Tehran University Medical Journal

Background: Cervical pregnancy is a rare type of ectopic pregnancy (EP) in which the pregnancy implants in the lining of the endocervical canal. It accounts for less than 1 percent of ectopic pregnancies. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role given an apparent association with a prior history of curettage or cesarean delivery. The most common symptom of cervical pregnancy is vaginal bleeding, which is often profuse and painless. Lower abdominal pain or cramps occur in less than one-third of patients; pain without bleeding is rare. It is important to think about the possibility of cervical pregnancy in such patients since early diagnosis is critical to avoidance of complications and successful treatment. Management of this pregnancy is dependent on the hemodynamic status of the patient. Conservative management and some more aggressive therapy such as emergency hysterectomy can be used. The aim of this report was to introduce a case of successful conservative management of cervical pregnancy.
Case presentation: A 30-year-old G2L1 woman with history of a previous cesarean section and possible diagnosis of missed abortion referred to the Gynecology Clinic of Ghaem Hospital, Mashhad University of Medical Sciences, Iran, in 21 May 2017. Cervical pregnancy was diagnosed during curettage. Severe hemorrhage occurred after curettage and the hemodynamic status of the patient was unstable immediately after curettage. Severe threatening vaginal bleeding was controlled with intrauterine Foley catheter containing 60 cc normal saline and then vaginal packing. The patient was discharged with good general condition.
Conclusion: In cervical pregnancy and unstable hemodynamic status and desire to preserve fertility, intrauterine Foley catheter and vaginal packing after curettage is helpful.

Background: Vitamin D deficiency can cause frequent infection of tonsil and adenoid. Recurrent upper airway infections are associated with hypertrophy of lymphoid tissues (adenoid and palatine tonsils) in children. Obstructive sleep disorders, failure to thrive, facial deformity, and cognitive disorders are among the most important complications of adenotonsillar hypertrophy. Surgery is indicated in cases with symptomatic adenotonsillar hypertrophy, who did not respond to conservative management. This study aimed to evaluate the relation between serum vitamin D level and size of palatine tonsils and adenoid. If there was a significant relationship between them, vitamin D replacement therapy could replace surgery in many cases. It seems to be a logical way to prevent possible complications of adenotonsillar hypertrophy and avoid many adenotonsillectomies. 
Methods: A prospective cross-sectional study was conducted among 3 to 15-year-old children, who were referred to the Otorhinolaryngology Clinic of Taleghani Hospital, Tehran, from 2015 to 2017. The patients should not have any history of chronic diseases and not be treated with vitamin D supplements. Adenoid hypertrophy was evaluated in patients with suspected symptoms. Lateral nasopharyngeal x-ray was used to determine adenoid hypertrophy. The tonsillar size was assessed in all patients by careful oral physical examination. They were divided into 4 groups, according to the grade of tonsillar hypertrophy. Then, each group was subdivided as with or without adenoid hypertrophy.
Results: The total number of cases was 140. Sixty-nine girls (49.3%) and seventy-one boys (50.7%) were enrolled. The average of their age was 7.69 years (SD=3.28). There was no significant difference in the vitamin D levels among all groups (P=0.211), but children with grade 3 and 4 of tonsillar hypertrophy had lower serum vitamin D levels compared with others. Also, the difference between serum vitamin D levels in patients with or without adenoid hypertrophy was not significant (P=0.254).
Conclusion: Although vitamin D deficiency may predispose patients to recurrent infections, it has no effect on creating adenotonsillar hypertrophy. The serum level of vitamin D does not seem to correlate with the adenoid size, but lack of vitamin D may predispose patients to more sever tonsillar hypertrophy. More extended studies should be conducted in this regard.

Background: Differentiated thyroid cancer (DTC) frequently occurs in women at fertility age. One of the cornerstones in treating this malignancy is Radioactive Iodine (RAI) therapy following thyroid resection. In this study, we evaluated the effect of RAI therapy on the fertility rate and pregnancy complications.
Methods: This is a retrospective study on 41 patients with differentiated thyroid cancer, with at least one experience of pregnancy after standard treatment (thyroid resection followed by radioiodine therapy). All patients have been signed a written consent form in initial admission to our department. Furthermore, we asked our patients to fill in a questionnaire about their thyroid cancer and its treatment as well as pregnancy and its complication. As a control group with no different mean age, the same checklist has also been filled in for the patient’s healthy sister too, just related to gravidity and its complications. The complications of pregnancy were registered in these patients and compared with the control group consisted of their healthy sisters. Also, the association of abortion rate with other underlying factors has been assessed. All data has been included in SPSS software, version 22 (IBM SPSS, Armonk, NY, USA) and analyzed using logistic regression. This study conducted at the Nuclear Medicine Department of Ghaem Hospital in Mashhad, from May 2017 to February 2018 with the support of Mashhad University of Medical Sciences, Iran.
Results: No significant difference was noted in the mean age between case (differentiated thyroid cancer) and control groups (P=0.9). The two groups were also statistically similar in terms of pregnancy frequency (P=0.05) and number of alive children (P=0.8). Abortion seems to be the only item in DTC patients which was more than healthy sisters (0.2 versus 0.7) (P=0.003). However, this statistical difference showed no direct relationship with radioiodine treatment (RIT). As in DTC patients before and after RIT, no significant difference has been detected in DTC patients before and after RIT (P=0.48). Birth weight was not statistically different in DTC patients before and after RIT (P=0.66) and between DTC patients and their healthy sisters (P=0.2).
Conclusion: Radioiodine therapy for differentiated thyroid carcinoma has no considerable negative impact on pregnancy, whether on fertility rate or on gravity complications.

The mammalian cochlea is a highly complex structure which contains several cells, including sensory receptor or hair cells. The main function of the cochlear hair cells is to convert the mechanical vibrations of the sound into electrical signals, then these signals travel to the brain along the auditory nerve. Auditory hair cells in some amphibians, reptiles, fish, and birds can regenerate or replace by new cells, but irreversible damage to the mammalian hair cells are not being replaced through differentiation of the internal epithelial cells in the inner ear. Indeed, mammalian auditory hair cells do not spontaneously repair or regenerate after development. Sometimes, functions of damaged hair cells may be restored, but in most cases, there is no such possibility and permanent hearing loss occurs. Several factors such as chronic ear infections, genetic disorders, drug abuse, acoustic trauma and aging can damage the cochlea, resulting in permanent hearing loss. More than 250 million people in the world have disabling hearing impairment. Deafness is caused by damage to sensory hair cells or spiral ganglion neurons. Although hearing aids and cochlear implants were used for improvement of hearing loss, but they do not restore normal hearing. In addition, application of new biological approaches to induce auditory hair cell regeneration provides more comprehensive treatment for hearing loss. Cell therapy is considered a promising way in the treatment of several diseases such as Parkinson, diabetes and cardiac diseases. According to recent research, cell therapy can be useful in hair cell regeneration. Cell therapy is effective in hearing loss when stem cell differentiates into hair cells with appropriate morphology, electrical activity and capacity for suitable innervations with inner ear tissues. In fact, stem cell-derived neurons need to project neural processes toward the sensory hair cells and the cochlear nucleus neurons. In this regard, studies focus on methods in which hair cells can be provided from exogenous and endogenous stem cells. Here, we review cell therapy approaches in repair damaged cochlear hair cells, as well as imitations and problems of its clinical application.

Background: Although cervical malignancy rate had grown up in recent years, primary cervical lymphoma is so rare. It must be high index of suspicious for primary cervical lymphoma diagnosis in patient with malignancy-like signs and symptoms for early detection. Primary cervical lymphoma has no standard treatment or follow-up protocol; so the management still is in doubt and based on previous case reports. In the other hand, the precise prognosis of patient is undetermined. In the present study, a case of primary cervical lymphoma is presented which was misdiagnosed at first. The patient accurate diagnosis was made at last due to multidisciplinary team working.
Case presentation: A 51-year-old woman, gravida 2, para 2, presented with complaint of abnormal vaginal bleeding and discharge, with no abnormal finding in cervical cytology and sonography, so uneventfully a diagnostic error had happened in the assessment of her. After several months and multiple different treatment, the patient referred to the Oncology Department of Obstetrics and Gynecology Center, Ghaem Hospital, Mashhad, Iran in May 2017. Re-assessment was performed by biopsy and imaging, and the final pathologic diagnosis of diffuse large B-cell non-Hodgkin's lymphomas was confirmed.
Conclusion: Primary cervical lymphoma is an uncommon malignancy; the diagnosis could be missed simply by low suspicious due to low accuracy of Pap smear and imaging in this situation. So an accurate evaluation and pelvic examination, high suspicious and close communication between clinician and pathologist are needed. By timely diagnosis of patient in early stage and appropriate approach, the prognosis could be excellent most of the time.

Background: Nonpuerperal uterine inversion is a rare medical condition that many gynecologists might not be encountered even with one case during their entire medical practice. It refers to the expulsion of uterine corpus from the dilated cervix resulting in uterus being turned inside out. There are two kinds of uterine inversion, puerperal and non-puerperal, which the second condition is less common. Acute uterine inversion usually presented by crampy abdominal or pelvic pain, vaginal bleeding, anemia, and even symptoms of severe sepsis. We describe a case of uterine inversion in a postmenopausal woman.
Case Presentation: A 66 years old grand multiparous woman (6 normal vaginal delivery) who was menopause since 15 years ago, was referred to the emergency unit of an academic hospital of Mashhad University of Medical Sciences at October 2016 due to postmenopausal uterine bleeding, cramp-like abdominal pain and mass protrusion from the vagina. The vital sign was stable at the first visit but a big non-necrotizing red vaginal mass was protruded from vaginal opening that connected to other soft intravaginal mass. Abdominal ultrasonography revealed the dilated vaginal cuff and some air-fluid levels in the uterine cavity. The patient referred to the operative room and vaginal myomectomy was done with diagnosis of pedunculated submocusal leiomyoma. Then, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed after the correction of uterine inversion by abdominoperineal approach.
Conclusion: Acute uterine inversion is a potentially dangerous condition (due to vaginal bleeding, severe abdominal or pelvic pain, and the possibility of uterine necrosis and even systemic infection). This condition should be considered as an important differential diagnosis as a vaginal mass in the post-menopausal period.

Background: Currently many hospitals around the country face increasing demands of their patients and readmission.The rate of readmission is a useful indicator for determining the performance of healthcare system and it shows the quality of services in the medical institutions. Readmissions have high economic, social and financial impact and studying the related factors seems to be high priority for healthcare systems.
Methods: This qualitative study performed by phenomenological method in three educational hospitals in Kerman from April to September of 2017. Data collection was performed through semi-structured interviews using targeted sampling among all patients who were hospitalized at internal medicine wards, nurses who were working in those wards, and in charge physicians. In total twenty patients, fifteen nurses, and five physicians were selected for interviews. The including criteria were for patients, the history of hospitalization at least once, during one month after the initial hospitalization, and for service providers, familiarity with the subject, work experience in the relevant department of at least three years for nurses and five years for physicians. A seven-step clustering method was used to analyze the data.
Results: The analysis of the interviews led to the identification of three main themes and 11 sub-themes. The main themes included patients' characteristics, manpower and clinical factors, hospital, and environmental factors. Some of the sub-codes included economic and living conditions, marriage status, insurance coverage, patients' beliefs and expectations, the presence or absence of underlying disease, education, lifestyle habits, dietary beliefs of hospitalized patients, lack of trust in medical staff, communication and cultural barriers, ignorance of service providers in treatment, lack of facilities, lack of motivation in medical staff, stressors and finally lack of hospital equipment.

Case Presentation: The patient was a 30-years old woman who presented with twin pregnancy in 31 weeks of gestation with a history of IVF (In-Vitro Fertilization) in the current pregnancy. She referred to Ghaem hospital of Mashhad University of Medical Sciences in March 2017 because of severe lower extremities edema and 3+ proteinuria. Considering severe proteinuria (more than 6 gr/24 hr), edema, hypoalbuminemia and hyperlipidemia, the nephrotic syndrome was diagnosed and she was treated with methylprednisolone, Hydrochlorothiazide and Fenofibrate. At last, premature rupture of membrane occurred at 36 weeks of gestation. Cesarean was done because of the breech presentation of both fetuses and two healthy neonates were born with an optimal Apgar score.

Background: Even after surgery, as the most effective treatment for colorectal cancer, about 30-40% of cases are recurring. Since growth inhibition is an important strategy in cancer treatment, many attempts are in the program to find new agents, so in this study, the cytotoxic and antimicrobial effects of Lactobacillus sakei on colon cancer cell line (HT-29) and some pathogenic microorganisms have been evaluated. Lactobacillus sakei is a probiotic that, when consumed affects the intestinal flora, causes beneficial effects on host health. Probiotics due to their anti-cancer effects, modulation of the differentiation process in tumor cells, changes in tumor gene expression and lack of immunological responses have attracted a lot of attention as a new and effective treatment for colorectal adenocarcinoma.

Background: Posterior reversible leukoencephalopathy syndrome (PRLS) is a clinical and radiological syndrome of heterogeneous etiologies that are grouped because of the similar findings on neuroimaging studies which may occur at any age. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. The syndrome is more commonly seen in women, RPLS has been described in several medical conditions, with hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressant drugs being the most common conditions. Prompt recognition and treatment are important in preventing the permanent damage that can occur in this otherwise typically reversible condition. The pathogenesis of RPLS remains unclear, but it appears to be related to disordered cerebral autoregulation and endothelial dysfunction. This report aimed to introduce a case of reversible posterior leukoencephalopathy following postpartum thrombotic thrombocytopenic purpura (TTP).
Case presentation: The patient was a 30-year-old primigravid woman at 33 weeks of pregnancy who was referred to the Ghaem hospital, Mashhad University of Medical Sciences in Mashhad in July 2017 due to high blood pressure, blurred vision, headache and generalized tonic colonic seizure. She did not report in previous history of high blood pressure or seizure before pregnancy. With a diagnosis of eclampsia remote from delivery, she underwent a cesarean section. After delivery, generalized tonic colonic seizure repeated several times and a significant reduction in consciousness level happened. Renal failure also occurred, so she underwent daily plasmapheresis with a diagnosis of TTP. After 35 days, she was discharged with a good general condition.
Conclusion: In predisposing conditions, such as high blood pressure in pregnancy, in the case of clinical suspicion of posterior leukoencephalopathy, any attempt for early diagnosis and appropriate treatment are important factors in reducing the rate of morbidity and mortality.

Background: Developmental delay in preterm infants was estimated to be more common than term infants. Identifying the factors predisposing to developmental delay can help experts and health professionals in this field to prevent developmental delay of the infants, and leads to better management of the condition of them. This study aimed to evaluate and investigate the predisposing factors of developmental delay in preterm infants in the first year of their lives.
Methods: In this analytical cross-sectional study, 87 preterm infants were enrolled in the study by convenience sampling during the period of April 2016 to the end of March 2017 from two educational hospitals of Shahid Beheshti University of Medical Sciences (Imam Hussein hospital and Mahdiyeh hospital). Demographic and other initial data such as age, sex, gestational age, and the data about clinical problems observed at birth were collected through infants' medical records and were recorded in a special form for each infant. Also, the ASQ test was used to assess infants' developmental status at one year of age.

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: Sigmoid volvulus is a rare complication in pregnancy. The clinical presentation is similar to that of non-pregnant volvulus, although the symptoms can be masked by the enlarged uterus and physiological changes during pregnancy and it can be challenged and delayed in diagnosis and treatment. Delay in diagnosis can also lead to ischemia, necrosis and perforation of the intestine, which can have adverse maternal and fetal outcomes.
Case Presentation: A primigravid woman with gestational age of 31 weeks was admitted to a 3^rd level center with abdominal pain and abdominal distention. From the beginning of pregnancy, the patient complained of bloating and epigastric pain, And had used herbal medicine for defecation. The patient's constipation had worsened since six days before admission to the hospital. She had no vomiting and her general condition was good. Abdominal Supine X-rays were reported completely dilated sigmoid and she was treated with a possible diagnosis of ileus. Due to the progression of symptoms and abdominal distension, rectosigmoidoscopy was performed for her, and scattered mucosal erythema was seen. Discoloration of the purple mucosa was seen from a distance of about 35 cm from the annulus and the secretions inside the sigmoid lumen were seen as blood. Ischemic necrosis and sigmoid volvulus were strongly suggested for the patient and she was immediately transferred to the operating room. The abdomen was opened with a midline incision. A 30 weeks uterus was seen and sigmoid volvulus was confirmed. Detorsion and colostomy were done. Due to the unprepared intestine and the possibility of leakage from the site of anastomosis, sigmoidectomy was not performed. After 4 days, the patient was discharged in a good general condition and became a candidate for sigmoid colon resection after delivery.

Results: Female students whose mothers were illiterate were 3.51 times more likely to develop head lice. Students who bathed once a week were 0.03 times more likely, and those who shared personal items were 3.6 times more likely to develop the disease.   In terms of father occupation, the highest incidence of head lice among the subjects was 8 people (66.7%) related to people whose father job was free and the lowest was related to other occupations of 4 people (33.4%). There was no significant relationship between     father's job and head lice infection in the subjects (P=0.061). Conclusion: The results of this study indicate the high infection rate of head lice in elementary school students of Kerman. This high level of infestation can cause more contamination among female students consequently, and may cause students to drop out of the school. Serious attention to reducing this infection by holding educational classes for school principals and teachers, as well as parents, seems necessary.

Results: Doing qualitative research and conducting thematic analysis, paraclinical services were classified into three categories: input, process, and outcome. The inputs  category had 5 organizing themes including paraclinical structure, human resource empowerment, cost management, social responsibility and service purchasing. The processes consisted of four themes: organizing the acceptance and delivery of services, monitoring and evaluating implementation, interdisciplinary coordination, applying innovation, and creativity in service delivery. Finally, outputs included three themes: organizing disease prevention and health promotion, gaining a competitive advantage, and reducing health costs. Conclusion: According to the study's findings, to purchase or rationally use paraclinical services, it is necessary to know the dimensions and components that affect them. Managers of the social security organization are urged to lay a greater focus on employee empowerment, the employment of innovative approaches, and interdepartmental collaboration to enhance paraclinical service supply. Additionally, they may better fulfill their social duties and enhance their workers' health services by monitoring and evaluating executive actions.

Conclusion: According to the findings of this study, the measuring of optic nerve sheath diameter in patients suspected of increasing the pressure of idiopathic intracranial hypertension can be helpful as a non–invasive diagnosis method.

Background: The training and education of competent and qualified surgeons have been one of the challenges of the surgical profession. The concept of surgical competence has been affected widely due to a series of developments in the new disease emergence, various surgical techniques and the introduction of advanced tools and equipment into the operating. The development of surgical competence and achieving this goal requires accurate identification and analysis of the dimensions of competence. This study was done to explain the concept of surgical competence using the 8-step Walker and Avant approach.
Methods: This study is a qualitative study that was conducted from May- October 2016 at Shahid Beheshti University of Medical Sciences. The present study is a qualitative and conceptual analysis study, which is done with Walker&Avant's eight-step approach to determine the defining characteristics of the concept of surgical competence. A systematic search was conducted between 1990 and 2020 by keywords search such as surgery, surgical, operation OR laparoscopy AND competence competency development competency proficient, proficiency, expertise, clinical, in the database like Google Scholar, PubMed, SID, Magiran, Scopus, Web of Science. Twenty articles were included in the study based on inclusion and exclusion criteria. Moreover, the defining features of the concept were extracted from it.

Results: Based on the results of this study, the concept of surgical competence was defined and the four dimensions of elements, goals, components and the process of developing surgical competence were identified. Then, by clarifying the characteristics of surgical competence, a model of surgical competence development was drawn. Surgical competence development depends on the acquisition of specialized knowledge and numerous skills that are acquired through experience and deliberated practice under the supervision of others in the surgical community of practice and over time. Conclusion: Surgical competence is a set of observable and measurable skills that allows a surgeon to manage the surgical process independently pbt while maintaining the patient's safety. It includes specialized knowledge, communication skills, cognitive and technical skills, and basic surgical skills.

Background: Breast cancer is the most common type of cancer in many countries, accounting for over 18% of all cancers in females. There are more than one million new cases of breast cancer each year. Most women diagnosed with breast cancer are over the age of 50, but younger women can also get breast cancer. About one in seven women are diagnosed with breast cancer during their lifetime. There's a good chance of recovery if it's detected at an early stage. In Iran, breast cancer is the most common cancer among women, making up 21.4% of all female cancers. The mortality rate of this cancer is 4.33 for every 100,000 people. The purpose of this research is to see how often different kinds of early breast cancer come back and how long people live after being diagnosed.
Methods: This retrospective study evaluated the medical records of 500 breast cancer patients at two hospitals in Mashhad, Iran during April 2006 to March 2016. We used SPSS software, version 16 (SPSS Inc., Chicago, IL, USA) to analyze data. A P value less than 0.05 means that the results are considered statistically significant.

Results: We included 230 women with breast cancer. The average overall survival was 130.7 months, with 83.2% of people surviving for five years and 78.8% surviving for 10 years. The stage of the disease is strongly linked to the recurrence (P=0.000). Additionally, the specific type of disease is also strongly related to disease recurrence (P=0.01) or metastasis (P=0.01). Patients who have the triple-negative subtype had the highest chance of the cancer spreading and recurrence compared to patients with other subtypes. Conclusion: The different types of breast cancer are strongly linked to the disease recurrence or metastasis. Patients with triple-negative subtypes had the most cases of cancer spreading to other parts of the body and coming back again, compared to other subtypes. Our findings also showed that patients with the triple-negative disease had the worst overall and disease-free survivals.

Background: Ultrasound is widely used to detect renal stones. A no-contrast CT scan is the most accurate modality for stone examination. Considering that determining the size of a stone is the main criterion in treatment planning, the purpose of this study was to compare ultrasound and non-contrast CT scans in determining renal stone size.
Methods: In this cross-sectional study, 140 patients were assessed from June to October 2017 at Namazi Hospital of Shiraz University of Medical Sciences. A radiologist compared the CT scans of patients with their ultrasound images. The ultrasound and CT scan results in terms of stone size were assessed. The correlation rate of stone size in ultrasound and CT scans in different subgroups was assessed by categorizing the stone size into three subgroups. The impact of stone location and the CT window on measuring stone size were evaluated.

Results: The mean stone size measured by ultrasound and CT scan was 11.23±5.26 and 9.48±4.7mm, respectively, which was significantly different. The highest rate of correlation was observed in the stones>10mm (81%) and then in 5-10mm (69.3%). The lowest agreement was observed in stones <5mm (37.5%). Conclusion: Using ultrasonography as a screening test or a primary test for detecting the renal stones is recommended. However, considering the importance of a precise assessment of stone size in choosing the treatment method and the limitations of sonography in the evaluation of small stones, a CT scan should be considered as a standard diagnostic tool if there is no contraindication. In CT images, the application of BW might underestimate the stone size in comparison to SW. Considering the results of previous studies, it is better to use magnified BW to assess the stone size on CT scan images. Although the axial view in a CT scan is more routine, for measuring the stone size it is better to use coronal or sagittal views together with axial views.