Tehran University Medical Journal

  SARS-CoV-2 emerging from Wuhan, China is a member of the Coronaviridae family, which has so far infected and killed many people. The SARS-CoV-2 pandemic affected various aspects of life in Iran and Worldwide, and governments have imposed quarantines and travel bans on an unprecedented scale. The virus causes COVID-19, which can spread through close contact with the infected person, contaminated equipment, and suspended air droplets. The most common symptoms of the disease include fever, cough, shortness of breath, gastrointestinal symptoms, and diarrhea. In severe cases, the lung infection can occur, which causes Severe Acute Respiratory Syndrome that leads to ICU admission and even death.
  Besides, this infection can cause gastrointestinal, neurological, and renal impairments. Not merely, this new coronavirus has infected many more people worldwide in comparison to MERS and SARS, but also it has killed more people. Patients with underlying diseases such as hypertension, diabetes, respiratory problems, kidney disease, heart disease and Immunodeficiency are at higher risk of infection and potential death. Also, the risk of death and complication increases in older adults, while most of the infected children are asymptomatic. Some infected people may have mild or no symptoms but can still transmit the disease and spread it to others.
To diagnose COVID-19, serology tests, and level of ESR, CRP and other acute-phase reactants are helpful, whereas molecular tests, such as RT-PCR tests, that detect the virus’s genetic material are still the golden standard. Also, CT scan detects lung involvement; Ground-glass opacification, especially in lower lobes and subpleural region, is the most common CT characteristic, although it is not specific for COVID-19. Because the disease is difficult to diagnose, hard to prevent and challenging to treat, it has become a major concern for many countries. This review aims to gather existing information in the fields of virology, molecular pathogenesis, disease symptoms, epidemiology, clinical presentations, diagnosis, treatment, and the spread of the disease. This study also provides evidence-based prevention and treatment strategies for health policymakers, doctors, nurses, and practitioners in the field of public health, including researchers and students.

In 2019 a newly emerged coronavirus was detected by the Center for disease control (CDC) in China. Nucleic acid sequencing from nose and throat swab samples of patients revealed that it was like severe acute respiratory syndrome coronavirus (SARS-CoV). World Health Organization (WHO) named it coronavirus disease 2019 (COVID-19) and reported more than 100000 positive tests until March 2020 for COVID-19. During the past 20 years, the world has been affected by three coronavirus epidemics, SARS-COV, Middle East respiratory syndrome coronavirus (MERS-CoV), and COVID-19 that make world attention. The mortality rate of COVID-19 was more than other coronaviruses, but because of more people affected by it, it seems that it has a less fatality rate compared with MERS- CoV. Initial data showed that more than 80% of patients did not have any symptoms or may had light symptoms. 15% showed severe pneumonia, 5% became critically ill, and developed multiorgan dysfunction and septic shock. Due to the epidemic of emerging viruses and the lack of information about it, this study aimed to provide a quick overview of the most recent studies in the world. To perform this review, keywords such as COVID-19, severe acute respiratory syndrome coronavirus 2, and Angiotensin-converting enzyme 2 were retrieved using the medical subject headings (MeSH) system and then searched in English in PubMed, Scopus, Google Scholar, and Web of Science databases.
COVID-19 virus enters its genome into the cells by binding to Angiotensin-converting enzyme 2 in some organs such as the lungs. Although the transmission route is unclear, it enters the body through respiratory droplets. The clinical symptoms includ fever, cough, dyspnea, myalgia, confusion, headache, sore throat, rhinorrhea, chest pain, diarrhea, nausea, vomiting, malaise, and convulsion. The standard diagnostic method is Real-time polymerase chain reaction (RT-PCR), but due to the time-consuming and sensitivity and the existing errors in this technique, chest CT and hematologic data are preferred. No definitive cure for the virus has been suggested so far, but antiviral drugs such as Oseltamivir, Ganciclovir, Lopinavir, Ritonavir and Remdesivir, and the anti-malarial drug Chloroquine phosphate and Interferon are in use until the discovery of the vaccine.

Background: Because deep vein thrombosis (DVT) is one of the most common problems in the intensive care unit, it may lead to complecating the patient's general condition. This study aimed to investigate the predictive factors of DVT in patients admitted to the intensive care unit (ICU) of Amin hospital in Isfahan.
Methods: In this retrospective study, all the records of patients admitted to the ICU ward of Amin Hospital located in Esfahan, from April 2015 to March 2018, were investigated and from all patients with DVT, 20 records were extracted and 40 cases of patients without DVT were also randomly selected. Information such as age, sex, Wells score, Apache score, nutritional status, clinical parameters, cause of hospitalization, length of stay, ICU induced disease and treatment were extracted from these records and compared between both groups with and without DVT.

Conclusion: In the general intensive care unit, the incidence of deep vein thrombosis was higher in internal ward patients. Pneumonia was the most common disease associated with deep vein thrombosis and the risk of deep vein thrombosis was higher in the anemic patient. Patients with upper limited normal levels of potassium were less likely to develop deep vein thrombosis. It seems that potassium in the upper limit of normal reference can play a protective role against deep vein thrombosis. Further studies with larger sample sizes are suggested.

Background: Phacoemulsification surgery is one of the most common surgeries in the world. Various drugs have been used alone or in combination with each other to provide effective and safe sedation in patients, but so far, a drug method agreed upon by anesthesiologists has not been proposed. The purpose of this research was to evaluate the sedative quality of midazolam or propofol with a low dose of ketamine in phacoemulsification surgery.
Methods: This study was a double-blind randomized clinical trial conducted from November 2017 to August 2019 at Faiz Hospital, Isfahan. In this study, 68 patients were assigned in the groups of midazolam (M) and propofol (P) using randomization software entered the study. The midazolam (M) group received 0.04 mg/kg and the propofol (P) group received 0.5 mg/kg, then in both groups, ketamine 0.3 mg/kg was injected intravenously. The quality of sedation, cardiovascular response and patient and surgeon satisfaction were assessed and recorded. Data were entered into SPSS 23 software and analyzed by using ANOVA and Independent samples t‐test.

Background: Understanding hand structures is necessary to diagnose its diseases and injuries. Several methods have been used to teach the anatomy of this body part. In this article, we introduce a new educational tool and examine the impact of its use in learning anatomy.
Methods: Color images of different layers of hand structures were connected with a spring. On each page, the desired structure was cut and that part could be turned from another direction so that the tool was beyond a booklet and could create a three-dimensional image of the region. In this way, a multi-layered structure was made that looking at each part of it and going to the next part was equivalent to removing a layer from the palm of the hand and observing the layer beneath. After making the educational tool, 280 students who participated in the study were divided into two groups: control (A) and experimental (B). Both groups participated in a pre-test. After teaching the theory of hand anatomy for both groups, the control group received practical training using the traditional method and the experimental group using the proposed educational tool, and both groups participated in a post-test and the scores of the pre and post-test groups were compared. Data were analyzed using SPSS 24 statistical software using Mann-Whitney and Wilcoxon tests.

Primary Immune Deficiencies are a group of heterogeneous disorders that involve the innate or acquired immune system, or a combination of them. The underlying disorder may be related to decreased levels or function, or a complete lack of one or more components of the immune system in general. These diseases can occur with a prevalence of about 1 in 10000 live births. According to the fourth update on the Iranian national registry of Primary Immune Deficiency in October 2018, the total number of registered PIDs in Iran are 3056 patients. However, it is supposed to be more prevalent and it seems increasing awareness shall reveal many new cases, especially in societies with prevalent consanguineous marriages like Iran. These disorders predispose patients to recurrent infections, autoimmunity and malignancy and can cause a huge burden on health care systems. This group of diseases has a wide range of symptoms, which quick recognition and timely treatment of them, can greatly reduce the complications of the disease. These symptoms may include recurrent or severe infections, failure to thrive, autoimmune disorders, as well as articular-skeletal manifestations. A variety of skeletal manifestations are seen in patients with primary immunodeficiency, among which septic arthritis caused by pyogenic bacteria or mycoplasma arthritis is the most common joint-bone manifestation. Joint and skeletal involvement is less commonly seen as a sign of primary immune defects. This issue is importance in reducing the cost of diseases and improving the patients’ quality of life. Our review attempted to introduce the most common manifestations of bone and joint in patients with primary immunodeficiency and available treatments for these manifestations. Because of the wide range of symptoms in these patients, it is recommended to observe the rare and suspicious manifestations in the patients with any atypical bone and joint presentations such as: recurrent septic arthritis, infection with unusual germs, immunodeficiency in their relatives, and any history of well-known red flags of PIDs. The Rheumatologist should consider these manifestations and think about the possibility of deficiency disorder.

Background: lumbar disc degeneration is a multifactorial degenerative disease which is affected by genetic inheritance and environmental factors. Type XI collagen is important for organization of the extracellular matrix and cartilage collagen construction. Rs1676486 is a SNP that causes the conversion of C-T, resulting in a change in the expression of the collagen 11 alpha chain. The T allele reduces the alpha 1 chain transcription of collagen 11 and ultimately leads to an imbalance in gene expression.
Methods: This study aims to determine the genetic variant of alpha1 type11 collagen is associated with the progress of intervertebral disc degeneration. All patients were selected from the AL-Zahra Hospital of medical university of Isfahan, Iran, between April 2016 and September 2017. SNP rs1676486 of alpha1 type11 collagen was genotyped in 100 patients and 100 healthy controls. The inclusion criteria for patients were: individuals who had typical clinical and imaging symptoms and signs of intervertebral disc degeneration. Exclusion criteria were: patients with trauma, metabolic and neuromuscular diseases, and congenital disorder of the spine. The Genomic DNA was extracted from peripheral blood samples by a Whole Blood Genomic DNA Extraction Kit. The chi-square test and fisher’s exact test were evaluated to determine differences of genotype and allele distributions between intervertebral disc degeneration patients and healthy controls. To compare the relationship between genotypes and clinical features the Mann-Whitney U test was used.

Background: The risk of anesthesia increases with age, so it is necessary to choose a safe and effective method. In this study, we compared the effectiveness of intranasal fentanyl with intravenous fentanyl in patients undergoing cataract surgery.
Methods: This study was a triple-blind prospective randomized clinical trial (The patient, physician, and data analyzer were unaware of the patient grouping). The study was performed from April 2017 to March 2019 in Feyz Hospital, Isfahan, Iran. 90 patients over 18 years of age who were candidates for cataract surgery were included in the study and were divided in two groups receiving intravenous fentanyl (IVF) or intranasal fentanyl (INF). The dose of fentanyl in both groups was 1.5 μg/kg with a maximum of 100 μg. In the IVF group, 1 ml of normal saline was dripped into each nasal passage 10 minutes before surgery and intravenously fentanyl was injected 2 minutes before surgery. In the INF group, 1 ml of fentanyl was administered into each nostril 10 minutes before surgery and 2 ml of saline was administered intravenously two minutes before surgery.

Background: The preparedness and safety of hospitals in disasters are essential to maintain the health and survival of the community. Numerous studies have shown that the level of preparedness of Iranian hospitals is moderate and low. Lack of comprehensive hospital standards for disaster preparedness is one of the reasons. This study aimed to develop hospital accreditation standards for hospital disaster risk management.
Methods: This comparative study was conducted between April and September 2016. Hospital disaster risk management accreditation standards were extracted from the hospital accreditation standards of 11 countries including the United States, Canada, Australia, Malaysia, India, Thailand, Egypt, Turkey, Saudi Arabia, Denmark and Iran. Overall, 27 hospital disaster risk management accreditation standards were introduced. The opinions of 22 disaster risk management experts were used to assess the content validity of the proposed disaster risk management accreditation standards.
Results: Differences were observed in the quality and quantity of those countries’ disaster risk management standards. The national accreditation standards of the United States, Australia, and Canada had comprehensive standards and covered all aspects of the disaster risk management cycle. Finally, 27 standards were proposed for developing Iranian hospitals’ disaster risk management accreditation standards. The CVI & CVR validity of the proposed standards were acceptable.
There were significant differences in the quantity and quality of hospital disaster risk management accreditation standards in selected countries. The most comprehensive standards belonged to the US National Standards (12 standards and 113 sub-standards), followed by the Australian and Canadian accreditation standards. The accreditation standards of the developing countries and Iran were not comprehensive and did not meet the international goals of disaster risk management. The proposed hospital disaster risk management accreditation standards had high content validity.
Conclusion: Disaster risk management accreditation standards in Iran and developing countries need to be revised and upgraded. Comprehensive standards based on international experiences and expert opinions were introduced in this study that can be used to develop hospital accreditation standards in Iran and other countries.

Background: Immunosuppressive drugs that are widely used to prevent acute and chronic organ rejections, predispose organ transplant patients to a variety of diseases including skin problems. This study aimed to determine the prevalence of skin lesions and to investigate their association with demographic characteristics in renal transplant patients.
Methods: This cross-sectional study was performed on 100 patients who were referred to the nephrology clinic of Baqiyatallah Hospital, Tehran, Iran and underwent kidney transplantation within a year (from the first working day of the Iranian Hijri calendar in April 2015 until the last working day in March 2016). Patients were referred to a dermatologist in case of any skin lesions. Patients' data were collected in a researcher-made questionnaire and were analyzed using SPSS software, version 18. The p values less than 5% were considered to be significant.

Background: Rheumatoid Arthritis patients are evaluated during treatment for various inflammatory factors such as C-reactive protein, Erythrocyte Sedimentation Rate, and Disease Activity Score, and other immune system-related factors. In the follow-up of patients with rheumatoid arthritis, hematologic factors associated with the immune system especially Platelet to Lymphocyte Ratio and Neutrophil to Lymphocyte Ratio are important. In this study, platelet to lymphocyte ratio and Neutrophil to lymphocyte ratio were compared in two groups of patients with and without ocular complications.
Methods: This cross-sectional study was performed on 246 patients with rheumatoid arthritis who were referred to the rheumatology clinic of Kermanshah from December 2018 to May 2019. This study was carried out in accordance with the approval of the ethics committee (IR.KUMS.REC1397.311) at Kermanshah University of Medical Sciences. Of these patients, 191 had no ocular complications and 55 patients had ocular complications and were matched for age and sex. The blood samples were taken from patients and blood cell count was measured by Sysmex KX-21 hematology analyzer. The Spearman correlation test was used to evaluate the relationship between platelet to lymphocyte ratio and neutrophil to lymphocyte ratio in both groups of patients without ocular complications and with ocular complications. The Disease Activity Score was compared between the two groups using the Mann-Whitney test.

Background: Urinary tract infections are among the most common diseases in different communities and occur in all age groups. Failure to diagnose the disease correctly and promptly can cause complications such as damage to the urinary tract and kidney parenchyma, increased blood pressure, uremia. Also, in pregnant female patients It may lead to premature birth and even abortion. Therefore, correct and timely administration of antibiotics is very important in the treatment of patients. This study aimed to compare the results of antibiogram testing of patients with suspected urinary tract infections by both rapid and classical methods.
Methods: This cross-sectional study was performed from the beginning of March to the beginning of September 2019, on patients with urinary tract infection Who had been referred to Sina Hospital of Hamedan, Iran. Urine samples were collected 20 cc from patients. The test was performed directly at the same time with urine culture to determine antibiotic susceptibility. The agreement between the two methods was considered as a huge error, major error and minor error. Finally, the data were statistically analyzed with SPSS software version 16.