Tehran University Medical Journal

An evaluation of treatment volume coverage and dose delivered to vital organs in the management of low-grade brain gliomas using three-dimensional conformal radiotherapy (3DCRT) compared to intensity-modulated radiation therapy (IMRT)

Ehsan Saraee

Background: Gliomas are the most common primary brain tumors in adults, with low-grade gliomas making up 15% of cases. These slow-growing tumors often occur in young adults. Radiotherapy is one of the treatment options. New radiotherapy techniques like IMRT may reduce complications by sparing normal tissue. The study aims to determine which tumors benefit most from IMRT based on tumor location and size.
Methods: Patients diagnosed with low-grade glioma who were referred for treatment at the Cancer Institute of Imam Khomeini Hospital between September 2017 and September 2020 were included in this study. All patients underwent CT simulation with a thermoplastic mask for immobilization. A diagnostic MRI (performed within two weeks prior) was fused with the planning CT to define the target volume (GTV/CTV), with contours verified by a neuroradiologist. A doctor outlines the treatment volume and critical organs for both 3D and IMRT techniques. Radiotherapy physics experts design treatment plans using both techniques, which are then approved by a radiation oncologist. The treatment volume coverage and doses to critical organs are compared between the two techniques.
Results: Among 25 patients, 14 patients (56%) with single-lobe involvement, 7 (28%) with two lobes, and 4 (16%) with multifocal disease. Right-side brain involvement was seen in 32%, with the frontal lobe most affected. IMRT significantly reduced the mean and maximum cochlear dose on the treatment side in all patients. It also lowered the mean chiasma dose in those with both lobes involved and reduced cochlear dose on the opposite side in frontal lobe cases. No significant difference was found between the techniques for patients with multiple lobe involvement.
Conclusion: According to our study on 25 patients with low-grade glioma, it was shown that there is no clear difference between the two techniques. Given the young age and long survival of LGG patients, IMRT may be preferred when hearing preservation is a priority. Further studies with larger cohorts are needed to confirm these findings.

Predictive value of early changes in serum β-HCG levels for treatment failure with single-dose methotrexate in tubal ectopic pregnancy

Afsaneh Amirabi

Background: Ectopic pregnancy (EP) is a leading cause of maternal mortality globally. Early diagnosis and treatment has been associated with reduction in maternal mortality and has shifted treatment to conservative methods. The most widely used drug for Medical treatment is methotrexate (MTX). This study aimed to investigate the predictive value of early changes (day 1/4) in serum β-HCG levels in managing tubal pregnancy with single-dose MTX.
Methods: In this cross-sectional analytical study, 135 eligible women with tubal pregnancy who received a single dose of methotrexate, were included. Methotrexate was administered intramuscularly (50 mg/m²), and serum β-HCG levels were measured on days 1, 4, and 7 following the injection. The percentage change in serum β-HCG levels compared to the initial values was calculated. Treatment failure was defined as the need for surgery and/or additional dose of methotrexate.
Results: The treatment success rate was 67% while the treatment failure rate was 33%. Among patients whose β-HCG levels increased on day 4 compared to day 1, the treatment failure rate was 86%. In contrast, for patients with decreased β-HCG levels, the failure rate was only 19%. The changes in β-HCG levels from day 1 to day 4 indicated that a decrease of less than 20% in β-h-CG levels on day 4 compared to day 1 was associated with a sensitivity of 72.2% ( CI95%: 62.2% to 82.4%) and a specificity of 80% (CI95%: 66.18% to 89.1%). This change in β-HCG levels also exhibited a positive predictive value of 60% and a negative predictive value of 88% for predicting treatment failure.
Conclusion: Based on the findings of this study, changes in β-HCG levels on days four and seven may serve as predictive factors for the failure of single-dose methotrexate treatment in patients with tubal pregnancy.

Evaluation of the accuracy of MAGIC polymer gel dosimeter in measuring dose in small electron fields in radiotherapy

Abbas Haghparast

Background: Recent advances in modern radiotherapy techniques such as Intensity-Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS) have significantly increased the need for accurate and reliable dosimetry in radiation therapy. Accurate dose delivery is particularly critical in small electron fields, which are increasingly used in targeted treatments. However, these fields pose unique challenges due to factors such as electron disequilibrium, increased lateral scatter, and steep dose gradients. These physical characteristics can introduce significant uncertainties in dose distribution, thereby reducing the effectiveness and safety of the treatment if not properly accounted for. Traditional dosimeters often struggle to maintain accuracy under such conditions. The aim of this study was to evaluate the performance of MAGIC polymer gel as a three-dimensional (3D) dosimeter in small electron fields and to compare its dosimetric characteristics with standard dosimeters including diode, semiflex, and pinpoint.
Methods: This experimental and applied study was conducted at the Radiotherapy Department of Imam Reza Hospital, Kermanshah, Iran, over a one-year period from December 2022 to December 2023. Five electron field sizes (2×2, 2.5×2.5, 3×3, 4×4, and 5×5 cm²) were generated using an Elekta linear accelerator at two electron beam energies of 6 and 9 MeV. MAGIC polymer gel phantoms were irradiated accordingly and scanned with a 1.5 Tesla MRI system to obtain three-dimensional dose distributions. These were compared to measurements obtained from diode, semiflex, and pinpoint dosimeters.
Results: The depth dose curves of MAGIC gel exhibited greater agreement with diode measurements compared to those from semiflex and pinpoint detectors. As field size decreased and beam energy increased, discrepancies in absorbed dose readings between different dosimeters became more apparent. These results underscore the importance of selecting appropriate dosimetric tools for accurate dose evaluation in small-field electron beams.
Conclusion: MAGIC polymer gel demonstrated strong potential as a reliable 3D dosimeter for small electron field dosimetry, showing the highest compatibility with the diode dosimeter.

Diagnosing the severity of non-alcoholic fatty liver disease based on explainable artificial intelligence

Ahmad Shalbaf

Background: Nonalcoholic fatty liver disease (NAFLD) represents a growing global health burden, strongly associated with rising rates of obesity, diabetes, and metabolic syndrome. This study introduces a machine learning framework to precisely diagnose NAFLD, classify disease severity, and stratify risk using routine clinical data. Our model improves early detection and risk prediction, supporting evidence-based clinical decisions. Leveraging predictive analytics, this scalable approach identifies high-risk patients and enables personalized interventions. The data-driven strategy optimizes NAFLD management by extracting maximal value from standard healthcare records, delivering both clinical and operational advantages.
Methods: This study examined 181 NAFLD patients across disease stages. The dataset was compiled from February 2010 to January 2019 at Eheim University Hospital, comprising general volunteers who were diagnosed with or without fatty liver based on histopathological evaluation of liver biopsy samples. Forward selection and mutual information identified predictive features, applied in classification models (e.g., random forest) to assess steatosis severity. Explainable AI (XAI) improved model interpretability. Combining robust feature selection, machine learning, and XAI ensured accurate, clinically actionable NAFLD severity evaluation.
Results: The XGBoost classifier with forward feature selection attained a classification accuracy of 69.23%±5.5% for steatosis severity. Interpretability analysis highlighted age, Body Mass Index (BMI), High-Density Lipoprotein (HDL), Low-Density Lipoprotein (LDL), A1c Hemoglobin (HbA1c), and glutamate pyruvate transaminase (GPT) as the most impactful variables across three severity classes. Furthermore, GPT, age, BMI, HDL, HbA1c, LDL, triglycerides, and cholesterol were critical to model performance, emphasizing their diagnostic significance in NAFLD progression. These findings suggest their utility in clinical assessments and risk stratification.
Conclusion: This study developed a machine learning model for accurate NAFLD diagnosis and severity stratification using routine clinical data. Accessible biomarkers reliably predicted disease progression, enabling gastroenterologists to facilitate early intervention. This cost-effective approach reduces healthcare costs while improving outcomes through precision medicine. Implementing such predictive tools in clinical practice could optimize resource allocation and enhance long-term NAFLD management. The framework supports timely diagnostics and targeted therapies, advancing patient-centered care.

Comparison of endotracheal intubation and laryngeal mask airway methods based on dynamic compliance and airway resistance

Majid Vatankhah

Background: This study was designed to compare the effects of using a laryngeal mask airway (LMA) and endotracheal intubation on airway resistance and compliance in patients undergoing orthopedic surgery under general anesthesia. Evaluating these two methods is crucial for improving respiratory quality and reducing complications related to airway management in patients.
Methods: This analytical cross-sectional study was conducted on 50 patients undergoing orthopedic surgery under general anesthesia at Hospital in Bandar Abbas between May and September 2024. The patients were equally divided into two groups: the first group received a laryngeal mask airway (LMA), while the second group underwent endotracheal intubation under general anesthesia. The primary variables, including airway resistance and compliance, were measured at 0, 15, 30, and 60 minutes after anesthesia induction. Demographic characteristics such as age, gender, and ASA class were also recorded. Data analysis was performed using SPSS version 21, with descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistical tests (Mann-Whitney U test and Chi-square test), considering a significance level of P<0.05.
Results: The findings of the present study showed no statistically significant differences between the two groups regarding age distribution and ASA class. A comparison of airway resistance and compliance between genders revealed no significant differences at 0, 15, 30, and 60 minutes. There was no significant difference between the two anesthesia groups (laryngeal mask airway and endotracheal tube) in terms of age distribution. There was no statistically significant difference in ASA classification between the two anesthesia groups. At minute 0 of anesthesia, airway resistance was significantly higher in the endotracheal intubation group compared to the LMA group (P<0.001). At 30 and 60 minutes of anesthesia, airway resistance remained significantly higher in the endotracheal intubation group (P<0.001). Airway compliance was significantly higher in the LMA group at all measured time points (0, 15, 30, and 60 minutes) compared to the endotracheal intubation group (P<0.001).
Conclusion: The results of this study demonstrated that using a laryngeal mask airway (LMA) compared to endotracheal intubation leads to improved airway compliance and reduced airway resistance during anesthesia. These findings may influence the selection of anesthesia methods and enhance postoperative care quality.

Comparison between two methods of sedation with ketamine and sedation with ketamine combined with local anesthesia in repairing finger injuries in children

Behrang Rezvani Kakhki

Background: Controlling pain and anxiety in children is important and at the same time more difficult compared to adults. In the present study, an attempt has been made to reduce the overall dose and, as a result, the complications caused by ketamine by adding local anesthesia with lidocaine after analgesia and intravenous sedation with ketamine.
Methods: A double-blind, randomized clinical trial was carried out at the emergency ward of Khatam Al-Anbia Hospital, Zahedan, between June 2018 and March 2019. A total of 60 children with finger injuries with the age range of 1 to 5 years were divided into two groups of 30 people by random block method. The control group was injected with only intravenous ketamine at a dose of 1.5 mg/kg, and the intervention group was injected with local anesthesia with lidocaine after the injection of intravenous ketamine. Data analysis was performed using SPSS software (version 21) with descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistical tests (Student’s t-test, chi-square test, and Mann-Whitney U test) at a significance level of P<0.05.
Results: The recovery time in the intervention group (29.27±9.48 minutes) was significantly less than the control group (35.90±10.59 minutes) (P=0.01). No significant cardiopulmonary complications occurred in the two groups. The incidence of vomiting (P=0.08) and the drop in blood oxygen saturation percentage (P=0.3) were higher in the control group than in the intervention group, but it was not statistically significant. Adding local anesthesia to intravenous injection of ketamine significantly delays the duration of the second repetition of ketamine injection (P=0.01), But it did not affect the time of the first and third repetition of ketamine dose.
Conclusion: The findings of this study indicate that the intervention group required significantly fewer ketamine doses than the control group. Notably, adjunctive lidocaine local anesthesia was associated with shorter recovery times and prolonged intervals before second-dose ketamine administration, while no such effects were observed for the first or third doses. These results imply that lidocaine supplementation could optimize intravenous ketamine therapy by accelerating recovery and reducing subsequent dose requirements, though additional research is needed to validate these observations.

Investigation of risk factors for death in heart failure patients at Shahid Mustafa Khomeini Hospital

Hossein Moradkhani

Background: Chronic heart failure (CHF) is a leading cause of cardiovascular mortality and hospitalization. Heart failure (HF) imposes both direct costs to healthcare systems and indirect costs to society through complications, unpaid care costs, premature mortality, and loss of productivity. The aim of the present study was to investigate the quality of care, laboratory and clinical indicators affecting mortality in heart failure patients.
Methods: In a descriptive study conducted in the summer of 1402, data were collected by extracting the list of patients who died with a diagnosis of heart failure from the hospital's information management system, based on random sampling, and recorded in a checklist. The number of patients selected was from a study of factors affecting mortality in heart failure patients at Shahid Mustafa Khomeini Hospital.
Results: 25.8% of patients had bilateral rales on pulmonary auscultation, and 88.7% of them reported shortness of breath, 58.1% edema, and 22.6% chest pain. LVEF of most patients was 10-25. With a decrease in systolic blood pressure and an increase in diastolic and HR, the probability of mortality increased significantly (1.058, 0.932, and 0.983) times, respectively. With a decrease in oxygen level, the probability of mortality increased significantly by 0.983 times. The mean ALT and AST increased significantly and the mean HCT also decreased significantly. With each unit increase in ALT and AST and each unit decrease in Hct, the probability of mortality increased (1.008, 0.985 and 1.283) times, respectively. With the decrease in Hb and FBS and the increase in Cr and BUN, the probability of mortality increased by 0.314, 1.013, 1.884 and 0.969 times, respectively. However, no significant relationship was observed between mortality and the factors Hb, FBS, Cr and BUN with patient mortality.
Conclusion: Dyspnea and edema were common in patients, and bilateral rales and chest pain were observed in less than half of the patients. A decrease in systolic blood pressure and an increase in diastolic and HR significantly increased the probability of mortality. A decrease in oxygen levels also significantly increased mortality in patients.

The effect of eight weeks of high-intensity interval training on carcinoembryonic antigen, quality of life, and sleep quality in female colorectal cancer survivors

Hosna Moradi

Background: With the rising survival rates among individuals with colorectal cancer, improving quality of life and reducing the risk of recurrence have become key priorities in supportive care. High-intensity interval training (HIIT), due to its pronounced effects on physical function, inflammatory markers, and tumor-related indicators, has emerged as a promising intervention. This study aimed to evaluate the effect of an eight-week high-intensity interval training (HIIT) program on serum carcinoembryonic antigen (CEA) levels, quality of life, and sleep quality in female survivors of colorectal cancer.
Methods: This quasi-experimental study employed a pretest-posttest control group design and was conducted from July to September 2021 at the Kosar Women’s Sports Complex in Kermanshah, Iran. Twelve female colorectal cancer survivors (mean age=55.66±4.99 years) were randomly assigned to either an experimental (n=6) or control group (n=6). The experimental group participated in a supervised HIIT program for eight weeks. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), and quality of life was evaluated using the World Health Organization Quality of Life (WHOQOL) questionnaire.
Results: Post-intervention analysis revealed a non-significant increase in CEA levels in the experimental group (mean±SD: 2.49±0.79; CI95%: 1.66-3.33; P=0.456), while the control group showed a statistically significant reduction (mean±SD: 1.04±0.22; CI95%: 0.84-1.25; P=0.044). However, significant improvements were observed in both sleep quality (mean±SD: 5.00±2.19; CI95%: 3.27-6.72; P=0.027) and quality of life (mean±SD: 77±9.40; CI95%: 84.11-88; P=0.028) within the experimental group. No significant changes were reported in the control group for either variable.
Conclusion: Findings suggest that high-intensity interval training may serve as an effective non-pharmacological intervention for enhancing sleep quality and overall quality of life in female colorectal cancer survivors. Nevertheless, the effects of HIIT on biological markers such as CEA require further investigation through larger and longer-term studies.

Fertility following bilateral varicocelectomy and resection of ejaculatory duct obstruction: a case report of infertility treatment after twenty years: a case report

Hossein Hakimelahi

Background: Varicocele, defined as an abnormal enlargement and tortuosity of the veins in the pampiniform plexus, is the most common cause of correctable male infertility that might increase chance of fertility even in presence of further male factor infertility causes. While it is well known to be reason of fertility in male and is easy to treat, here we present a case with 20 years of infertility due to missed opportunity of varicocelectomy.
Case Presentation: A 39-year-old male patient with a family history of infertility for about 20 years was referred for azoospermia and stated that after two testicular biopsies and failure to obtain sperm in one of the equipped infertility treatment centers, he was recommended to receive a donated embryo, but he wanted to have his biological child genetically. In the history taken, he had a history of mild left varicocele and no other clinical problems, and mild bilateral varicocele was evident on examination. Karyotype and Y chromosome examination were normal, and hormonal tests and gonadotropin and testosterone levels were within normal limits. Semen volume was 1 ml in two tests one month apart, and semen was alkaline. The patient underwent microscopic bilateral varicocelectomy with an inguinal incision. The patient underwent fluoroscopy, vasography, which showed distal dilatation of both Vas deferens. Diluted methylene blue solution was also injected into the vas deferens and Folley was fixed. But the urine color did not turn blue, so the patient's position was changed to lithotomy and the patient underwent resection of the ejaculatory duct via the urethra, that is the Verumontanum was resected with a cautery-cutting cautery. Three months later, the patient presented with a completely normal semen analysis. The patient was advised to try to conceive at least four months after the operation. Two months later, pregnancy occurred again, and after 9 months, a healthy male fetus was born by cesarean section.
Conclusion: This study demonstrates that varicocele treatment can significantly improve fertility parameters and enhance the chances of successful conception in affected patients. The most important suggestion of this case report is to highlight the importance of timely diagnosis and treatment of varicocele as a correctable cause of male infertility. Unfortunately, our patient suffered from infertility for 20 years due to not undergoing varicocelectomy. Even obstruction treatment may not necessarily be needed in this case, as a sole varicocelectomy might make sperm extraction possible for further in vitro procedures.

Health of policy making as a prerequisite for health policy making: letter to the editor

Ali Mohammad Mosadeghrad