Tehran University Medical Journal

Background: Hepatitis B is the most common blood-borne viral infection that is considered as a major public health problem of the world's major health problems. The aim of this study was to investigate the prevalence of hepatitis B virus (HBV) infection among blood donors referring to blood transfusion centers.
Methods: This retrospective cross-sectional study was performed on 216004 volunteer blood donors referring to blood transfusion centers of Iran from the beginning of April 2011 to April 2015. Then the positive hepatitis B surface antigen (HBsAg) test was performed using the enzyme-linked immunosorbent assay (ELISA) and neutralization methods.
Results: Of the 216004 blood donors, 279 (12.12%) were positive for HBsAg, and the incidence of infection was a decreasing trend over a four-year period. Among HbsAg positive cases, 97.14% and 2.86% were male and female, respectively. Significant differences between males and females were found (P=0.000). The number of HBsAg positive cases among married people (238 cases, 85.3%) in compared with single people (41 cases, 14.7%) was significantly higher (P=0.000). The average age of HBV infected cases was 39.6±10.3 years. Most HBsAg positive cases were 45-36 years old (30.8%) and lowest prevalence was seen in the age group above 56 years old (4.6%). Highest infected people with Hepatitis B Virus had low degree of education. Relationships between HBV infection with age and degree of education were statistically significant (P=0.000).
Conclusion: The results of this study showed that based on our findings, prevalence of hepatitis B surface antigen among blood donors have declined significantly during the four years of study.

Background: Amphotericin B is one of the most useful therapeutic modalities for the treatment of patients with invasive fungal infections, in spite of serious side effects, namely kidney injury, electrolyte imbalances, and infusion-related reactions. The goal of this study was to assess the different aspects of premedication practice and the incidence and types of infusion-related reactions in patients receiving amphotericin B.
Methods: This observational study was performed on 70 hospitalized patients who received amphotericin B in different departments of two university hospitals, affiliated to Isfahan University of Medical Sciences, Isfahan, Iran, from January 2017 to February 2018. Information on physicians’ performance regarding premedication administration for amphotericin B, including the types and doses of medications administered prior to amphotericin B infusion, as well as patients’ clinical data including infusion-related side effects were collected and then analyzed in comparison with the standard practice guidelines.
Results: The study population consisted of 70 patients with the mean age of 51.6±18.3 years, who received amphotericin B for 8.2±3.5 days. From 70 evaluated patients, 21 patients (30%) had encountered the infusion-related reactions, including chills, fever, urticaria, headache, and hypotension. These side effects were evident in 19 patients (27%) who received no premedication and 2 patients (3%) who received only one drug as premedication, before amphotericin B administration. Twenty patients (28%) experienced chills, fever and headache, while 7 patients (10%) had nausea and vomiting during amphotericin B infusion. Hydrocortisone 50-200 mg, was the most prescribed agent for premedication (in 67% of patients), while chlorpheniramine 10 mg (in 50% of patients) and promethazine 10 mg (in 35% of patients) were the second and third prescribed ones, respectively.
Conclusion: In this study, the patients who received no or only one drug as premedication experienced infusion-related side effects. This emphasizes the necessity for standard premedication practices to prevent this type of adverse reactions. Considering the higher price of liposomal form of Amphotericin-B, if prescribed correctly, even the conventional form would be an effective and tolerable treatment for invasive fungal infections.

Background: The onset of primary progressive multiple sclerosis (PPMS) can be triggered by sun exposure and physical activity. The present study aimed to determine the risk of sun exposure and physical activity in PPMS development.
Methods: The case-control study recruited PPMS cases and healthy controls from the general population from September 2019 to September 2020 in Tehran, Iran. The selection of sex-matched controls from the same source population of cases was performed. Sun exposure was assessed in terms of exposure time in two age groups of 13-19 years and over 20 years in winter and summer.

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.

Background: Since numerous chemotherapy regimens for the treatment of patients suffering from acute lymphoid leukemia (ALL) have been recently developed, having basic information about the previous results of using the Hyper-CVAD regimen in order to compare with other common chemotherapy regimens is essential. The aim of this study was to evaluate demographic, clinical and outcome of ALL patients receiving Hyper-CVAD regimen.
Methods: In this retrospective study, nighty eligible ALL patients treated with the Hyper-CVAD chemotherapy regimen in Omid Hospital, Isfahan, Iran during April 2016 till April 2019 were considered. We evaluated the demographic variables, pathological data and other clinical factors by an information sheet designed by main investigator. The main purpose of this study was to evaluate overall survival, progression-free survival, and overall response rate of patients along with patients’ clinical characteristics and other relevant factors using Kaplan-Meier or Cox-regression and other statistical analyses. 

Results: The mean overall survival and the median survival of patients were 44.8±2.93 and 36.7±7.47 months; respectively. Also the mean progression free survival of patients was 44.44±3.30 months. More than 84.4% of patients encountered complete remission (CR) after receiving Hyper-CVAD regimen. Reaching to CR had positive significant effects on patients’ overall survival and median survival. However, the bone marrow transplantation variable alone did not affect the patients’ overall survival. The variables such as being B/T Cell ALL, Philadelphia, myeloid marker, and central nervous system involvement did not affect the overall survival of patients but the relapse index indicated the significant effects. The median survival time is higher in patients with no relapse episode. None of the initial lab data had any significant effects on patients’ overall survival. Conclusion: For the first time in Iran, we have obtained the mean survival outcome of ALL patients after applying the Hyper-CVAD regimen. According to the results, the mean overall survival, progression free survival and other survival items in Iranian patients suffering from ALL and receiving Hyper-CVAD regimen were in consistent with previous studies in the world.

Background: Brain-computer interface systems provide the possibility of communicating with the outside world without using physiological mediators for people with physical disabilities through brain signals. A popular type of BCIs is the motor imagery-based systems and one of the most important parts in the design of these systems is the classification of brain signals into different motor imagery classes in order to transform them into control commands. In this paper, a new method of brain signal classifying based on deep learning methods is presented.
Methods: This cross-sectional study was conducted at Isfahan University of Medical Sciences, School of Advanced Technologies in Medicine, from February 2020 to June 2022. In the pre-processing block, segmentation of brain signals, selection of suitable channels and filtering by Butterworth filter have been done; then data has transformed to the time-frequency domain by three different kinds of mother wavelets including Cmor, Mexicanhat, and Cgaus. In the classification step, two types of convolutional neural networks (one-dimensional and two-dimensional) were applied whereas each one of them was utilized in two different architectures. Finally, the performance of the networks has been investigated by each one of these three types of input data.

Results: Three channels were selected as the best ones for nine subjects. To separate 8-30 Hz, a 5th degree Butterworth filter was used. After finding the optimal parameters in the proposed networks, wavelet transform with Cgauss mother wavelet has the highest percentage in the both proposed architectures. Two-dimensional convolutional neural network has higher convergence speed, higher accuracy and more complexity of calculations. In terms of accuracy, precision, sensitivity and F1-score, two-dimensional convolutional neural network has performed better than one-dimensional convolutional neural network. The accuracy of 92.53%, which is obtained from the second architecture, as the best result, is reported. Conclusion: The results obtained from the proposed network indicate that suitable, and well-designed deep learning networks can be utilized as an accurate tool for data classification in application of motion perception.

Background: Intraoperative bleeding is an unwanted and common complication in orthopedic surgeries, which can be aggravated by the preventive administration of anticoagulants to prevent deep vein thrombosis. The present study examines the effect of prophylactic enoxaparin to prevent thromboembolism on the amount of bleeding in femoral head surgeries where it is not possible to use a tourniquet.
Methods: A prospective descriptive-analytical study was conducted from July to March 2017 in Kashani Hospital, Isfahan, in 120 patients without a history of coagulation disorders who were candidates for reconstructive surgery for femoral head and neck fractures. Inclusion criteria involved age over 18, BMI less than 30, no history of coagulation disorders, no preoperative use of anticoagulant drugs, normal PT, PTT, and INR before starting enoxaparin. The patients didn’t have any coagulation disorder and all of them were under prophylactic dose of enoxaparin before surgery. The patients were subjected to spinal anesthesia with the same method. Signs related to degree of bleeding recorded during surgery and recovery care.  Data were collected and entered into SPSS software version 20, and central tendency and dispersion indices were calculated for quantitative variables. Descriptive tables and charts were utilized for qualitative variables. Correlation coefficient and linear regression analyses were performed for the final interpretation of results.

Results: There was a significant relationship between mean arterial pressure and intraoperative bleeding (p-value=0.001). The dose of enoxaparin prescribed was associated with the volume of fluids received, the amount of bleeding, the amount of tranexamic acid, phenylephrine, labetalol, TNG and fentanyl administered during the operation with a p-value of less than 0.05. Also, there is a significant relationship between the prescribed dose of enoxaparin and the duration of surgery and duration of recovery care (p-value less than 0.05). Conclusion: The study examines the impact of prophylactic enoxaparin on intraoperative bleeding, finding a significant correlation with dosage and duration. No notable difference in bleeding was observed in patients with a GFR below 30. Enoxaparin administration correlated with increased bleeding, MAP levels, fluid volume, tranexamic acid use, and hypotension medications during surgery.

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

Background: Dermatomyositis is a rare inflammatory muscle disease with systemic manifestations, in which muscle weakness, dysphagia, and pulmonary and cardiac involvement are common problems. The aim of this report is to examine the challenges and management of general anesthesia in a patient with dermatomyositis with the rare complication of buried bumper syndrome after PEG placement and gallbladder surgery.
Case Presentation: A 53-year-old male patient was referred to the operating room of Seyed al-Shohada Hospital in Jahrom for gallbladder stone surgery due to abdominal pain in April-May 2024. The patient had presented to the hospital approximately one month prior with complaints of myalgia and progressive lower limb weakness. He subsequently developed severe dysphagia. Based on clinical and paraclinical evaluations, a diagnosis of dermatomyositis was ultimately made and confirmed. Due to the swallowing difficulty, a Percutaneous endoscopic gastrostomy (PEG) tube was placed for him. His treatment regimen included high-dose corticosteroid pulse therapy and Intravenous immunoglobulin (IVIG). One month later, the patient was readmitted with acute abdominal pain. Imaging studies revealed multiple gallstones, leading to a referral to a general surgeon for operative management. Additionally, a complication related to the PEG tube, known as Buried Bumper Syndrome, was considered as a potential cause of the abdominal pain. Given the patient's history of dermatomyositis and swallowing disorder, a comprehensive re-evaluation was performed in the operating room. Cricoid pressure (Sellick maneuver) was applied to prevent aspiration. The surgery was successfully completed, and the patient remained hemodynamically stable throughout the procedure.
Conclusion: General anesthesia in patients with dermatomyositis requires careful preoperative evaluation, continuous muscle and hemodynamic monitoring, selection of appropriate doses of muscle relaxants, and use of stress doses of steroids. In addition, attention to specific complications such as buried bumper syndrome after PEG and proper airway management and prevention of aspiration are of particular importance. The present report emphasizes that multifaceted and planned management can lead to successful outcomes in these patients.