mmHg (P<0.05). Pain six and 24 hours after surgery according to age, body mass index, type of surgery (emergency or elective), and duration of surgery had no statistically significant difference (P>0.05).
Conclusion: In our study, female gender, use of three incisions for surgery, and history of previous surgery were associated with more pain after laparoscopic cholecystectomy.

Biomarker role of CH25H and GYPE genes in osteoarthritis and rheumatoid arthritis

Akram Gholipour

Background: Osteoarthritis (OA) and rheumatoid arthritis (RA) are both joint diseases with many different causes. Inflammatory arthritis, also known as rheumatoid arthritis, is one of the most complex types of arthritis. Non-inflammatory arthritis, also known as osteoarthritis, is a disease caused when the cartilage between the joints begins to be damaged. Considering the different treatment approaches for OA and RA, an accurate diagnosis of the type of arthritis is very important. The present study was conducted with the aim of finding gene expression and introducing reliable molecular biomarkers for RA and OA.
Methods: The microarray dataset was obtained under the GSE27390 number. The samples included nine samples of mononuclear cells obtained from the bone marrow of RA patients, 10 samples of mononuclear cells obtained from the bone marrow of OA patients. Differential expression analysis between the OA and RA groups was performed using GEO2R, and genes with differential expression were separated by examining two factors such as logFC#1 and p.adj. Value<0.05. Signaling pathways were determined using Enrichr databases. Next, the genes with the most expression changes were introduced. This study is a bioinformatics analysis and was conducted jointly at Bam University of Medical Sciences and Rajaie Cardiovascular, Medical and Research Institute from September 2022 to March 2023.

Results: The results showed that, 5083 genes had significant expression differences. Analysis of signaling pathways showed that antigen processing and presentation, natural killer cell-mediated cytotoxicity, the, IL-17 signaling pathway, Th17 cell differentiation and cytokine-cytokine receptor interaction, as inflammatory pathways, were important in this disease. It was also determined that CH25H (upregulated in RA samples) and GYPE (downregulated in RA samples) genes can distinguish rheumatoid arthritis from osteoarthritis.
Conclusion: Since accurate diagnosis helps with better disease treatment, it is very important to obtain new biological diagnostic markers. Overall, our data showed that genes can act as novel biomarkers with potential utility in the diagnosis of RA and OA and can be considered novel molecular biomarkers for the diagnosis of these two diseases.

Risk assessment of carcinogenic and non-carcinogenic effets of exposure to heavy metals in hookah smoke using the monte carlo simulation technique

Taibe Ruenifard

Background: This study aimed to evaluate the carcinogenic and non-carcinogenic health risks of heavy metals in seven types of tobacco widely consumed in the east of the country through inhalation exposure.
Methods: This descriptive-analytical study was conducted from April 2022 to October 2022 in the city of Bojnord, Iran on sook of seven popular tobacco brands. Metal concentrations in sook of tobacco were determined using inductively coupled plasma-optical emission spectroscopy. In order to analyze the data and ensure the accuracy of the results, the amount of metals in the samples was repeated three times, and their average was analyzed. Monte Carlo software was used to assess possible risks.

Results: The results of this study showed heavy metal concentrations in sook tobaccos were, respectively, Fe>Zn>Mn>Ba>Pb>Ni>Cu>Mo>Cr>As>Cd. The concentration of heavy metals such as arsenic, cadmium and molybdenum in Alrah brand tobacco was higher than other types of tobacco. So that the amounts of heavy metals including arsenic, cadmium and molybdenum for this brand were 14.2±0.05, 10.4±0.06 and 11.6±0.04 micrograms per gram, respectively. The hazard index (HI) values for different types of tobacco, including Al-Rah, Amordadsub, Al-Fakher, Al-Rubi, Mazaya, traditional flavorless, and Nakhle, were 2.64, 2.41, 2.05, 1.7, 1.49, 1.46, and 1.44, respectively. The lifetime cancer risk (ILCR) for Amordadsub, Al-Rah, Nakhla, Mazaya, Al-Rubi, Al-Fakher, and traditional flavorless tobaccos was 2.8×10^-3, 2.43×10^-3, 1.72×10^-3, 1.58×10^-3, 1.43×10^-3, 9.58×10^-4, and 8.08×10^-4, respectively. Lead in Alrah tobacco sook had the highest non-carcinogenic risk value with a value of 1.59.
Conclusion: According to the obtained results, Alrah tobacco sook has a higher cancer and non-cancer risk than regular tobacco and can cause non-carcinogenic and carcinogenic risks for consumers. Thus, it is necessary to regularly monitor the quality of prevalent tobacco to reduce delete human health risks.

Realizing the early prediction chronic kidney disease based-on identifing

Mahdieh Jamshidi

Background: Due to the fact that various factors are involved in the development of chronic kidney disease, this disease appears with different clinical and laboratory symptoms. The variety in type and number of clinical symptoms often misguides the treating physician. The aim of this study is to extract the key features of the disease and find the best data mining methods to improve the accuracy of kidney disease diagnosis.
Methods: This cross-sectional study was conducted from September 2021 to March 2023 for 30 months at Rafsanjan Ali Ebn Abi Taleb Hospital. Predictive models were developed and tested using different combinations of disease characteristics and seven data mining methods in RapidMiner Studio software. The limitations of the study are as follows: 1) The models were based on 40-year-old and older patients records, which may limit the generalization of results to a wider age group. 2) Despite the high accuracy and comprehensiveness of the method, the models were based only on the information of kidney disease patients at Ali Ibn Abi Talib Rafsanjan Hospital. 3) The climate parameter has not been considered in the data set of the investigation to discover the hidden relationships of this parameter with the kidney disease.

Results: The results of the experiments in this study showed that the proposed prediction model using the Bayes method and eight identified key features (age, renal biopsy, uremia, sedimentation, albumin, edema, nocturnal enuresis, and urine-specific gravity), can detect kidney disease in people of different clinical characteristics, with 99.38% accuracy.
Conclusion: Considering that the early diagnosis of kidney disease and the adoption of appropriate treatment methods can prevent the progression of kidney damage, in this study, an attempt has been made to achieve this goal by using new statistical methods and artificial intelligence techniques. Based on the proposed method and the conducted experiments, the most important features and the best data mining method were obtained, and finally, kidney disease prediction was possible with high accuracy.

Effects of deep brain stimulation in a patient with chronic refractory pain: a case report

Sara Ranji

Background: Stroke is one of the most important causes of chronic pain. In patients with chronic pain medical therapy with analgesic drugs, anti-epileptic drugs, and serotonin receptor modulators is the first choice. However, for patients who are refractory to the usual medical treatments, different strategies have been proposed to treat these pains. One of these treatments involves the implantation of deep brain electrodes and deep brain stimulation in the thalamus nucleouses. In this article we are reviewing the first case done in Iran.

Case Presentation: A 51-year-old male presented with sudden-onset left side hemiparesis and impaired sensation on the left side of the body, eight years ago. He complained of gradually developing pain on the left side of the body, adding to his symptoms. In his examination, he had dysarthria and his left extremities were spastic and their forces were decreased. Despite numerous medical treatments with gabapentin, pregabalin, duloxetine, carbamazepine and the replacement of an intrathecal baclofen pump during the last few years, he didn't respond very well. This goes so far as to induce severe depression symptoms, which disturbed his daily routine and even induced suicidal ideas. Due to the debilitating symptoms which were resistant to medical treatment, the patient underwent deep brain electrode implantation and deep brain stimulation in the ventral posterior lateral/posterior medial nucleuses in April 2023 at Imam Khomeini Hospital. No remarkable adverse effects were observed after implantation. In the patient’s follow-up, he had a significant improvement in pain and some other symptoms.
Conclusion: Deep brain stimulation of the thalamus nucleus is a known treatment in patients with Parkinson's disease and dystonia. However, for patients with chronic refractory pain, deep brain stimulation is a controversial therapy and has been introduced recently as an effective alternative treatment. In our patient, who suffers from severe unilateral refractory pain after stroke, a deep brain electrode was implanted and after deep brain stimulation significant improvement in pain was seen.

Evaluation of the validity and reliability of the persian version of the rotator cuff quality of life (RC-QOL) questionnaire in patients with rotator cuff injuries: a brief report

Babak Vahdatpour

Background: The objective of this study was the transcultural adaptation of the Rotator cuff quality of life (RC-QOL) questionnaire and the determination of the reliability and validity of the questionnaire in the Persian-speaking population with rotator cuff disease.
Methods: This study was conducted in Isfahan from April 2022 to February 2023. The participants consisted of 56 people with rotator cuff pathology. The process of adapting and translating the questionnaire was done with the methodology presented previously by Beaton et al. Content validity was first tested by a group of orthopedic and physical medicine and rehabilitation specialists and then through a pilot study consisting of 15 Persian-speaking patients with rotator cuff disease. Test-retest reliability was established with an intraclass correlation coefficient. Internal consistency was calculated using Cronbach's alpha. The measurement's error estimation was calculated with the standard error of the measurement. Reproducibility evaluation was measured with a 3-day interval between the completion of the test-retest questionnaire.

Results: The age range of the participants was 34 to 68 years (55% men and 45% women). The mean (standard deviation) of the total score of the RC-QOL questionnaire was 44.33(10.81) and ranged from 17.35 to 70.88. Cronbach's alpha was 0.971, which showed high internal consistency. The intraclass correlation coefficient was 0.99, indicating high test-retest reliability. The mean values (standard deviations) of the DASH and SPADI questionnaires were equal to 77.66(13.69) and 66.66(18.25), respectively. The results of the study showed excellent and significant convergent validity of the RC-QOL questionnaire with both the DASH and SPADI questionnaires. The correlation value with the DASH and SPADI questionnaires was equal to 0.907 and 0.941, respectively.
Conclusion: The Persian version of the RC-QOL questionnaire is a valid and reliable tool to evaluate the quality of life in patients diagnosed with rotator cuff injuries.

The role of value and correct pricing of services in the Ministry of Health and its importance in preventing the migration of elites: a letter to editor

Ali Asghar Khaleghi