Tehran University Medical Journal

Challenges and solutions of integration in the health service delivery: a scoping review

Ebrahim Jaafaripooyan

Background: Communication and cooperation among health care organizations have become nowadays crucial for improving the quality and equity in providing health services, and integration has been expressed as a solution by the World Health Organization. The purpose of this review was to identify the challenges and solutions of integration in health services.
Methods: This research was carried out from September 2023 to April 2024. All articles on the challenges and solutions of integration in health, using scoping review, were identified and used in the PubMed, Scopus, Web of Science and Google Scholar search engines in the period from 2000 to 2024. The total number of English articles found was 4996, of which 662 were removed due to repetition. Among the remaining 4334 articles, 4249 articles whose titles and abstracts were not related to the research topic were removed, left a total of 85 articles, and after reviewing the full text of the articles, 27 articles entered the data extraction phase, which were finally analyzed using the framework analysis method.

Results: Finally, 27 articles were selected from which, 46 challenges and 26 solutions were extracted as to the integration in health services and categorized based on the framework of WHO six building blocks in five areas of governance and leadership, financing, human resources, information system and service delivery. The most important challenges of integration include; weakness in planning, imbalance of power between organizations, differences in geographical and spatial boundaries of organizations, weakness in maintaining data security, workforce resistance and the lack of laws and regulations, needs assessment from patients, related knowledge, financial resources, suitable payment models, integrated communication and information systems and interoperability between technologies.
Conclusion: Integration of health service endures a series of challenges such mainly as the lack of rules and regulations for collaborative processes and resistance from providers and employees requiring innovative solutions. Addressing issues such as stakeholder power-benefit analysis, interoperability and data sharing among the providers could be essential for successful integration.

The effect of laughter therapy on promoting the health of women with breast cancer: a systematic review

Shohre Behrouz

Background: Breast cancer is one of the most important cancers in women. Considering the importance of design for improving physical and mental health, quality of life of vulnerable women, the present study aims to design of humor and laughter programs in women with breast cancer and its effects in promoting their health.
Methods: In this systematic review, in order to access relevant articles used from Persian and English databases SID, Magiran, Cochrane Library, MEDLINE/PubMed, Scopus and Science direct, and the key words "Humor therapy", "Laughter therapy", "Breast Cancer", "Wit and Humor as Topic" and "Breast Neoplasms" using logical operators (AND, OR, NOT) were used. All articles were evaluated between January 2008 and January 2023. To assess the quality of the articles, the "Jadad" scale was used.

Results: Among the 975 articles in the initial search, 525 articles are due to the repetition of the title and 442 articles due to other reasons such as not assigning humor therapy in breast cancer, not implementing the joke and laughter intervention program, the language of the article not being related to English or Farsi, and not Conducting clinical trials were excluded, and finally eight articles that scored higher than 3 were included in the systematic review. The results of the studies showed that laughter therapy had an effective role in improving the quality of life, improving various aspects of mental health, reducing negative emotions such as anxiety, stress, depression, pain intensity, fatigue and strengthening positive emotions such as self-esteem, mood. while There has been a non-significant decrease in the dermatitis caused by radiotherapy and the activity of immune cells and the serum level of cortisol.
Conclusion: Considering the positive effect of laughter therapy in reducing the negative emotions of patients, it is recommended that nursing managers and psychologists use this easy, fun, uncomplicated and accessible intervention to improve the physical, mental and emotional health of women with breast cancer.

Mohsen Sadat Shahabi

Background: Major Depressive Disorder (MDD) is one of the most prevalent and disabling mental disorders in the world. Due to the life quality decline caused by this disease and its growing nature, timely detection and treatment is of paramount importance. In the present study Electroencephalogram (EEG) signal utilized for the precise detection of MDD using Artificial Intelligence (AI) Methods.
Methods: In this analytic study, which is done in Shahid Beheshti University of medical Sciences in 2023, fifty eight subjects were investigated using an experienced psychiatrist that 30 subjects diagnosed as MDD and 28 determined to be healthy. Nineteen channels EEG signals in resting state with eyes closed situation acquired for five minutes from all of the participants including 36 men and 22 women with the average age of 39.3 years. The EEG signals were preprocessed to remove contaminating signals from brain-originated signals. The EEGLAB package in MATLAB utilized to re-reference channels to the average reference, apply a band-pass filter between 1 and 40 Hz and to remove non-brain components of the signal using Independent Component Analysis (ICA). The cleaned data segmented to the three seconds windows with 50 percent overlapping. These segments were used as the input to the AI models. Deep Learning (DL) models utilized in the present study were EEGNet, ShallowConvNet and DeepConvNet which were developed based on the deep convolutional models for the classification of healthy and MDD brain signals. The main difference between these models laid in the number of specific convolutional layers and the model complexity.

Results: MDD and Healthy signals classification has been done using EEGNet, ShallowConvNet and DeepConvNet models and accuracy of 92.3%, 83.2% and 92.2% were achieved, respectively. Also EEGNet acquired the highest sensitivity of 98.9% and specificity of 79.1%.
Conclusion: The detection of MDD patients using EEG signals with high accuracy and generalizability is possible and proposed AI models can be utilized in the clinical settings as assistant tools.

Survey of pregnancy outcome in preterm premature rupture of membranes

Fedyeh Haghollahi

Background: Preterm premature rupture of membranes (PPROM) significantly impacts perinatal mortality and maternal-fetal outcomes. The purpose of this study is to investigate the frequency of maternal risk factors, maternal and fetal outcomes and the role of care in the occurrence of outcomes.
Methods: This retrospective cross-sectional study involved 317 pregnant women with premature rupture of membranes (PPROM) at Shahid Beheshti Hospital in Isfahan, between April 2020 and April 2022. Data were collected from medical records, including demographic information, risk factors, and maternal and neonatal outcomes. Patients were categorized into two groups: those receiving care (24-34 weeks of gestation) and those undergoing pregnancy termination (less than 24 weeks or more than 34 weeks). The chi-square test was used for qualitative variables, while the T-student test was applied for quantitative variables.

Results: In this study, the average age of patients was 29.42±6.56 years. The most common risk factors for PPROM were 20.2% for abortion records, 20.2% for urinary infections, 18% for cervical insufficiency, and 13.6% for gestational diabetes. Comparing maternal outcomes between the two groups revealed that chorioamnionitis occurred more frequently in the care group (18% vs. 2%, P=0.0001), as did emergency cesarean sections (37% vs. 4.5%, P=0.0001) and NICU hospitalization (71% vs. 17%, P=0.001). In the next stage, a regression test identified the independent effects of variables on maternal and newborn outcomes without intervention or confounding factors. The analysis indicated that mothers in the care group experienced significantly more complications than those in the pregnancy termination group, and their babies also faced significantly more complications.
Conclusion: The study results indicate that a history of abortion, urinary infections, cervical insufficiency, and gestational diabetes are significant risk factors for PPROM. Expectant management of PPROM is associated with more neonatal and maternal complications than pregnancy termination. Thus, timely identification of these risk factors allows healthcare providers to educate mothers and potentially prevent and manage them, significantly reducing the incidence of PPROM and its complications.

The impact of selenium and astaxanthin on sperm parameters and sensory-motor function recovery in spinal cord injured rats

Soheila Bani

Background: Spinal cord injury (SCI) is a significant medical and social issue, leading to varying degrees of sensory and motor impairments. Most men experience sexual dysfunction and fertility problems. These issues can be partially attributed to pathophysiological mechanisms, including damage caused by reactive oxygen species (ROS). Targeted antioxidant therapy can significantly reduce oxidative stress and neuro inflammation. This study sought to examine the impact of selenium and astaxanthin on sperm parameters and the recovery of sensory-motor function in rats with spinal cord injury (SCI).
Methods: This experimental study utilized the rat animal model and was carried out at the Neuroscience Research Center Laboratory of Tabriz University of Medical Sciences from December 30, 2022, to November 27, 2023. Fifty adults male Wistar rats were randomly allocated into five groups of ten: control, sham, SCI, selenium-supplemented, and astaxanthin-supplemented. Except for the control and sham groups, spinal cord injury was induced in all other groups. Six weeks after the injury and upon completion of the treatment, the effects of selenium and astaxanthin supplementation on sperm parameters and spinal cord repair were assessed. The Basso, Beattie, and Brenham (BBB) scale was employed to evaluate motor function, while the Von Frey test was utilized to assess sensory status.

Results: A considerable rise in sperm concentration was noted in both the selenium-fed group and the astaxanthin-fed group when compared to the spinal cord injury group (P=0.001). Supplementation with selenium and astaxanthin improved sperm concentration, progressive motility, and viability, bringing these parameters close to control levels (P<0.001). However, neither of these substances had an effect on abnormal sperm morphology (P>0.05). Both selenium and astaxanthin supplementation enhanced the motor and sensory functions of the injured rats (P<0.001), with selenium showing a greater role in promoting repair compared to astaxanthin (P<0.001).
Conclusion: Selenium and astaxanthin supplements improved sperm parameters, except for sperm morphology, and were effective in enhancing motor and sensory functions after spinal cord injury. Selenium was found to be more effective than astaxanthin in promoting spinal cord repair.

Effects of EN12791-based surgical scrub with tgsept al plus on normal flora of hands among operating room staff in Hazrat Fatemeh Hospital of Tehran

Vahid Malekzadeh

Background: Considering the emergence of new diseases, increased prevalence of nosocomial infections, and microbial resistance in recent years, it is necessary to disinfect the hands with a suitable hand sanitizer, as instructed by the Center for Disease Control (CDC). This is because hand hygiene is the most important way to control infections. Surgical hand antisepsis protocols emphasize the importance of both mechanical cleaning and antimicrobial action to effectively eliminate microbial contamination. Recommendations from organizations such as the Association of Perioperative Registered Nurses (AORN), the World Health Organization (WHO), and the Association for Professionals in Infection Control and Epidemiology (APIC) underscore this principle. While routine handwashing removes visible debris and transient microbes, surgical hand antisepsis requires additional steps and the use of antimicrobial agents. This may involve a surgical scrub with an antimicrobial soap or the application of an alcohol-based hand rub (ABHR). The latter approach has demonstrated greater efficacy in reducing microbial contamination compared to soap and water alone. Since a few compressive studies in Iran have dealt with global standards for disinfectants, this study investigated the effects of surgical scrub based on the European standards with TGSept AL Plus, produced by the research team of Tajhiz Gostar Sharif , on normal flora of hands in a group of the operating room medical staff in Hazrat Fatemeh Plastic Surgery and Repair Hospital of Tehran, in 2023.
Methods: This study evaluated the short-term durability and effectiveness of this solution according to the EN12791 standard on microorganisms and microbial contamination reduction. To this end, 30 members of the surgical team were randomly selected. The bacterial sampling was performed three times: after washing the hands with common detergents, after hand scrubbing with the studied disinfectant (about 90 seconds), and three hours after surgery. The samples were immediately transferred to a laboratory for swap culture and pour plate test.

Results: Then bacterial colonies were counted, contamination reduction was measured, and the shelf life of the solution was determined according to the standards. Results showed that a 60-to-90-second scrub with an alcohol-based disinfectant is the best way to reduce hand contamination and, thereby, nosocomial infections.
Conclusion: Based on the study findings, alcohol-based solutions can be recommended for surgical scrubs, according to WHO guidelines.

Evaluation of the frequency of drug interactions in patients admitted to the emergency department of Imam Khomeini Hospital in Urmia in the first half of 2020

Hamidreza Mehryar

Background: Medicines that are used to prevent and cure disease may affect patients if used incorrectly, and this study was conducted with the aim of evaluating the frequency of drug interactions in patients admitted to the emergency department of Imam Khomeini Hospital in Urmia.
Methods: This study is descriptive-analytical in a cross-sectional way, From March 20, 2020 to September 21, 2020, a census was conducted on patients admitted to the emergency department of Imam Khomeini Hospital in Urmia, who were 1901 people. The data was collected using a checklist that included information (age, sex, type of drug and severity of interference and type of interference). After collecting the data, it was entered into SPSS software, version 18 (IBM SPSS, Armonk, NY, USA) and analyzed with the help of descriptive and analytical statistics.

Results: In this study, the results showed that out of 1901 studied patients, 1101(57.9) were male and the rest were female 801(42.1), And the average age of the patients was 61.67±17.13 years, and 1160(60.9) patients did not have drug interactions and 724(39.01) had drug interactions, and the most common type of drug interaction was the moderate type, which was present in 75.1% of cases; And the final clinical outcome of the patients was 1088(57.2) discharge, 296(15.5) personal consent discharge and 506(26.6) death. Also, the most common drug interactions were serotide/salbutamol, azithromycin/ondansetron, and aspirin/nitroglycerin, respectively. And there was no significant relationship between the occurrence of drug interactions and the gender of patients (P=0.27) and finally, the average age of patients with drug interactions was 17.7±61.2 years and in patients without drug interactions was 16.7±61.9 years. Conclusion: The overall incidence of drug interactions in the studied patients was equal to 39.01, and the most common drug interactions in patients were of moderate and mild type; and there was no statistically significant relationship between the age of the patients and the gender of the patients and the incidence of drug interactions.

The effect of moderate-intensity interval training (MIIT) on autophagy-related proteins in the soleus muscle of type 2 diabetic rats

Hamed Alizadeh Pahlavani

Background: In people with diabetes, metabolic changes can affect the body's response to physical activity. On the other hand, for people with diabetes, exercise can be a powerful tool to manage diabetes and improve overall health through key regulatory proteins such as adenosine monophosphate-activated protein kinase (AMPKα1/2), dynamin-like protein (DLP1), and autophagy-related protein 13 (ATG13). In diabetes, AMPK regulation is often disrupted, contributing to the metabolic imbalances that characterize diabetes. In diabetes, disruption of DLP1 protein as a key regulator of mitochondrial fission leads to the accumulation of damaged mitochondria and metabolic imbalance. ATG13, as an autophagy regulator causes the recycling of damaged cells and damaged components.
Methods: This study was conducted in May to July 2023. In this experimental research, 12 two-month-old male Sprague-Dawley rats with an average weight of 280±30 grams participated. To induce type two diabetes, nicotinamide solution with a dose of 110 mg/kg and streptozotocin (STZ) with a dose of 60 mg/kg were injected, and blood glucose between 126 and 260 mg/dl was determined as the index of diabetes induction. Then the diabetic rats were randomly divided into training (six heads) and control groups (six heads). The moderate-intensity interval training (MIIT) group trained for 4 weeks and four sessions every week. The MIIT program consisted of 4 rounds of 3 minutes with an intensity equal to 55-75% of the maximum speed and active rest periods of two minutes with an intensity of 35-45% of the maximum speed. After 24 hours from the last training, the rats were anesthetized and the soleus muscle tissue was isolated and the proteins were measured by western blot methods.

Results: The results showed that MIIT causes a non-significant increase in AMPK protein (P=0.29) and ATG13 (P=0.079), while it has a significant decrease in DLP1 (P=0.002).
Conclusion: It seems that MIIT, through decreasing DLP1, can have a beneficial effect on energy metabolism and autophagy process in order to optimize cells mitochondria in the soleus muscle of diabetic rats.

Factors affecting the interest of specialized assistants to continue studying in subspecialized fields: a brief report

Fatemeh Karami Robati

Background: Choosing a specialty in medicine is an important decision for the individual. It is also important decision for the health system. This study aimed to investigate the factors affecting the interest of specialized assistants to continue studying in subspecialized fields.
Methods: This descriptive cross-sectional study investigated the factors affecting the interest of 261 specialized assistants to continue their studies in subspecialized fields from March 2021 to March 2022. All the specialized assistants of Kerman University of Medical Sciences (KMU), whose assistantship continued until the end of March 2022, were included in the study by census method. The data collection tool was a 4-part questionnaire. 1) demographic information including 13 questions (age, gender, marital status, city where the family lives, place of residence to complete the residency course, specialized field, level of education, grade point average, parents' education, parents' occupation and having first-degree relatives with subspecialized degrees), 2) the willingness or unwillingness to continue studying in subspecialized fields and the field of interest, 3) the reasons for the assistants' interest in continuing their education, included 14 questions, and 4) the reasons for the assistants' lack of interest in continuing their education, included 14 questions.

Results: The average age of the assistants was 31.53±3.90 years old. Most of the assistants were women (57.9%). 57.5 percent of the assistants were interested in continuing their studies in subspecialized fields. The most important reason for residents' interest in continuing their studies was "increasing practical-clinical knowledge" (80.1%). The most interest in continuing education was observed in internal assistants (17.33%). The assistant's age, specialist field and having first-degree relatives with a subspecialist degree had a significant relationship with the interest of the assistants to continue studying in subspecialist fields.
Conclusion: The results showed that a significant percentage of assistants were interested in continuing their studies in subspecialized fields. Age, the assistant's specialty and having first-degree relatives with a subspecialist degree had a significant effect on this interest.

Grade five liver laceration following cardiopulmonary resuscitation: a case report

Seyed Hassan Seyed Sharifi

Background: Cardiopulmonary resuscitation (CPR) is a potentially life-saving treatment for cardiac arrest but puts the subject at risk for iatrogenic skeletal and soft tissue injuries including the liver. In this study, an elderly patient with grade 5 liver rupture after cardiopulmonary resuscitation following laparotomy is reported.

Case Presentation: A 76-year-old female patient with diffuse abdominal pain that started a week ago and worsened since 2 days ago in the winter of 2024, referred to the emergency room of Imam Ali Bojnurd Hospital. In the examination, the patient met the criteria for shock. Abdominal examination revealed peritonitis. After initial resuscitation and stabilization of the patient's condition, an X-ray was performed for the patient. According to the Standing chest x-ray, pneumoperitoneum report, the patient underwent surgery with midline incision. In the performed surgery, evidence of gangrene and perforated was evident in a part of the small intestine, and The patient is a candidate for resection of the gangrenous and perforated intestinal segment, and then the two proximal and distal ends of the resected area were removed as an ileostomy from the right side of the abdomen. At the end of surgery, before closing the abdominal wall, the patient suffered a cardiac arrest, and CPR was started for the patient in operation room. After starting the chest massage, the patient suffered a grade 5 liver tear, the bleeding of the liver was stopped by packing with four Large Abdominal pads and CPR continued for 45 min, but unfortunately the patient died.
Conclusion: One of the rare complications of cardiopulmonary resuscitation and chest massage is visceral damage, including liver rupture. Considering that its symptoms are similar to cardiac arrest, it is difficult to diagnose in case of rupture and has a high mortality rate. According to the reports of liver and visceral damage after CPR, some studies have recommended the use of Focused Assessment with Sonography for Trauma (FAST) to detect visceral damage after CPR.