Tehran University Medical Journal

Background: Accurate detection of deep sleep (Due to the low frequency of the brain signal in this part of sleep, it is also called slow-wave sleep) from awakening increases the sleep staging accuracy as an important factor in medicine. Depending on the time and cost of manually determining the depth of sleep, we can automatically determine the depth of sleep by electroencephalogram (EEG) signal processing. In this paper a new EEG bispectrum based feature is introduced for deep sleep discrimination.
Methods: This cross-sectional study was conducted at Isfahan University of Medical Sciences, Faculty of Advanced Technologies in Medicine, from February to October 2017. In this study a gray scale image was made of electroencephalogram bispectrum amounts and converted to binary image with Otsu’s Thresholding. Then the ratio of white bits in the above of the secondary diagonal to white bits in the down of secondary diagonal (low to high frequencies bispectrum rate) is extracted as a new feature. This feature is an effective method for detecting deep sleep from awakening.
Results: One of the important methods in biomedical signal processing is the use of the power spectrum or signal energy. In sleep studies, energy-related features have also been used to determine the depth of sleep. Low to high frequencies bispectrum rate is able to separate deep sleep from awakening by accuracy of 99.50 percent, while energy-based features as one of the most important approaches to sleep classification do not have this ability.
Conclusion: In this study we show that “Low to high frequencies bispectrum rate" feature has this capability to use in sleep staging. It is not used in previous works. The accuracy obtained in deep sleep separation from the awakening with the introduced feature (99.50 percent) is greater than the accuracy obtained by all the energy-based features (The simultaneous use of the 6 bands energy leads to 99.42 percent accuracy). This feature indicates the ratio of the phase coupling at low frequencies to high frequencies and can be used in all cases where the bispectrum is used (such as determining the depth of anesthesia).

Background: Pseudomonas aeruginosa is an opportunistic pathogen and one of the important factors of hospital infection. It causes many issues such as urinary tract infections, respiratory infection in cystic fibrosis patients, and wound infection in burn patients, septicemia and meningitis. Antibiotic resistance through various mechanisms is one of the challenges for the treatment of pseudomonad-caused infections. According to the inherent and acquired capacity of this bacterium in creating resistance against the antimicrobial factors, it is very important to identify a pattern for its antibiotic resistance. The aim of this study was to deliberate the frequency of pattern antibiotic resistance of pseudomonas aeruginosa strains.
Methods: In this cross-sectional study, 200 pseudomonas aeruginosa isolations (from 86 males and 114 females) were collected from different samples such as urine, blood, wound, catheter and other samples from teaching hospitals in Zahedan City during nine-month period in 2017. After conducting biochemical tests and confirming bacterium type, based on Clinical Laboratory Standards Institute (CLSI), the antibiotic resistance of strains for 10 antibiotics was determined using disk diffusion method. In addition, the minimum inhibitory concentration of three antibiotics such as imipenem, piperacillin/tazobactam and ceftazidime were determined through E-test. The Chi-square test was used for statistical analysis through the SPSS software, version 16 (IBM SPSS, Armonk, NY, USA).
Results: Out of 200 pseudomonas aeruginosa isolations (from 86 males and 114 females), the maximum resistance was related to ciprofloxacin (37%) and gentamicin (28.5%). The minimum resistance was related to piperacillin/tazobactam (6.5%) and ceftazidime (6%). The highest separated strain was from urine sample (54%), blood sample (23.5%) and wound sample (10.5%). Additionally all strains were sensitive to colistin. In this study, the percentage of multidrug-resistance (MDR) and extensively drug-resistant (XDR) strains were investigated, which were 13% and 5.5%, respectively.
Conclusion: In this study, pseudomonas aeruginosa isolates had the lowest resistance to ceftazidime which this antibiotic could be the main treatment option. The high prevalence of MDR strains is a serious warning.

Background: Coronary artery bypass surgery is one of the surgeries in which high blood transfusions are needed. About 20% of all surgical operations require a blood transfusion. Packed cell administration increases perioperative morbidity and mortality. In the United States, from every 1000 people, one has undergone a coronary artery bypass graft surgery, and it is estimated that around 800,000 coronary artery bypass grafts undergo each year. Knowledge about relative blood administration during coronary artery bypass graft surgery improves the ability of blood transfusion centers in healthy and adequate blood donations. For this purpose, this study was conducted to determine the effective factors in the need for blood in a coronary artery bypass graft surgery.
Methods: This cross-sectional study was performed on 317 patients undergoing coronary artery bypass graft surgery in the heart surgery operating room of Imam Khomeini Hospital in Tehran, Iran, from September 2017 to February 2018. Sampling method has been available. The data of this study were extracted from patient files. The products analyzed in the study included packed cell, fresh frozen plasma and platelets. Demographic data, type of surgery, transfusion of blood and products, and hemoglobin level have been reported. P-value less than 0.05 was reported as meaningful.
Results: In this study, 317 patients underwent coronary artery bypass graft surgery. 236 cases (74.4%) were male and the rest were women. The mean of administration of packed cell in women was 2.74±1.3 and in men it was 2.29±1.09 (P<0.001). The mean packed cell administration in patients with hemoglobin levels less than 10 g/dl was 3.27±1.8 and in patients with hemoglobin levels greater than 10 g/dl was 0.99±2.25 (P<0.0001).
Conclusion: The present study showed that the mean transfusion of packed cells in women were more than men in coronary artery bypass graft surgery. Also, hemoglobin levels were the only factor that had a significant effect on infusion of packed cells.

Background: Copenhagen hip and groin outcome score (HAGOS) is the only valid and reliable self-reported questionnaire for assessing symptoms and activity limitations of subjects with hip and groin problems. The aim of this study was to translate and culturally adapt the English version of the HAGOS to Persian and to evaluate its reliability in young athletes with hip and groin pain.
Methods: This cross-sectional study was performed in Tehran University of Medical Sciences, School of Rehabilitation, Iran, from June 2014 to May 2015. In order to develop the Persian HAGOS, the English HAGOS was translated and culturally adapted into Persian language based on the standard forward-backward translation and expert committee review. Then, for the test-retest reliability investigation, young male athletes suffering from hip and groin pain, recruited from sport physical therapy clinics, completed the Persian HAGOS two times with 1-2 weeks interval. Independent samples t‐test and Intraclass correlation coefficient (ICC) was used to determine the test-retest reliability of the six subscales and the total score of Persian HAGOS. The SPSS statistical software (IBM SPSS, Armonk, NY, USA) was used for all analyses.
Results: Fifty young male athletes, mean age 26.12±3.37 years (range: 18-33), participated in this study. ICC value for test retest reliability of total score was 0.74 (95% CI: 0.59-0.84). ICC values for subscales scores ranged from 0.6 for participation in physical activities subscale to 0.79 (P<0.0001) for pain subscale (P<0.0001). There were no significant differences between the test and retest scores obtained for subscales and total scores (t-test, P>0.05).
Conclusion: The HAGOS was successfully translated and cross-culturally adapted from English into Persian language. The Persian version of HAGOS is a reliable questionnaire for the evaluation of young athletes with hip and groin pain in clinics and research.

Background: Asymptomatic hemorrhagic transformation infarct (AHTI) is known as a complication of ischemic attack and maybe occurs in the entire stroke. However, the role of AHTI in the result of the treatment is still not clear, because it is based on the definition of an asymptomatic and not identifiable. The aim of this study was assessment and evaluation frequency of AHTI in acute ischemic stroke patients.
Methods: This prospective cross-sectional study was done in Neurologic Department, Tehran University of Medical Sciences, Tehran, Iran, from April 2015 to April 2016. Second evaluation was done about new neurologic signs and symptoms ten days after stroke. In addition, brain CT scan was used to diagnose of hemorrhagic event in infarct area. If the hemorrhagic event was occur in different area, the patient was consider as a non-hemorrhagic transformation and excluded from the study. Other exclusion criteria include intracranial hemorrhage (ICH), trauma to the head during admission, cerebral vein thrombosis, coagulation disorder, anti-coagulant (heparin, warfarin) administration, induced transformation within 10 days of onset of ischemia, lacunar ischemic and unobservable in thirty T-brain scan, patient's lack of referral for examination and CT scan 10 days after the onset of symptoms, died before CT was considered.
Results: Three hundred and eighty seven patients had inclusion criteria. 249 cases were excluded due to lost following, vein thrombosis of the brain, lacunar ischemia, anti-coagulants recipient (heparin, warfarin), asymptomatic hemorrhagic transformation and death. Finally, 138 cases (86 men, 52 women) with 66.61±9.37 years (50-101 years) were participated in data analysis. Frequency of positive CT scan was evaluated for ischemic stroke evidence in two stages. Of the 138 patients who participated in the study, 75 (54.3%) were positive in the first and 63 (45.7%) cases in the second time. 27 cases (19.6%) had AHTI.
Conclusion: Coronary artery bypass graft (CABG) had significant correlation with ATHI in acute ischemic attack. However, stroke history correlated with decreasing of ATHI. Concerning smoking and consuming the results showed that smoking did not affect the asymptomatic hemorrhagic transformation. Also, the results showed that the use of aspirin and Plavix also had no significant effect on increasing the incidence of ATHI.

Background: Hospital accreditation is an external evaluation of a hospital’s structures, processes and results by an independent professional accreditation body using pre-established optimum standards. Accreditation has an important role in improving the quality, safety, effectiveness and efficiency of hospital services. This study aimed to examine the effects of hospital accreditation program from hospitals managers’ perspective.
Methods: This descriptive and cross-sectional study was carried out in 2015 using a valid and reliable questionnaire designed to examine accreditation effects on hospital performance, hospital employees, patients, and the society. The study population consisted of 914 hospital managers in Iran. Overall, 547 hospital managers were surveyed through stratified random sampling.
Results: About 71% of hospitals achieved grade one and above accreditation status. The mean score of accreditation positive effects in hospitals was 3.16±0.66 out of 5 (Average). Almost 38% of managers were satisfied with the accreditation results in their hospitals. Hospital accreditation program was successful in improving patient and staff safety, reducing medical errors and enhancing staff competencies. Its success in improving communication, promoting organizational culture, continuous quality improvement, resource utilization, and reducing nosocomial infections and hospital mortality rates was moderate. Accreditation was less successful in improving staff satisfaction, getting physicians involved in process improvement, practicing evidence based medicine, attracting patients and increasing hospital income. A statistically significant correlation was found between hospital size and accreditation results (P=0.038, r=-0.090). There was no correlation between using quality management models and getting better accreditation results (P=0.085). However, there was correlation between using accreditation consultants and positive accreditation results (P=0.045, r=-0.087). Utilizing hospital resources, organizational learning, continuous quality improvement and effective communication had the most effect on accreditation success.
Conclusion: The accreditation program had a moderate effect on hospital performance. It is costly to implement accreditation standards in hospitals. Hence, changes should be made to the accreditation system including accreditation standards and methods in order to have more positive effects on the staff and hospitals’ performance.

Background: Intensity-modulated radiotherapy (IMRT) is one of the most usable methods in prostate radiotherapy that is used with different techniques. The aim of this study was to evaluate and compare the dosimetric and radiobiological effects of prostate IMRT techniques regarding to joint volume between the target tissue and organs at risk as a patients anatomical parameter.
Methods: This research was a cross-sectional, analytical, and quantitative study that was carried out from April 2016 to June 2018 at the radiotherapy and oncology center of Shoheday-e-Tajrish Hospital and Medical Physics Department of Tarbiat Modarres University Tehran, Iran. Four various prostate IMRT techniques (9, 7 and 5 fields and automatic) were planned on 63 prostate cancer patients CT scans. Radiobiological effects were calculated using Relative Seriality model for the organs at risk (bladder and rectum) and target tissue. Results of mentioned prostate IMRT techniques were compared based on the patient’s anatomical parameter. 
Results: For the patients with joint volumes ranged from 0 to 15%, statistical differences were not observed among various IMRT techniques. The tumor control probability and complication free tumor control probability values decreased as a function of joint volume. The normal tissue complication probability value increased as a function of joint volume. The 9 and 7 fields IMRT techniques had not any significant differences (P=0.06) in all of the joint volume ranges. In patients with the joint volumes higher than 30%, the 9 and 7 fields techniques showed significantly better radiobiological values in comparison with 5 fields and automatic techniques (P=0.009).
Conclusion: In the patients with lower percentage of joint volume, all the mentioned prostate IMRT techniques showed same radiobiological effects; however, in the patients with higher joint volume percentages (> 30%), the 9 and 7 fields techniques have better results. It is proposed to use the 7 fields technique instead of the 9 fields technique, especially in prostate cancer cases with high uncertainty in patients’ setup.

Background: Staphylococcus aureus is a common pathogen in human that can be the cause of a wide range of infectious diseases including bacteremia, pneumonia, cellulitis, and osteomyelitis and skin and soft tissue infections. The coagulase enzyme is one of the most important virulence factors of this bacterium. The polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) Coa pattern is one of the molecular base typing methods. Molecular typing plays an important role in epidemiological studies of nosocomial infection, such as methicillin-resistant Staphylococcus aureus (MRSA) infection. The PCR-RFLP Coa gene technique provides a useful preliminary method to monitor variations in MRSA populations. We were done Coa-RFLP typing according to the method of Hookey et al., with some modifications.
Methods: In this cross-sectional study, one-hundred fifty isolates of S. aureus from urine and blood samples of patients that collected from educational hospitals of Imam Hossein and Al Zahra Isfahan University of Medical Sciences, Iran, from February 2018 to October 2018 were analyzed. After bacterial confirmation of isolates by Coa gene in polymerase chain reaction (PCR) technique, to perform coagulase gene typing, the repeated units encoding hypervariable regions of the coagulase gene of S. aureus were amplified by PCR. This was followed by AluI restriction enzyme digestion and analysis of restriction fragment length polymorphism (RFLP) patterns.
Results: Of 150 samples, 45 isolated of S. aureus were confirmed by biochemical methods. Of previous positive samples, 36 (80%) isolates carried Coa gene. Two different genotypes of Coa gene were obtained that include bp680 fragment in 20 specimens and bp750 fragment in 16 specimens. After enzymatic digestion by AluI restriction enzyme for RFLP, four different restriction patterns were obtained that including, the 280+400 pattern in 16 specimens (44.4%), 280+470 pattern in 7 specimens (19.4%), 340+340 pattern in 6 specimens (16.6%) and 750 patterns without digestion were in 7 specimens (19.6%).
Conclusion: Using the present experiments, it was determined that the PCR-RFLP pattern, 280+400, was the dominant pattern in the Staphylococcus aureus samples isolated in Isfahan.

Background: The new version of relative values of diagnostic medical services was published in 2014. It was criticized that the previous edition was suffering from an imbalance between relative values related to various specialties and sub-specialties. The main aim of the new edition of the book was to address this problem by providing more balance relative values related to various specialties and sub-specialties. So far, there have not been studies to analyze to what extent the new addition has been succeeded to reach its main goals. The aim of this study was to provide a cross-specialty analysis of the new edition of Iranian relative values for physicians. To our knowledge, this analysis has been performed for the first time in Iran.
Methods: Having reviewed description for each relative value, each of them has been assigned to one or more corresponding specialty or subspecialty. Only relative values for surgical operations were considered and finally 3238 procedures have been recognized to be included in the analysis. The latest version of Iranian relative values for physician was considered for this analysis. In order to compare the average relative values among various specialties and subspecialties, analysis of variance (ANOVA) and Tukey's post-hoc test was used.
Results: Oral and maxillofacial surgery and neurosurgery get the highest (62.81, 60.47 (P<0.001)) and ophthalmology and obstetrics and gynecology get the lowest (28.95, 28.81 (P<0.001)) average relative value. Cardiovascular surgery and plastic surgery get the highest and the lowest (85.25, 50.51 (P<0.001)) average among subspecialties, respectively.
Conclusion: The average relative values are significantly different among specialties and subspecialties. Seeing the difference, itself sounds logical as the job of relative values are to make a difference based on various criteria such as the time and skill needed for each operation, the potential risk for patient and provider it may have, etc. The results of this study provide evidences on how much these differences are. However, if these differences are as there should be needs to be analyzed by further research.

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: QT dispersion means the difference between the minimum and maximum QT interval in a standard twelve standard electrocardiogram, which indicates ventricular repolarization and electrical instability of the heart. In this study, we try to find a link between methadone poisoning and the change in QT dispersion, so that we can accurately assess the patient's condition and medical needs in the future.
Methods: In a descriptive, randomized/ cross-sectional study in the poisoning ward of Imam Reza Hospital in Mashhad from October 2013 to April 2015, all patients who referred to the emergency department because of their methadone toxicity or symptoms, had an ECG with 12 leads taken from them, at the time of the arrival. QT dispersion was calculated manually in comparison to other parameters. Also their blood sample were taken to the lab in order to measure different electrolytes (Mg, K, Ca). To ensure the accuracy of study, patient’s urine samples were taken and tested for methadone. There was no intervention in this study. The control group was also not considered QT scattering and dispersion was compared with normal reference in this study.
Results: In this study, 100 patients were studied, 65 of them males (65%) and 35 females (35%). Mean age of subjects entering the study was 33.87±14.5. The average dose of methadone in these cases was 35.5±35.7 mg. However, their usual dose was 1.11±4.85 mg prior to overdoses, and the average duration of use mentioned in patients who had a history of usage was 5.1 months, but 90% of the subjects did not mention any history. The average measured potassium was 3.99±0.5 meq/l, calcium was 8.94±0.5 meq/l, and magnesium was 1.98±0.26 mg/dl. Average measured oxygen saturation at the time of admission was 94.43±5.6%. Mean QT dispersion was 0.041±0.018 millisecond.
Conclusion: In our study, no significant correlation was found between QT dispersion and methadone poisoning.

Background: Breast cancer is the most commonly diagnosed and the leading cause of cancer death among females worldwide. The rate of breast cancer incidence among Iranian women is 17% of all cancers, it has been ranked first in Iran. This study aimed to investigate the factors affecting axillary lymph node involvement in female patients with breast cancer.
Methods: A cross-sectional study was conducted on 167 patients with breast cancer diagnosed between March 2012 and March 2015 at Shahid Beheshti of Babol, Shahid Rajaei of Tonekabon and Imam Sajad of Ramsar hospitals. A researcher-made questionnaire was used to collect information on the patients and pathology report of tumor and lymph nodes was completed.
Results: The rate of axillary lymph node involvement was observed in 117 patients (70.1%). Mean age was 49.64±11.62 years in the patients with breast cancer. The highest frequency of lymph node involvement was observed in the 40-49 age group (24%). The average size of tumor was 3.39 cm and the majority of patients had a tumor 2-5 cm (T2) but the most involvement was related to T3 (>5cm). The most common type of cancer and grading were invasive ductal carcinoma (93.4%) and tumor grade 2 (52.1%), respectively. Most lymph node involvement was observed in invasive ductal carcinoma and 85.1% of patients had tumor degree 3. 22.2% of patients with vessels involvement had axillary lymph node involvement. 63% of patients’ tumors had receptors of estrogen and progesterone. A statistically significant association was observed between axillary lymph node involvement and tumor size (P=0.031), tumor type (P=0.007), tumor grade (P=0.011), estrogen receptor (P=0.008) and progesterone receptor (P=0.038).
Conclusion: There was a statistically significant association between axillary lymph node involvement and tumor size, type and grade, estrogen and progesterone receptor status, but there was no statistically significant association between axillary lymph node involvement and age and estrogen as well as progesterone receptor status.

Background: Rotator cuff injuries are the most common causes of shoulder pain and supraspinatus muscle is usually involved. Clinical tests are available and inexpensive tools for assessment of shoulder dysfunctions. The empty can (EC) and full can (FC) tests are considered as shoulder gold standard tests. Recently, hug up (HU) test has been developed to assess the supraspinatus. So far, no ultrasonographic study has compared supraspinatus muscle thickness in these testing positions. The present study aimed to compare the supraspinatus muscle thickness in the hug up testing position with the full can and empty can testing positions in young and healthy women.
Methods: Forty healthy women (mean age 21.62±2.4 years) participated in this cross-sectional-comparative study from April to June 2018 in the Biomechanic Laboratory of Rehabilitation School, Shahid Beheshti University of Medical Sciences in Tehran, Iran. The supraspinatus muscle thickness was scanned during rest and contracted states with a 0.5 Kg weight cuff. For contracted states, (A) EC testing position: the arm was at 90º abduction in the scaption plane with the thumb-down, (B) FC testing position: the arm was maintained at 90º abduction in the scaption plane with the thumb-up, (C) HU testing position: the palm of hand was placed on the opposite shoulder with the elbow flexed.
Results: The Bonferroni test showed significant differences (P<0.001) between the muscle thickness in the rest and the testing positions. The muscle thickness in the empty can testing position was significantly less than the full can testing position (P=0.001), no significant difference was found between the muscle thickness in the hug up testing position compared to the full can and empty can testing positions.
Conclusion: All of the empty can, full can and hug up testing positions demonstrated increased mean muscle thickness when compared to the rest position and the greatest muscle thickness was in the full can testing position. It seems that supraspinatus muscle thickness in hug up testing position is similar with empty can and full can testing positions.

Background: Recently, the surgical methods are used in patients with anterior cruciate ligament rupture and have been associated with successful results. There are different results in the term of using of the surgical methods for anterior cruciate ligament that often is associated with some complications such as infection, static laxity, remaining the pain, need to recurrence surgery, and limitation in the range of motion. Therefore, in this study, we aimed to compare outcomes of anterior cruciate ligament reconstruction with the fixed loop and the adjustable loop.
Methods: This cross-sectional study was done on 60 patients undergoing anterior cruciate ligament reconstruction referred to Kashani Hospital of Isfahan, Iran, from March 2017 to February 2019. Also, this study was approved in the Isfahan University of Medical Sciences, Isfahan, Iran. 30 patients were assigned to a fixed loop and 30 patients under the adjustable loop method. Postoperative outcomes were compared with the fixed loop group and the adjustable loop group.
Results: The frequency of static laxity below 8 mm in the fixed loop group was 83.3% and the frequency of static laxity below 8 mm in the adjustable loop was 76.7%. There was no significant difference between the fixed loop group and the adjustable loop group based on static laxity. Also, no infection was seen in the fixed loop group and the adjustable loop group. There was no significant difference between the fixed loop group and the adjustable loop group in terms of range of motion and knee score before and after surgery. After surgery, 96.7% of the fixed loop group and 86.7% of the adjustable loop group returned to normal activity. There was no significant difference between the fixed loop group and the adjustable loop group in terms of return to normal activity and satisfaction.
Conclusion: Using the fixed loop is effective, useful, and with low-complication for the patients with anterior cruciate ligament and also using the adjustable loop grafts is effective, useful, and with low-complication for the patients with the anterior cruciate ligament rupture.

Background: Congenital heart diseases are the second group of congenital anomalies in infants. These disorders are a major cause of death in the first year of a child's life. Early detection helps to treat these diseases better. In this study cardiology consultations of hospitalized infants in the neonatal intensive care unit were evaluated.
Methods: In this cross-sectional study, two hundred and fifty pediatric cardiology consultations conducted in Shahid Beheshti Hospital in the year 2012 were reviewed. Information such as the cause of consulting, delivery type, age of parents, relative couples, family history of congenital heart disease, maternal medications, maternal background diseases, the final diagnosis, and prognosis follow-up of the patients were recorded in a designed questionnaire. Finally, the data were entered into the SPSS software, version 16 (IBM SPSS, Armonk, NY, USA) and analyzed using descriptive statistics and chi-square test. P-value of less than 0.05 was considered significant.
Results: The mean age of the consulted neonates was 4.845±5.14 days with a gestational age of 33.933±3.65 weeks. Male sex and cesarean section were the most frequent. Fifty-six percent of consulted infants were male. The present study revealed that prematurity (76%), murmurs (30.8%), respiratory distress syndrome (14.4%) and cyanosis (13.2%) were the most common causes of the cardiac consultation seeking among infants. Seventy-six percent of infants were consulted due to prematurity. Eighty-four percent of infants had a normal conditions. Septal defects (ventricular or atrial septal defect) and patent ductus arteriosus were the most common disease diagnosed with the prevalence of 27.5 and 17.5%, respectively. There was a significant relationship between preterm labor and congenital heart disease (P<0.001). Additionally, prematurity associated with respiratory distress syndrome and using assisted reproductive techniques.
Conclusion: The higher prevalence of congenital heart disease in the present study, compared with other studies, reflects the fact that cardiology consultation based on clinical suspicion leads to the more identification of congenital heart disease that means the right referral of newborns for consultation was accompanied with a higher incidence of heart failure.

Background: dehydration fever is a common problem during the first week of life. This study aimed to compare the characteristics of neonates with fever due to dehydration and healthy infants.
Methods: This cross-sectional study was performed on 324 neonates including 120 neonates with normal body temperature and 204 neonates with fever due to dehydration (hyperthermia) referred to Ghaem Hospital in Mashhad, Iran from 2017 to 2019, using a convenience sampling method and a researcher-made questionnaire. Infants presenting with elevated body temperature and having an axillary temperature above or equal to the rectal temperature and with no clinical or laboratory evidence of infection were considered as fever due to dehydration (case group). Infants who were referred for a routine examination or had jaundice but did not require treatment were considered as controls. Infant characteristic (neonatal age, sex, Apgar score, defecation frequency, the first defecation, breastfeeding frequency, urinary frequency, duration of feeding, birth weight, daily weight loss, daily weight loss percentage, lethargy, irritability, mucosal dryness, status fontanelles, hyperthermia, convulsion, apnea, decreased consciousness and  infant hospitalization) and maternal information (age, weight, parity, hospital stay, breast problems, mode of delivery, breastfeeding position, delayed breastfeeding, and pregnancy problems. The data were analyzed using Student’s t-test, Chi-square and SPSS software, version 20 (IBM SPSS, Armonk, NY, USA).
Results: In dehydration fever of newborn, admission weight, frequency and duration of feeding, defecation frequency, maternal age were low, but time to first feeding were high (P<0.05). In fever of dehydration: restlessness, mucosal dryness, fontanel status, seizure, apnea, decreased consciousness, breastfeeding with traditional remedies, inappropriate breastfeeding position, lack of let-down reflex, delayed onset of lactation, breast problems and jaundice were more frequent.
Conclusion: Infants with fever of dehydration were more likely to weight loss, delayed in first feeding, shorter feeding times and lower duration of feeding, higher sodium, urea, creatinine, and blood glucose levels. According to the results of this study, breast problems, inappropriate breastfeeding position, absence of reflux, delayed lactation, less frequent breastfeeding, consumption of breast milk with dextrose, manna, and clay tap were risk factors for dehydration fever.
 

Background: Sepsis or blood stream infection is a clinical lethal syndrome with severe systemic inflammatory response to infection, if not treated quickly, is associated with dangerous consequences and high morbidity and mortality. The traditional and conventional method for identification of sepsis is blood culture method which is so time-consuming and long that it eliminates the possibility of rapid treatment. Although, new molecular methods, due to their high sensitivity, specificity, and speed, lead to the rapid and accurate and exact detection of bacterial sepsis within only a few hours. The aim of this study was diagnosis of bacteremia in patients with suspected sepsis using amplification of 23S rRNA gene by polymerase chain reaction (PCR).
Methods: This cross-sectional study was performed in two clinical and analytical steps at Shahid Beheshti University Hospital in Kashan City, Iran, in twelve months from November 2016 to December 2017. The blood samples of two hundred and fifty-six patients with suspected sepsis admitted to Shahid Beheshti Hospital were studied by PCR method using specific primers of 23S rRNA gene of the bacteria.
Results: The finding of molecular assays using PCR showed that of 256 blood samples that were collected from patients with clinical signs and symptoms of sepsis, 80 (30.2%) diagnosed with bacteremia. Of these patients diagnosed with sepsis, 46 out of 80 (57.5%) were male while 34 out of 80 (42.5%) were female. The most PCR positive results were obtained among patients with diabetes and bedsore as underlying diseases (21.3%). Statistical analysis showed that there was a significant correlation between results of molecular methods by PCR assays and history of antibiotic use. 
Conclusion: Overall, the results of the present study showed that the molecular methods such as polymerase chain reaction using universal 23S rRNA primers is an appropriated test for diagnosis of bacteremia in blood samples of patients with suspected sepsis.

Background: Medical malpractice is one of the most important legal issues in medicine committed more or less by physicians. The medical staff has inadequate or deficient awareness of medical errors and their importance. Therefore, this study investigated the frequency of medical malpractices/errors resulting in death in files referred to the Iranian Legal Medicine Organization.
Methods: The study population in this descriptive cross-sectional research consisted of all doctors who had been sued in Tehran's Legal Medicine Organization (Forensic Committees of Tehran Province) from the first day of July 2018 to the end of December 2018. The study was carried out in and under supervision and support of the Legal Medicine Research Center. Data were collected using a checklist of the files from Tehran's Legal Medicine Organization.
Results: The results showed that most medical errors are of organizational types. Major medical failures occur in university-affiliated hospitals among the male technical staff aged 41-50 years with a work experience less than 6 years. Most complaints were recorded against general practitioners, general surgeons, and anesthesiologists, respectively. The smallest percentage of the complaints related to orthopedics, urologists, and ear, nose, and throat (ENT) specialists.
Conclusion: The results of the study indicated that most of medical failures have of an organizational nature and occur in university hospitals among male technical officials who are in the fifth decade of life with a low work experience. So, paying attention to these issues can help the better selection of technical officials. The technical authorities of the hospitals must be careful about the responsibilities given to them. In order to reduce the failure of the technical authorities of the hospitals, doctors with a high standard of service should be appointed as technical officers. These doctors ought to possess legal knowledge and be familiar with the course of complaints filed in the judiciary.

Background: Health care associated infections (HAIs) are a class of infections that infect patients during hospital admissions and receive medical services. These infections occurs within 48 to 72 hours of admission and up to 6 weeks after discharge. Surveillance of device-associated infections (DAIs) in intensive care units (ICUs) is substantial in planning healthcare strategies. This study was conducted to determine the device-associated infections' burden and antimicrobial resistance patterns.
Methods: In this descriptive-analytic study, three common device-associated infections included central line-associated bloodstream infection (CLA-BSI), ventilator associated pneumonia (VAP), and catheter-associated urinary tract infection (CA-UTI), were assessed in intensive care units of Besat Hospital in Hamedan from April 2017 to April 2018. In order to determine the incidence of device-associated infections, the number of device-associated infection cases was calculated during the study period and divided into the number of device-days used. The device-days included all days of exposure to that device (vascular catheter, endotracheal tube (ventilator), or urinary catheter) in all patients in the study population.
Results: Out of 1806 intensive care unit admitted cases, 168 patients (9.3%) were device-associated infection with distribution of 92 cases (55%) of ventilator-associated pneumonia (VAP), 56 cases (34%) of catheter-associated urinary tract infection (CA-UTI) and 20 cases (11%) of central line-associated bloodstream infection (CL-BSI). The incidence of VAP, CA-UTI and CL-BSI was 44.7, 17.5, and 21.61 days, respectively. The most organisms were Acinetobacter (27.4%), Klebsiella (18.3%), Escherichia coli (E. coli) (15.4%). Vancomycin-resistant enterococcus (VRE) was 75%. Acinetobacter resistance to colistin and carbapenem was 16.8%. About half of Pseudomonas isolates were resistant to meropenem.
Conclusion: According to the present findings of this study, a high incidence of device-associated infections and resistant organisms in our intensive care units were documented, which represents a need to reinforce the preventive and control programs. Various results in different studies can be due to differences in the level of health care in different centers and countries.

Background: Arterial pressure is one of the most important physiological variables and often needs to be monitored repeatedly or continuously in perioperative period. Arterial pressure monitoring is one of the standard monitoring in operating room. During general anesthesia, blood pressure can be measured by using a noninvasive arterial pressure method or continuous invasive arterial pressure by an invasive arterial line. Comparison of invasive measurements in the patient’s candidate to esophagectomy has not been assessed. The aim of this study was to compare invasive and noninvasive blood pressure in these patients.
Methods: In a prospective, cross-sectional, observational study, 42 hemodynamically stable patients candidate for esophagectomy under general anesthesia in supine position were evaluated at Urmia Imam Khomeini Hospital operating room from June 2017 to April 2018. The patients had American Society of Anesthesiologists (ASA) physical status II or III and the patients who had complete heart block and marked arterial blood pressure differences greater than 10  mmHg in the two arms were excluded. After induction of anesthesia and patients monitoring, the radial artery was cannulated for invasive blood pressure monitoring and noninvasive blood pressure was measured via the arm cuff on the other hand at the four-time intervals: after radial artery cannulation (T1), during release of esophagus (T2), during anastomosis (T3) and at the end of operation (T4).
Results: The mean difference between indirect and direct systolic blood pressure was 0.85±2.93, -8.42±2.9, 6.50±3.60 and 2.67±2.6 mmHg and for diastolic blood pressure was 3.53±2.67, 4.57±2.22, 2.10±2.58 and 1.03±1.53 mmHg respectively, at the T1 to T4. At the all-time intervals, there were no statistically differences between systolic and diastolic blood pressure measurement regarding invasive and noninvasive blood pressure (P=0.77)
Conclusion: Noninvasive arterial blood pressure showed acceptable agreement with invasive measurements for systolic, diastolic and mean pressure. According to fhe finding of this study, there were no statistical differences between systolic and diastolic blood pressure measurement regarding invasive and noninvasive blood pressure and these two methods can be used in selected patients.