Tehran University Medical Journal

Comparison of the benefits and complications of the classic surgical method and the plastic ring method in neonatal circumcision: a systematic review

Background: Neonatal circumcision is one of the most common surgical procedures worldwide, performed for cultural, religious, and health-related reasons. The two primary methods for neonatal circumcision are the classic surgical method (using sutures or clamps such as Gomco or Mogen) and the plastic ring method (e.g., Plastibell). This systematic review and meta-analysis aimed to compare the benefits and complications of these two methods in neonates.
Methods: A systematic search was conducted in PubMed, Scopus, Web of Science, and Google Scholar databases for articles published between 2000 and 2024. Inclusion and exclusion criteria: Included studies included randomized controlled trials (RCTs), cohort studies, and cross-sectional studies that compared the benefits and harms of classical surgery and plastic ring in infants (<28 days). Studies without a comparison group, studies conducted in older children or adults, and articles that did not provide sufficient data were excluded. Keywords included "neonatal circumcision", "plastic ring", "Plastibell", "classical surgery", "Gomco clamp", "Mogen clamp", "benefits", "complications" and their English equivalents.
Studies comparing the benefits and complications of the classic surgical method and the plastic ring method in neonates were included. Data were meta-analyzed using a random-effects model, and risk ratios (RR) with 95% confidence intervals (CI) were calculated.
Results: From a total of 12 included studies (involving 5,342 neonates), the plastic ring method was associated with a significant reduction in bleeding (RR: 0.45; 95% CI: 0.32-0.64) and healing time (mean difference: -2.3 days; 95% CI: -3.1 to -1.5) compared to the classic surgical method. However, the risk of skin adhesion was higher with the plastic ring method (RR: 1.32; 95% CI: 1.05-1.66). Serious complications, such as urethral injury, were rare in both methods (less than 0.2%).
Conclusion: The plastic ring method is a suitable option for neonatal circumcision due to its ease of use, reduced bleeding, and faster healing time. However, careful post-procedural care is essential to minimize the risk of skin adhesion. The choice of method should consider the operator’s expertise and parental preferences.

Investigating the effect of dexmedetomidine and ketamine as adjuvants in supraclavicular block in orthopedic surgeries of the forearm in reducing postoperative pain

Artadokht Khoshooei

Background: Nowadays, there is an increased emphasis on using safer and more modern anesthetic drugs. The addition of adjuvants not only enhances the anesthetic effect of the medication but also reduces the required dosage, thereby improving the safety margin. Effective postoperative pain control is a critical component in enhancing recovery and improving outcomes for orthopedic patients. Proper pain management not only facilitates early mobilization but also reduces complications and increases patient satisfaction. This study aimed to evaluate the impact of dexmedetomidine and ketamine as adjuvant drugs in supraclavicular nerve block for reducing postoperative pain following forearm orthopedic surgery.
Methods: This randomized, triple-blind clinical trial was meticulously conducted between April 2024 and March 2025 at Razi Hospital, a major teaching facility affiliated with Jundishapur University of Medical Sciences in Ahvaz, Iran. A total of 102 eligible patients were carefully enrolled and randomly assigned to three distinct groups: dexmedetomidine, ketamine, and control. Each patient received a standardized supraclavicular block using 2% lidocaine combined with the designated adjuvant drug to enhance analgesic efficacy. Vital signs, including heart rate, oxygen saturation, and Mean arterial pressure (MAP), were closely monitored every 15 minutes during surgery. Postoperative pain intensity was assessed using the Visual analog scale (VAS) at 1, 2, 6, 12, and 24 hours after surgery.
Results: Patients in the dexmedetomidine group showed significantly lower heart rate, MAP, and pain intensity compared to both ketamine and control groups at all measured time points (P<0.001). Ketamine also demonstrated better pain control and hemodynamic stability than the control group, although it was less effective than dexmedetomidine. Most differences in mean values between groups were statistically significant, confirming the superior performance of dexmedetomidine.
Conclusion: Dexmedetomidine, when used as an adjuvant in supraclavicular block for forearm orthopedic surgery, resulted in superior pain relief and greater hemodynamic stability compared to ketamine and standard care. These findings support its clinical use as an effective adjunct in regional anesthesia protocols.

Determining the prevalence of refractive errors among boy students in Asadabad County, Hamedan Province

Ali Ayatollahi

Background: Refractive errors are among the most common and preventable causes of visual impairment in children. Early detection and proper correction are essential to prevent long-term visual complications such as amblyopia and reduced academic performance. The present study aimed to determine the prevalence and distribution patterns of different types of refractive errors among elementary school boys in Hamedan Province, located in western Iran, where limited data are available on this age group.
Methods: This cross-sectional study was conducted between October 2022 and December 2023 on 1053 male students aged 6-12 years, selected through a multistage cluster sampling method covering both urban and rural areas. Examinations included Uncorrected visual acuity (UCVA), Best-corrected visual acuity (BCVA), cycloplegic refraction, cover test, and ophthalmoscopy, all performed by a trained optometrist following a standardized protocol. Based on cycloplegic spherical equivalent refraction, myopia was defined as -0.50 diopter or worse, hyperopia as +2.00 diopter or more, and astigmatism as a cylinder of -0.50 diopter or more. The data were statistically analyzed to explore the association between age and the type of refractive error.
Results: Data from 1027 students were included in the final analysis. The mean age of participants was 9.52±1.63 years. UCVA of 20/40 or worse was found in 16.5% of students, and BCVA of 20/40 or worse in 1.2%. The prevalence rates of myopia, hyperopia, and astigmatism were 6.5%, 5.6%, and 18.9%, respectively. With-the-rule astigmatism was the most frequent type observed. The prevalence of myopia tended to increase with age, while hyperopia showed a decreasing trend.
Conclusion: The findings revealed a relatively high prevalence of refractive errors, particularly astigmatism, among school-aged boys in western Iran. These results emphasize the importance of implementing periodic, school-based vision screening programs and ensuring better access to refractive care services. Promoting awareness among parents, teachers, and health authorities regarding the need for early eye examinations could play a crucial role in preventing avoidable visual impairment and improving children’s visual health and academic success.

Levothyroxine dose determination in pregnant women with and without a history of hypothyroidism and its association with thyroid peroxidase antibody (TPO) antibody levels

Elham Shirvani Naghani

Background: Thyroid disorders are common among young women, and hypothyroidism ranges clinically from subclinical to overt disease, potentially causing various maternal and fetal complications. Determining the appropriate levothyroxine (LT4) dose during pregnancy is crucial for maintaining maternal euthyroidism and optimising pregnancy outcomes. This study aimed to evaluate the dose requirements of LT4 in pregnant women with and without a prior history of hypothyroidism, and to investigate the association with Thyroid peroxidase antibody (TPO) levels.
Methods: This hospital- and clinic-based study was conducted from September 2022 to March 2023 among 146 pregnant women attending a private clinic or Golestan Hospital in Ahvaz, Iran. A total of 146 pregnant women diagnosed with subclinical hypothyroidism (SCH, n=62) or overt hypothyroidism (OH, n=84) were randomly selected. Participants were divided into groups based on their history of hypothyroidism and received LT4 treatment. LT4 requirements were determined according to trimester-specific TSH ranges: >10 mIU/L or 2.5-10 mIU/L in the first trimester, and 3-10 mIU/L in the second and third trimesters. Data analysis was performed using SPSS version 22, employing descriptive statistics (mean±SD, frequency, and percentage) and analytical tests, including the independent t-test and Mann-Whitney U test.
Results: Pregnant women with overt hypothyroidism showed a statistically significant difference in mean LT4 dose between those with and without a prior history of hypothyroidism (P<0.05). In contrast, no significant difference was observed in LT4 requirements among women with subclinical hypothyroidism. TPO Ab positivity was associated with higher LT4 requirements, particularly in women with overt disease. Dose adjustments were most frequent during the first trimester, with incremental increases observed in subsequent trimesters. These findings support individualized monitoring, iodine testing, adherence checks, and coordinated antenatal endocrinology care to improve maternal and neonatal outcomes.
Conclusion: Following the diagnosis of hypothyroidism in early pregnancy, LT4 dosing should be tailored according to disease severity, prior history of hypothyroidism, TPO Ab status, and study location to ensure optimal maternal and fetal outcomes.

Diagnostic value of the long non-coding RNA KCNQ1OT1 in the detection of breast cancer

Background: Breast cancer is the most prevalent malignancy among women and remains a leading cause of cancer-related mortality worldwide. Early detection can markedly improve patient survival, yet existing screening methods often lack sufficient accuracy and sensitivity. lncRNA KCNQ1OT1 has been implicated in the initiation and progression of tumors in several cancers, including breast cancer. This study aimed to evaluate the diagnostic potential of serum lncRNA KCNQ1OT1 expression as a biomarker for early detection of breast cancer.
Methods: This case-control study was conducted at Ahvaz Jundishapur University of Medical Sciences, Shafa Hospital, Ahvaz, Iran, between September 2024 and March 2025. Serum samples were obtained from 30 patients with histologically confirmed breast cancer and 30 healthy women serving as controls. Total RNA was extracted from 500 µL of serum, and cDNA was synthesized using oligo (dT) primers. Real-Time PCR was performed in triplicate, with GAPDH as the internal control. Relative gene expression was calculated using the 2^{^-ΔΔCt} method, and data were analyzed using the Mann-Whitney U test and ROC analysis.
Results: The patient and control groups were homogeneous for most demographic parameters, but showed significant differences in age (P=0.023) and ethnicity (P=0.004). Most patients were in stage I of the disease. The median expression of serum KCNQ1OT1 was significantly lower in patients (0.024, IQR 0.013-0.033) than in controls (0.039, IQR 0.027-0.051), indicating marked downregulation in the patient group (P=0.0003). The ROC analysis yielded an AUC of 0.82 (95% CI: 0.67-0.96, SE=0.07, P=0.0005). At an optimal cutoff value of >0.031, the sensitivity was 70%, the specificity was 95%, and the positive likelihood ratio (LR⁺) ≈ was approximately 14, demonstrating strong discriminative ability.
Conclusion: Serum KCNQ1OT1 exhibits promising diagnostic performance for identifying early-stage breast cancer and may serve as a reliable noninvasive biomarker. Larger multicenter studies incorporating molecular subtyping and tissue correlation are required to validate its clinical applicability and strengthen diagnostic accuracy.

Correlation between serum vitamin D levels and postoperative pain following cholecystectomy at Imam Ali Hospital of Bojnurd

Background: Postoperative pain is a significant concern after cholecystectomy. Given the role of vitamin D in pain management, this study investigated the correlation between preoperative vitamin D levels and postoperative pain severity in patients undergoing laparoscopic cholecystectomy, with the aim of improving pain management and enhancing postoperative care.
Methods: This prospective observational study (January 2024- February 2025) was conducted on 87 patients undergoing laparoscopic cholecystectomy at Imam Ali Hospital of Bojnurd. Inclusion criteria were age 18-45, non-urgent laparoscopic cholecystectomy, and good physical status. Exclusion criteria were chronic pain, regular analgesic use, known psychiatric or neurological disease or treatment, substance abuse, emergency cholecystectomy, or conversion to open surgery. Participants fasted for 12 hours preoperatively. All received 1 g (IV) ceftriaxone one hour before and 12 hours after surgery. Anesthesia was induced with propofol and fentanyl and maintained with isoflurane, nitrous oxide, or oxygen. Anesthesia and surgical technique were standardized, with any deviations recorded. We collected demographic data and extracted perioperative details from records and interviews. Pre-induction venous blood samples were collected, processed, and stored at -20°C. Serum vitamin D concentrations were quantified via ELISA method, and participants were subsequently stratified into two groups based on these measurements. Postoperative pain was assessed on a Visual Analog Scale (0-10) at 6, 12, 18, and 24 hours. Analgesic regimens followed standard protocol under physician supervision and were unaffected by the study.
Results: Lower serum vitamin D levels were associated with higher postoperative pain scores (P<0.01), with this relationship being significant at 6, 12, and 18 hours postoperatively (P<0.01, P<0.01, and P<0.05, respectively). Insufficient vitamin D levels and female gender were also independent risk factors for acute pain after laparoscopic cholecystectomy (P<0.01).
Conclusion: Based on the results of the present study, preoperative vitamin D deficiency is associated with increased postoperative acute pain scores in patients undergoing laparoscopic cholecystectomy, especially in women. These findings may be useful for postoperative pain management in patients with vitamin D deficiency.

Evaluation of the impact of colored filters on visual quality of visually impaired people

Alireza Akbarzadeh Baghan

Background: This study investigates the use of color filters, which represent a scientific and standardized approach to assist individuals with visual impairment. Although there is no fixed protocol for prescribing color filters, these filters, which are often prescribed by ocular care providers in a trial-and-error manner today, help improve visual performance, control glare, and enhance motor skills in affected individuals. Given the absence of formal guidelines and standardized protocols in this area, this study tested common diseases leading to visual impairment against various color filters.
Methods: The study population consisted of patients visiting the Optometry Clinic of Labbafi Nejad Hospital. Participants were voluntarily referred from retinal and corneal departments to this clinic. This quasi-experimental study evaluated acuity at distance and near and contrast sensitivity function with and without color filters, and compared the results. After analysis, filter(s) suitable for each participant were identified and applied clinically, with one-month monitoring and re-evaluation.
Results: A total of 99 participants (54 male, 45 female) with a mean age of 32.19±15.41 years were included. The results showed that after using color filters, distance visual acuity (BCVA) improved significantly in most diseases (P<0.001). However, in albinism and diabetic retinopathy patients, there was no significant improvement in distance vision. At near distance, there was generally a significant improvement in near vision in most diseases after applying the filters (P=0.001). Exceptions included albinism and glaucoma, where no significant difference was observed (P=0.073). For contrast sensitivity (CSF), most patients showed improvement and increased contrast sensitivity (P<0.001), but this increase was not significant in albinism and glaucoma (P=0.483).
Conclusion: The study suggests that the use of certain color filters in visually impaired patients leads to significant improvements in both distance and near acuity and contrast sensitivity function, potentially enhancing quality of life. Based on the quantitative results, selecting the appropriate filter should be disease-specific and done with greater precision. However, the diversity and severity of diseases, the degree of vision loss, and genetic differences among individuals require greater attention to practical experiences and statements from this patient group. Additionally, patients with more than one ocular condition often changed the type and color of the filter.

Comparison of the frequency of delirium in patients requiring anesthesia receiving a Presedex and fentanyl regimen with a midazolam and fentanyl regimen in the intensive care unit

Background: Patients undergoing mechanical ventilation in the intensive care unit (ICU) are at higher risk for delirium. The present study aimed to compare the frequency of delirium in patients requiring anesthesia receiving the Presedex and fentanyl regimen with the midazolam and fentanyl regimen in the intensive care unit (ICU).
Methods: This historical cohort study was conducted on all patients hospitalized in the intensive care unit of Kowsar Hospital in sanandaj from May 2018 to December 2024 as a census with a sample size of 40 people in each group. Delirium and restlessness were assessed based on RASS criteria and the GCS scale was used to assess the level of consciousness of the patients. The data were entered into SPSS 24 software and a significance level of less than 5% was considered.
Results: The average age of the patients in Perdex, fentanyl, midazolam, and fentanyl regimens was 41.52 and 34.05 years, respectively. 53(66.3%) patients were male and the rest were female. The GCS score in the Presdex and Fentanyl group was 14(35%) and the Midazolam and Fentanyl group was 4(10%) with a level of consciousness above 7. The RASS score (5 patients in the Presdex and fentanyl group (12.5%) and the midazolam and fentanyl group (36 patients in the midazolam and fentanyl group (90%) had an anxiety score of zero or higher) was 0. The frequency of delirium based on CAM-ICU criteria in the Presdex and fentanyl group was 27(67.5%) mild delirium and 13(32.5%) moderate delirium, but in the midazolam and fentanyl group, 6(15%) mild delirium, 24(60%) moderate delirium, and 10(25%) severe delirium were present, and this difference was significant in the results of level of consciousness and restlessness and incidence of delirium (P=0.000).
Conclusion: The results showed that the use of Presedex and fentanyl would be more effective in reducing the incidence of delirium, and the use of this drug could be effective.

Evaluation of the prognosis of the first seizure without a trigger factor in terms of recurrence

Zahra Mohebinejad

Background: Seizures are common neurological disorders in childhood, with a prevalence of 4 to 6 cases per 1,000 children in the community. This study was conducted to evaluate the prognosis of the first non-provoked seizure in terms of recurrence.
Methods: In this descriptive-analytical study, the records of all patients hospitalized with a diagnosis of seizure without a trigger for the first time at Imam Khomeini Hospital in Ilam from April 2016 to March 2019 were reviewed retrospectively. Information was extracted from the patients' records. All records were reviewed in terms of seizure type characteristics.
Results: The results of imaging with seizure recurrence in these patients showed that there was a significant relationship between the result of the first imaging and the report of seizure recurrence (P≥0.001 and Phi-Cramers=0.729). Since EEG of all patients was not recorded, they were excluded from the study. There was also a significant relationship between drug treatment and seizure recurrence at a significance level of 5% (P=0.004 and Phi-Cramers=0.273). This study showed that among the 64 patients who had started drug treatment, 44 reported no seizure recurrence and 20 reported seizure recurrence, and among the 54 patients who had not received drug treatment, 23 reported no seizure recurrence and 31 reported seizure recurrence. In the first year, the highest frequency of seizure recurrence was in the first 6 months. With increasing time after seizure, the rate of seizure recurrence decreased. The highest percentage of seizures without a triggering factor was in the age group of 5-10 years and the lowest percentage was in the age group under 5 years.
Conclusion: Identifying key factors associated with seizure recurrence will enable healthcare professionals to tailor their diagnostic and therapeutic approaches, ultimately enhancing patient care and safety. By understanding the importance of family history, seizure characteristics, and neuroimaging findings, clinicians can make informed decisions that may prevent life-threatening complications and minimize cognitive impairment in affected children.

Abdominal compartment syndrome following abdominoplasty: a case report

Background: Although abdominoplasty is cosmetically effective in patients with obesity or a history of significant weight loss, it can lead to serious complications. This case report highlights the role of elevated intra-abdominal pressure and delayed diagnosis of Abdominal compartment syndrome (ACS) in the development of multiorgan failure and patient mortality.
Case Presentation: A 49-year-old female patient with a history of appendectomy and hysterectomy in the past years was admitted to the hospital for cosmetic abdominoplasty. She had a history of hypothyroidism and was taking levothyroxine regularly. Occasional tobacco use was also mentioned in the patient's history. During the operation, in addition to abdominoplasty, liposuction and flank surgery were also performed. The patient was initially placed in the supine position and then in the prone position for the last two hours. During recovery, the patient complained of shortness of breath and developed tachycardia. Despite persistently elevated BUN and creatinine, and progressive acidosis, a surgical consultation was performed with suspicion of Abdominal compartment syndrome (ACS), but this diagnosis was rejected by the surgeon. Also, despite clinical suspicion of Abdominal compartment syndrome (ACS) by the anesthesia team, in the early stages, the surgeon responsible for the patient did not have sufficient clinical suspicion of this complication and accordingly, intra-abdominal pressure measurement via bladder catheter was not performed. Since monitoring intra-abdominal pressure via bladder catheter requires a specific technique and coordination between anesthesia, surgery, and critical care teams, and since the possibility of ACS had been ruled out by the surgeon at that time, this procedure was not performed. Ultimately, the patient was transferred to the dialysis unit, but during hemodialysis, he suffered respiratory arrest and, after tracheal intubation, subsequently suffered cardiac arrest. Unfortunately, despite cardiopulmonary resuscitation efforts, the patient died.
Conclusion: Although rare, abdominal compartment syndrome should be considered a critical differential diagnosis in high-risk patients following prolonged surgeries such as abdominoplasty with extensive plication. Monitoring intra-abdominal pressure and early intervention upon symptom onset may prevent fatal outcomes.