Tehran University Medical Journal

Relation between Helicobacter pylori Infection and gastrointestinal cancer by IL-21, and IL-23: a review article

Fatemeh Kiaee

Background: Helicobacter pylori (H. pylori) infection is the most common infection worldwide and results in chronic gastritis, and rarely gastric carcinoma. Chronic inflammation, which is a major engine of disease development. Is dominantly controlled by adaptive and humoral immunity. This study reveals the intricate IL-21 and IL-23 relationship in H.pylori associated diseases as well as inflammatory GI disorders, as the crtically govern the differentiation and activity of T helper 17 (TH17) cells in the gastric mucosa. Understanding these cytokines pathways is essential for comprehending the immune pathogenesis of H. pylori infection and its outcome.
Methods: A literature search was conducted in the PubMed database using the MESH keywords "Helicobacter pylori" "Interleukin 21," "Interleukin 23," and "gastric cancer" to identify relevant English-language studies. Articles that were reviews, case reports, or letters to the editor were excluded.
Results: IL-23 significantly exacerbates both intestinal and gastric inflammatory responses by stimulating T cells particularly Th17 cell subsets, through the mediation of STAT3 signaling pathways and reducing IL-10 production, while T cells lacking the IL-23 receptor promote Treg expansion and intestinal homeostasis. IL-21 is implicated in chronic inflammation of the gastric and intestinal mucosa, with elevated levels observed in ulcerative colitis patients, contributing to the recruitment of inflammatory cells, increased inflammation, and angiogenesis. This particular cytokine plays an essential role in the recruitment of inflammatory cells, the increase of tissue inflammation, and the promotion of pathological angiogenesis. Moreover, IL-21 exerts influence over B cell differentiation and the production of antibodies, establishing a connection to humoral immune responses within chronic inflammations.
Conclusion: CD4+ T helper 17 (Th17) cells exhibit both antimicrobial and pathogenic immune functions in the gastrointestinal environment. These processes are interconnected, as cytokines such as IL-21 and IL-23 are essential for Th17 cell maintenance and support humoral immune responses. A comprehensive understanding of the dynamic immunological interactions in H. pylori-related and inflammatory gastrointestinal diseases may facilitate the development of novel immunology-based therapeutic interventions.

Investigation of immunohistochemical markers in pathological samples of patients with pituitary neuroendocrine tumors

Shahram Sabeti

Background: This study aimed to investigate the markers ACTH, KI67, CAM5.2, GH, PRL, FSH, LH, TSH in pathological samples of patients with pituitary neuroendocrine tumors by IHC staining.
Methods: In this retrospective study, all patients with PitNETs who had undergone surgery at Loghman Hospital from 2020 to 2022 were included in the study. The slides were prepared by IHC staining and with the markers ACTH, KI67, CAM5.2, GH, PRL, FSH, LH, TSH were evaluated. IHC staining for SF1-PIT1-TPit transcription factors was performed for 16 patients with negative initial markers.
Results: 424 patients participated in this study. The mean and standard deviation of the age of the patients studied were 43.7 and 13.7 years, respectively. LH and FSH markers had the highest and TSH marker had the lowest proportion of positive cases. The possibility of LH and FSH markers being positive in men was significantly higher than in women, and conversely, the possibility of GH and ACTH markers being positive in women was significantly higher than in men. The possibility of LH and FSH markers being positive in patients over 40 years of age was significantly higher than in patients 40 years of age and younger, and conversely, the possibility of GH and PRL markers being positive in patients 40 years of age and younger was significantly higher than in patients over 40 years of age. Most cases (66.3%) were treated during the follow-up period.
Conclusion: The findings indicate that accurate pathological identification of tumors plays an important role in the selection of treatment methods, especially drug and surgical treatment, and can lead to improved patient management.

Studying the effect of intravenous dexmedetomidine on hemodynamic parameters in patients undergoing septorhinoplasty surgery

Mojtaba Ghaedi

Background: Hemodynamic instability is a significant perioperative complication that can threaten surgical outcome through various mechanisms: exacerbating intraoperative bleeding, compromising visibility of the surgical field, and elevating immediate and delayed postoperative complication risks. In septorhinoplasty, a procedure with challenging hemodynamic control due to the nasal anatomy's complexity of vessels, these effects are particularly relevant. This study examines the modulation of important hemodynamic parameters (SBP, DBP, MAP, HR, and SpO₂) by intravenous dexmedetomidine while ensuring cardiovascular stability and dose-dependent effects and optimal timing of administration at different phases of surgery. The findings aim to offer evidence-based recommendations for hemodynamic control in rhinoplasty surgery, which can reduce rates of complications and improve recovery profiles.
Methods: A randomized, double-blind clinical trial was conducted involving 50 eligible patients (aged 18-45 years) scheduled for septorhinoplasty at Ostad Motahari Hospital, Jahrom, during May-September 2023. Participants were randomly allocated to either a dexmedetomidine or control group. Collected data encompassed demographic characteristics (age, gender, BMI=Body mass index) and hemodynamic parameters (systolic/diastolic blood pressure, mean arterial pressure, heart rate, and oxygen saturation). The data were analyzed using SPSS software, version 21 (SPSS Inc., Chicago, IL, USA). Descriptive statistics (mean, standard deviation, percentage, count, and frequency) and inferential statistical tests (Mann-Whitney U test and independent t-test) were applied. A significance level of P < 0.05 was considered for all statistical analyses.
Results: The dexmedetomidine group demonstrated statistically significant variations in hemodynamic parameters (SBP, DBP, MAP, HR) from pre-induction through post-recovery phases (p<0.001). Significant between-group differences in blood pressure metrics were observed at all measured intervals following induction (1, 5, 15, 30, 60 minutes) and during recovery periods (p<0.05), with the dexmedetomidine group consistently showing lower values. Comparison between the intervention and control groups revealed no statistically significant differences in heart rate and oxygen saturation (O₂ sat) levels (except during recovery time).
Conclusion: The results of this study indicate that dexmedetomidine administration had a significant effect on reducing systolic blood pressure, diastolic blood pressure, and MAP compared to the control group, with this reduction being evident at all measured time points from post-induction to post-recovery. These findings suggest that dexmedetomidine can be effectively used as a blood pressure-lowering agent during surgery without significantly affecting heart rate or the patient's blood oxygen levels.

Frequency types of ocular side effects of anti-TNF-α drugs in patients with rheumatic diseases

Maedeh Ekhtelat

Background: Autoimmune inflammatory diseases, which are often associated with severe and chronic complications, affect approximately 7.6-9.4% of world's population. The present study was conducted with the aim of investigating the frequency of ocular side effects of anti-TNF-α drugs in patients with rheumatic diseases.
Methods: In this analytical epidemiological study, 122 patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis who were treated with TNF-α inhibitory drugs (including Infliximab, Adalimumab and Etanercept) referred to Golestan Hospital of Ahvaz, Iran, in 2019-2022 were examined. Ocular complications including anterior uveitis, macular edema, anterior ischemic optic neuropathy, diplopia with paired neurological involvement, anterior uveitis with diplopia and keratitis sicca were evaluated by an ophthalmologist after six months of treatment with TNF-α inhibitory drugs. Infliximab was used on day zero, week two and four, and then every 6 to 8 weeks with a dose of 3 to 5 per kilogram of body weight. Adalimumab dosage was 40 mg every other week and Etanercept was taken at a dose of 50 mg weekly.
Results: From 122 patients, 59 (48.36%) and 36 (29.51%) had rheumatoid arthritis and ankylosing spondylitis, respectively. Among 7.38% of reported ocular complications, anterior uveitis was the most common complication (3.28%). Type of anti-TNF-α drug had no significant correlation with the occurrence of ocular complications and eye complications were mainly observed in patients who used etanercept, but there was no significant difference compared to the other two drugs (P=0.1). The mean duration of disease in patients with and without eye complications was 5.47±4.13 and 3.22±2.58 years, respectively (P=0.03). No significant relationship was observed between the duration of anti-TNF-α drugs use and eye complications (P=0.66).
Conclusion: Given the higher incidence of ocular complications in patients taking etanercept, as well as the significant association between the duration of the disease and the occurrence of ocular complications, monitoring long-term treatment and follow-up of rheumatic patients taking anti-TNF-α drugs is of great importance.

Investigating the frequency of anterograde amnesia after endoscopy with midazolam as a premedication

Mehrdad Sayadinia

Background: Endoscopy is a common medical procedure that often involves the administration of sedative agents to ensure patient comfort and cooperation. Midazolam, a short-acting benzodiazepine, is commonly used as a premedication for its anxiolytic and amnestic properties. Despite its widespread use, there is limited research specifically assessing the occurrence of anterograde amnesia, a potential side effect associated with midazolam administration during endoscopic procedures. Understanding the frequency of this adverse effect is crucial for optimizing patient safety and procedural outcomes.
Methods: In this prospective cohort study After obtaining approval and ethical clearance, patients eligible for endoscopy at Bandar Abbas Shahid Mohammadi Hospital were included in the study. They received 2mg midazolam intravenously before the procedure, followed by propofol for anesthesia maintenance. A memory test involving personal details was conducted before and after the procedure to assess progressive amnesia. Additionally, patients were asked about the procedure 5 minutes before discharge.
Results: 342 endoscopy candidates participated, with an average age of 46.77 years, over half being men. Less than a quarter had a diploma. Average endoscopy time was 2.96 minutes, mostly ASA class 2. Recall scores after midazolam injection and endoscopy were 5.22 and 2.87, respectively. Post-graduate education showed a significant difference in midazolam amnesia. No significant gender difference was observed. Longer endoscopy duration correlated with decreased recall scores. ASA class 2 patients had lower post-endoscopy recall scores than ASA class 1. Recall scores decreased with age, with the highest in the 19-29 age range, a statistically significant finding.
Conclusion: This study In conclusion, this study provided valuable insights into the factors influencing midazolam anterograde amnesia. Key findings include a significant association between higher education levels, particularly post-graduate education, and increased recall scores after midazolam injection. Gender did not show a significant impact on midazolam amnesia, but the duration of endoscopy played a crucial role. Additionally, patients in ASA class 2 exhibited lower recall scores than those in class 1, highlighting the influence of overall health status. Age also emerged as a factor, with the youngest age group showing the highest recall scores after endoscopy. These findings contribute to our understanding of factors affecting midazolam-induced amnesia during endoscopy procedures.

Clinical and paraclinical findings of patients with a diagnosis of acute pancreatitis and its related factors

Ramyar Rahimi Darehbagh

Background: Acute pancreatitis is a common and challenging disease that can develop local and systemic complications. It is divided into biliary and non-biliary pancreatitis, based on ultrasonographic findings. This study aimed to evaluate the clinical and paraclinical findings of patients with acute pancreatitis and related factor.
Methods: This cross-sectional study included all patients hospitalized with a diagnosis of acute pancreatitis in Besat and Towhid hospitals of Sanandaj from March 2016 to March 2018. All patients admitted with a confirmed diagnosis of acute pancreatitis during the mentioned period were enrolled. Inclusion criteria were a definitive diagnosis of acute pancreatitis based on clinical features (characteristic abdominal pain), laboratory findings (serum amylase or lipase elevated more than three times the normal level), and/or imaging evidence. Patients with chronic underlying conditions such as diabetes, chronic renal or hepatic failure, advanced cardiac disease, or neoplasms were excluded to reduce confounding effects.
Results: Of the 150 patients, 89 were female (59.33%), and 61 were male (40.67%). The mean age of the patients was 53.11 years old. 62% of patients had biliary pancreatitis, and 38% had non-biliary. The prevalence of alcoholic pancreatitis in the population was 5.33%. The age of people with biliary pancreatitis was more than non-biliary. According to Ranson's criteria, 6% of patients had severe acute pancreatitis, all of whom were over 60.
Conclusion: Acute pancreatitis was more prevalent among women, particularly in the fifth decade of life, with gallstones being the leading cause. Patients with biliary pancreatitis were significantly older, and advanced age was associated with increased disease severity. Moreover, blood glucose, AST, and LDH were significantly higher in severe cases. These findings highlight the importance of early diagnosis, accurate severity assessment, and special attention to elderly patients and those with biliary pancreatitis to reduce complications and improve clinical outcomes.

Evaluation of serum amylase levels in hospitalized COVID-19 patients and its association with disease prognosis

Neda Faraji

Background: This study aimed to evaluate serum amylase levels in hospitalized COVID-19 patients and investigate its association with disease prognosis. Elevated serum amylase levels have been reported in some COVID-19 patients, particularly in severe cases. This increase may indicate pancreatic involvement (pancreatitis) due to viral infection. This cross-sectional study aimed to evaluate the role of serum amylase levels as a prognostic marker in COVID-19 patients.
Methods: This descriptive cross-sectional study was conducted on 150 hospitalized patients with confirmed COVID-19 at Baharloo Hospital, Tehran, over a one-year period (July 2021–July 2022). The results showed that 20% of patients (30 out of 150) had elevated serum amylase levels. Patients with high amylase levels had significantly longer hospital stays (mean 14 days vs. 8 days) and higher mortality rates (15% vs. 5%). Additionally, these patients were more likely to require intensive care (25% vs. 10%). Statistical analysis revealed that elevated serum amylase levels were independently associated with poorer clinical outcomes.
Results: These results have important clinical implications for patient management. Routine measurement of serum amylase at admission could help identify high-risk patients who may benefit from closer monitoring and early intervention. Further research is needed to determine whether specific treatments for pancreatic involvement could improve outcomes in these patients.
Conclusion: These findings suggest that measuring serum amylase levels at admission can serve as a simple and accessible marker for identifying high-risk patients. Elevated amylase in COVID-19 patients is an important biological indicator of multi-organ involvement (pancreas and kidney) and severe inflammation, which is associated with worse prognosis and higher mortality. Monitoring this marker may aid clinical decision-making and improve patient outcomes

Frequency of cytomegalovirus in patients with chronic lymphocytic leukemia: a brief report

Farkhondeh Ajdari

Background: The exact cause chronic lymphocytic leukemia (CLL) is still unknown. Cytomegalovirus (CMV) may play a role in the development of CLL, Therefore, the aim of this study is to investigate the frequency of CMV in patients with CLL and its relationship with blood and genetic factors.
Methods: This cross-sectional study was conducted between April 2020 and October 2022 on 40 CLL patients that referred to Dr. Daneshbod Pathobiology Laboratory (Shiraz, Iran). After taking blood and separating the buffy coat, viral DNA was extracted using a commercial DNA extraction kit and the CMV burden was measured using Real-time PCR assay. Moreover, a blood cell count test was performed. The amount of lactate dehydrogenase of the serum was measured using the kit. Also, common chromosomal disorders and CD38 marker related data were extracted from the file patients. SPSS software and Student's t-test were used to result analysis.
Results: The mean age of the patients was 62.25 ± 10.49 years. Of the 40 patients, 28 were men (70%). The average number of white blood cells was 46.06±1.49* 10⁹, which was significantly higher in women than in men (p=0.031). Real-time PCR results showed that two patients (5%) have detectable amounts of CMV virus genome. The level of lactate dehydrogenase, CD38 marker, and the number of malignant cells in male and female patients did not differ significantly (p=0.362). Moreover, chromosomal abnormalities include deletions in 11q (ATM) and 17P (TP53), were observed in 3 (7.5%) and 4 (10%) patients, respectively.
Conclusion: Our finding indicated the CMV might not involve in the pathogenesis of CLL disease. More studies are recommended for clarify this finding.

Congenital tuberculosis in a two-month-old infant presenting with respiratory distress: a case report

Mohammadreza Abdolsalehi

Background: Congenital tuberculosis is a rare but serious disease in neonates and infants that often presents with nonspecific respiratory symptoms. Pulmonary involvement in tuberculosis can have similar manifestations to bacterial pneumonia with common microorganisms. In case of failure to respond to treatment in pneumonia, tuberculosis infection should be considered. The aim of this study was to present a two-month-old infant suspected of bacterial pneumonia, who was ultimately diagnosed with tuberculosis.
Case Presentation: This case report describes a two-month-old infant diagnosed with tuberculosis who presented to the emergency department with severe respiratory distress. Despite repeated hospitalizations and initial antibiotic therapy, the patient's symptoms did not improve and he was eventually referred to the Children's Medical Center. Chest radiography showed diffuse reticular opacities, alveolar opacities in the lower lobe of the right lung, and parahilar opacities in the left lung. Initial laboratory tests included elevated CRP and ESR levels, elevated white blood cell count, thrombocytosis, and abnormal arterial blood gases. Despite three negative gastric aspirate samples for tuberculosis, bronchoscopy was performed and a Bronchoalveolar Lavage (BAL) sample was sent for Polymerase Chain Reaction (PCR) testing for Mycobacterium tuberculosis, which was positive, confirming the diagnosis of tuberculosis. Careful evaluation of the parents revealed that although they had no respiratory symptoms, the mother had imaging evidence of tuberculosis, and her AFB test was positive. The patient showed significant clinical improvement after starting anti-tuberculosis therapy. A six-month follow-up confirmed complete recovery.
Conclusion: In infants with recurrent pneumonia and failure to respond to initial treatments, tuberculosis should be considered as a possible diagnosis.

Induced Demand in health sector: a letter to editor

Parvaneh Isfahani