Tehran University Medical Journal

Background: Long after the implementation of the “Health System Transformation Project”, no comprehensive assessment of patient and nurse satisfaction rate has been carried out in Iran based on available databases. Thus, this review study was designed and performed to answer this question: “How is the evaluation of the Health System Transformation Project in nurse and patient satisfaction dimensions.”
Methods: A systematic review of related studies based on preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines was performed via keywords such as “Health System Transformation Project”, “Transformation Project”, “health”, “Iran”, “challenges”, “physician”, “nurse”, “patient”, and “satisfaction” to search Iranian (Magiran and Scientific Information Database, SID) and international databases (PubMed, ISI web of knowledge, Scopus, Google Scholar, and ProQuest) with OR and AND operators from March 2014 to April 2019. Also the quality of studies was assessed using STROB checklist (special for cross-sectional studies). Then required information (for example type of studies, sample size, mean age of participants and satisfaction score) were gathered from studies.
Results: From 43 articles that were gathered from primary stages, 18 articles were selected after passing different screening levels. On average, the level of patiaent satisfaction with the Health System Transformation Project was acceptable. Ghazvin province was seems more successful in satisfaction of patients against of other provinces. However, various positive and negative reports were found about the satisfaction of nursing groups. Generally, it seems that Tehran province (at the center of Iran) was more successful in performing the Health System Transformation Project (from the aspect of satisfaction of different groups).
Conclusion: Based on obtained results, patient’s satisfaction was appropriate in most of studies and also in nursing group was under average level.

Asthma is an inflammatory and chronic disease that affects about 300 million people globally. The disease is more common in developed countries. The increase in the prevalence of asthma is not only due to genetic factors, but also to many environmental factors related to urbanization and type of nutrition. It has been reported that obesity is an independent risk factor for asthma and obese children are at higher risk of asthma. The researchers found that many of the common phenotypes of obesity and asthma are due to genetic effects and some genetic component is common to asthma and obesity. Genetic data suggest that there are areas of genetic overlap between the obesity and asthma genes. These children experience more severe asthma and have a poor treatment outcome. On the other hand, there is an association between vitamin D deficiency in the earlier stages of life and incidence of asthma in the following years. Interestingly, obesity is a common risk factor for both asthma and vitamin D deficiency. Therefore, study on the interaction of asthma, obesity, and vitamin D deficiency may play an important role in unraveling the intricate nature of asthma. Prevalence of Pediatric asthma in 6-7 and 13-14 years-old children has been reported more than 10% in Iran. In this review we aimed to assess the latest findings about pediatric asthma and its association with obesity and vitamin D in Iran and the other countries. In addition, the results of a pilot study that has examined the frequency of overweight and obesity, as well as vitamin D deficiency in children with asthma in Tehran, are briefly presented. Enrolling a national study on obesity and vitamin D levels in children with asthma, can provide excellent information on the effects of obesity and vitamin D deficiency on asthma in Iranian children. Also the results could provide a basis for ecological studies to measure correlation between pediatric asthma and Sunlight and food and cultural habits in different parts of the country. Also, it is recommended that for a better understanding of the subject, experimental studies examine the effect of vitamin D supplementation and vitamin D-rich diets on the prevention and treatment of pediatric asthma in different age groups as well as different ethnicities of Iran.

Background: Health insurance literacy is a nascent concept that has emerged mainly after the implementation of the law known as Obamacare in the United States. This study seeks to identify the themes of health insurance literacy in Iranian society.
Methods: The study approach is qualitative. Data were collected using nine semi-structured interviews, ten focal group meetings with the presence of 86 experts of an insurance organization and a specialized meeting with fifteen academic experts, from September to December 2018 at the organization's location. MAX QDA10 software was used to organize the data. Qualitative data analysis was performed using continuous comparison analysis and in the form of directional qualitative content analysis based on the conceptual model (Paez et al 2014). Coding was performed independently by two researchers and then collected. Results were reviewed by an external observer. Finally, in a specialized meeting with the participation of representatives of specialized (groups secretaries) and academic experts(participants in the initial interviews), the findings of the study were re-examined and confirmed

Background: Since pulmonary angiography is the only non-invasive method for diagnosing pulmonary embolism, the use of radiation reduction methods without affecting the quality of images seems necessary. One of the simplest reasons for unnecessarily increasing of patient exposure is repetitive imaging due to poor image quality. Therefore, it is necessary to identify and eliminate the factors that reduce the image quality, which leads to duplication of imaging or reduced accuracy.  In this study, the reasons for decreasing the image quality of pulmonary computed tomography (CT) angiography were investigated.
Methods: This cross-sectional study was performed over a period of 6 months (May to November 2018) in a university-affiliated hospital. Data of 75 patients suspected of pulmonary embolism who were referred for CT angiography were collected. All CT scans were performed by a 16-slice CT scanner (Lights Speed, GE Healthcare) with fixed imaging parameters including 100 kVp and 100 mA. In order to evaluate the adequacy of pulmonary artery enhancement, the Hounsfield unit (HU) of the main pulmonary artery was measured in the aortic arch, upper, and lower segmental parts. Also, 8 factors affecting the image quality were examined.

Background: Wound healing is a complicated process involving the proliferation of the epithelial cells, deposition of granulation tissue as well as recruitment of inflammatory cells. It also is a hot topic of research for trauma, orthopedics and general surgery studies. There are many forms of cells involved in this process. This study aimed to design a tissue-engineered wound dressing consisting of chitosan fibers containing silver ion bioactive nanoparticles for wound healing.
Methods: The present study is an experimental study that was conducted in the research laboratory of the Department of Biology of Mohaghegh Ardabili University from April to November 2019. All experiments of this study have been performed under the ethical guideline of Helsinki and in accordance with the Ethics Committee of the Mohaghegh Ardabili University of Ardabil (Iran). The wound dressing of nanofibers was prepared by the sol-gel method. Cytotoxicity was assessed by MTT assay. Then the antimicrobial properties of nanofibers were determined by the disk diffusion method. SEM and AFM images were obtained from nanofibers. Finally, nanofibers were analyzed by the FTRI method.

Background: Emphysematous cholecystitis is a rare variant of acute cholecystitis with high mortality and morbidity rate. Emphysematous cholecystitis most often occurs in older men and Emphysematous cholecystitis often occurs in patients with chronic diseases such as diabetes and vascular disease. The combination of emphysematous cholecystitis and pneumoperitoneum is even rarer. In this study, we reported a rare case of pneumoperitoneum on plain abdominal X-ray with emphysematous cholecystitis in an 83-year-old woman.
Case Presentation: The patient was 83 years old, lady who had been referred to the emergency department of Ghaem Hospital, Mashhad University of Medical Sciences in April 2019, due to diffuse abdominal pain that had started suddenly 3 days earlier. Pneumoperitoneum, the air in the gallbladder wall and the air encircling the gallbladder were reported in standing and supine abdominal x-rays and standing chest X-rays. At first, the patient was resuscitated and treated with broad-spectrum antibiotics. After initial treatment, the patient underwent open cholecystectomy with a subcostal incision on the right and a diagnosis of emphysematous cholecystitis. After surgery, the patient's general condition improved and she was discharged without mortality and morbidity with oral third-generation Cephalosporin antibiotics. The general condition of the patient after discharge was good in the examinations performed in the clinic of Ghaem Hospital, 1 and 3 months after discharge.

Conclusion: Emphysematous cholecystitis is a rare and severe form of acute cholecystitis that occurs due to the process of arterial ischemia caused by contamination with anaerobic bacteria and the formation of gas in the wall and lumen of the gallbladder. Emphysematous cholecystitis is more severe than other types of acute cholecystitis and has higher mortality and morbidity and is life-threatening. Due to the acute and progressive course of emphysematous cholecystitis, correct and timely diagnosis and treatment are important.

Background: Hemorrhoids are one of the most common perianal diseases. They have several surgical and non-surgical treatment methods. Among surgical procedures, Stapler hemorrhoidopexy method has recently gained widespread acceptance. Hemorrhoidopexy with a circular stapler usually has a series of common and mild complications and a few rare and life-threatening complications such as rectal perforation, which requires emergency surgery. In this article, a case of rectal perforation in a middle-aged man following hemorrhoidopexy with Circular Stapler in a Procedure for Prolapse and Hemorrhoids (PPH) is reported that he underwent emergency surgery.
Case Presentation: The patient is a 43-year-old man who presented to the emergency department of Mashhad Ghaem Hospital in June 2020 due to acute general abdominal pain especially in the lower abdomen that started 3 days ago the patient has a history of hemorrhoidopexy with a Circular Stapler in a Procedure for Prolapse and Hemorrhoids (PPH) 5 days ago. The patient had a fever at the time of referral, other vital signs were normal. During the examination, the patient had tenderness and rebound tenderness, especially in the lower abdomen. Hydropneumoperitoneum or Retropneumoperitoneum or Hydroretropneumoperitoneum was reported on the abdomen and pelvic Computed Tomography (CT) scan with and without oral and intravenous contrast. The patient was diagnosed with intraperitoneal rectal perforation. He was then diagnosed with intraperitoneal rectal perforation and treated with intravenous antibiotics and surgery. After surgery, the patient's general condition improved and he was discharged without mortality and morbidity with the good condition after 6 days.

Conclusion: Hemorrhoidopexy with a stapler is more widely accepted than other hemorrhoidectomy methods especially manual methods for prolapse hemorrhoids due to less postoperative pain, shorter hospital stays, and faster return to work. Although this procedure usually has mild side effects that do not require surgery, sometimes life-threatening complications such as rectal perforation may happen, which requires prompt diagnosis and appropriate treatment.

Background: Osteoarthritis (OA) is the most common form of arthritis characterized by progressive loss of articular cartilage, causing pain and loss of articular function. High glucose is a crucial inflammatory factor playing a pivotal role in the pathogenesis of OA that induces ROS production. Since most of the current therapies for OA are short-term benefits, hence, there is high demand for finding novel therapeutic agents for OA treatment. Recent studies have demonstrated that mesenchymal stem cells secrete important therapeutic factors that protect chondrocytes. In the current study, we investigated the protective potential of Adipose-derived stem cell conditioned medium (CM-ADSC) as an alternative to cell therapy in high glucose-mediated oxidative stress in C28I2 human chondrocytes.
Methods: This experimental study was performed in the Department of Pharmacology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran from May 2018 to August 2020. Adipose-derived stem cells were cultured until they reached 90% confluence then washed with PBS and cultured in a FBS-free medium for 48 hours. The conditioned medium was collected and centrifuged. The protective effect of the concentration of conditioned medium on high glucose (75mM)-induced oxidative stress in C28I2 cell viability was evaluated by WST-1 assay. Total RNA was isolated from the treated and untreated cells with TRIzol reagent. The mRNA expression of antioxidant enzymes including, glutathione S-transferase-P1 (GSTP1), catalase (CAT), and superoxide dismutase1 (SOD1) was evaluated by reverse transcription-polymerase chain reaction in treatment and non-treatment groups.

Results: Adipose-derived stem cell conditioned medium pretreatment remarkably protected C28I2 cells against high glucose. The expression of mRNA of CAT, GSTP1, and SOD1 significantly increased following treatment with the conditioned medium (50%) for 24 hours in high glucose-exposed cells as compared to the control. Conclusion: Present study indicates that the Adipose-derived stem cell conditioned medium can reduce oxidative stress. It seems that the conditioned medium may protect cartilage in the progression of osteoarthritis.

Background: In most patients, the accessory spleen (AS) is small in size. However, in patients who have undergone splenectomy, AS may hypertrophy. This manuscript presents a rare case of spontaneous AS rupture nearly two decades after a prior splenectomy due to trauma. After searching multiple databases, only a few similar cases have been reported to date. In any acute abdominal patient with a history of previous splenectomy who presents with a mass in the anatomical location of the spleen, along with evidence of hematoma and free abdominal fluid on imaging, the possibility of AS rupture should be considered.
Case Presentation: In February 2022, a 36-year-old man who had undergone splenectomy due to trauma 16 years ago was referred to the emergency department at Imam Ali Hospital in Bojnord. He complained of sudden onset of severe abdominal pain, preferably in the upper region of the abdomen. The patient denied having any recent issues. Based on the patient's history and examination, at perforated stomach ulcer and pancreatitis were initially suspected. However, except for leukocytosis, no other abnormalities were observed in the laboratory tests. Ultrasound revealed a low-echo mass-like lesion in the anatomical location of the spleen. Another low-echo mass-like lesion, indicating a hematoma with abundant free fluid in the abdomen and pelvis, was also observed near the aforementioned mass. CT scan confirmed these findings. Open surgical and re splenectomy procedures were performed, and the diagnosis of spontaneous AS rupture was made based on clinical examination and imaging findings.

Conclusion: In any patient with a history of previous splenectomy who presents to the emergency room with diffuse and acute abdominal pain, even without recent trauma, if a mass-like lesion is observed in the anatomically suspicious location of the spleen in the left subphrenic space, along with other evidence of rupture such as hematoma/laceration and free fluid in the abdominal cavity, accessory spleen rupture should be considered as the main differential diagnosis.

Case Presentation: The patient is an 18-year-old woman, 20 weeks pregnant, who came to the Emergency department of Bentolhoda Hospital in Bojnurd with diffuse  sudden onset of abdominal pain in the September of 2023. On examination, the patient's vital signs were unstable, which was due to the presence of hemorrhagic shock. In the examination of the patient's abdomen, or generalized tenderness and rebound tenderness? was evident, suggesting peritonitis. According to the ultrasound report, abundant free fluid and fluid containing blood was drained from the abdomen under ultrasound guidance. The patient underwent surgery with the diagnosis of hemorrhagic shock with a midline incision of the abdomen above and below the umbilicus. In the performed surgery, evidence of splenic artery aneurysm rupture was evident. For the patient, ligature and resection of splenic vessels (artery and vein) and splenectomy were performed. After surgery and stabilization of the patient's condition, fetal health ultrasound was performed, and the fetus had no heartbeat. Therefore, medical induction of abortion was performed, and after 48 hours, the fetus was completely expelled, and then mother was transferred to the ward. And four days after the surgery, she was discharged with general improvement. No remarkable adverse effects were observed after surgery. Conclusion: One of the rare diseases is splenic artery aneurysm, which is difficult to diagnose due to its asymptomatic rupture and high mortality rate.

Background: Lower gastrointestinal bleeding, a symptom that can become the cause of a life-threatening condition, has a 33 per 100,000 prevalence. The origin of lower gastrointestinal bleeding in most cases is the small intestine, colon, or anorectal parts. Surgical consultation in patients with gastrointestinal bleeding is one of the most necessary measures so that the patient can be treated at the appropriate stage with a greater chance of success before reaching shock. In the case of uncontrolled gastrointestinal bleeding, surgery is recommended as soon as possible when endoscopic and radiological treatments are not possible or effective.
Case Presentation: In this article, we present a case of uncontrolled lower gastrointestinal bleeding in a 50-year-old patient who was admitted to Imam Khomeini Hospital in Tehran on December 15, 2021. Despite performing appropriate paraclinic measures such as sonography, endoscopy, and colonoscopy the gastrointestinal bleeding origin was not determined. On the other hand, our investigations showed that she had liver cirrhosis. Due to the instability of the patient's condition due to continued lower gastrointestinal bleeding, the medical team decided to perform surgery. The surgeon noticed that the origin of the bleeding was a vascular entanglement at the small intestine-navel junction, and the procedure involved segmental excision of the small intestine.

Conclusion: In cirrhotic patients, lower gastrointestinal bleeding is an emergency condition, and if the source of the bleeding is not accessible via endoscopy or colonoscopy, diagnosing and treatment become extremely difficult. Computed tomography angiography and subsequent surgery are effective approaches for diagnosing and treating these conditions. When lower gastrointestinal bleeding is uncontrolled, exploratory laparotomy should be considered. Due to the unknown origin of bleeding, exploratory laparotomy may not be successful, so using endoscopy during surgery can help to diagnose the location of the lesion in these cases; However, in some cases despite all measures, the source of bleeding may not be determined, in these case the rate of rebleeding after surgery will be high.

Background: one of the most common and important complications of COVID-19 is cough. The present study was designed with the aim of comparing the effect of althaea officinalis and eucalyptus nebulizer on the severity of cough in COVID-19 patients.
Methods: in this randomized clinical trial, from January 2022 to June 2022, 36 patients with COVID-19 were selected and randomly divided into three groups. Next, the severity of cough was recorded two hours before the intervention based on the visual analogue (VAS) in both groups until the patient was admitted to the hospital, then, one cc aqueous extract of althaea officinalis with five cc Normal Saline for the althaea officinalis group and four cc aqueous extract eucalyptus whit five cc Normal Saline for the eucalyptus group, were nebulized once a day for 15 minutes. Two hours after the intervention, the intensity of cough was again recorded in two groups. This intervention continued until the hospitalization of the patients. No intervention was done for the control group. The data was analyzed with Spss software at a significance level of less than 0.05.

Results: In this study before the intervention, there was no statistically significant difference between the three groups in terms of cough intensity (p>0.05), but after the intervention on the second and third days, there was a statistically significant difference between the three groups in terms of cough intensity. The rate of reduction in cough severity in althaea officinalis group was higher than the other two groups (p<0.05).  Also, the results of Friedman's test indicated that althaea officinalis and eucalyptus nebulizers incense improved the severity of cough in patients over time. Conclusion: the use of althaea officinalis and eucalyptus nebulizer improved the severity of cough in patients with COVID-19, but althaea officinalis nebulizer had a greater effect on cough severity compared to eucalyptus. It is suggested to use althaea officinalis nebulizer as well as eucalyptus as a treatment method along with other treatment methods.

Case Presentation: A 76-year-old female patient with diffuse abdominal pain that started a week ago and worsened since 2 days ago in the winter of 2024, referred to the emergency room of Imam Ali Bojnurd Hospital. In the examination, the patient met the criteria for shock. Abdominal examination revealed peritonitis. After initial resuscitation and stabilization of the patient's condition, an X-ray was performed for the patient. According to the Standing chest x-ray, pneumoperitoneum report, the patient underwent surgery with midline incision. In the performed surgery, evidence of gangrene and perforated was evident in a part of the small intestine, and The patient is a candidate for resection of the gangrenous and perforated intestinal segment, and then the two proximal and distal ends of the resected area were removed as an ileostomy from the right side of the abdomen. At the end of surgery, before closing the abdominal wall, the patient suffered a cardiac arrest, and CPR was started for the patient in operation room. After starting the chest massage, the patient suffered a grade 5 liver tear, the bleeding of the liver was stopped by packing with four Large Abdominal pads and CPR continued for 45 min, but unfortunately the patient died. Conclusion: One of the rare complications of cardiopulmonary resuscitation and chest massage is visceral damage, including liver rupture. Considering that its symptoms are similar to cardiac arrest, it is difficult to diagnose in case of rupture and has a high mortality rate. According to the reports of liver and visceral damage after CPR, some studies have recommended the use of Focused Assessment with Sonography for Trauma (FAST) to detect visceral damage after CPR.

Background: Benign tumors of the gastrointestinal tract with a muscular origin are typically found in the esophagus, stomach, or small intestine, and rarely in the large intestine. Approximately 3% of all gastrointestinal leiomyomas occur in the large intestine, primarily in the descending colon and sigmoid colon. These lesions are usually asymptomatic and are often discovered during endoscopic procedures.
Case Presentation: A 38-year-old female patient admitted to the emergency department of Imam Ali Hospital in Bojnurd city in January 2024, reporting vague and nonspecific lower abdominal pain, abdominal distension, nausea, vomiting, low appetite and signs of partial gastrointestinal obstruction over the past week that don’t have any history of weight loss, gastrointestinal bleeding, constipation or family history of cancer. Her symptoms had not responded to Over-the-counter (OTC) medicines and outpatient treatment. Given the nonspecific manifestations, a CT scan of the abdomen and pelvis with iv contrast was requested for further evaluation of inta abdominal disease. The CT findings indicated a 5.5 cm lesion at the beginning of the large intestine, which exerted pressure on the distal part of small intestine, leading to evidence of partial obstruction of the distal part of small intestin. The patient was diagnosed with small bowel obstruction due to an ascending colon tumor and was scheduled for surgical intervention. She underwent resection of right colon, 10-15 cm of terminal ileum along with drainage of the regional lymph nodes. The excised tissue sample was sent for histopathological examination, which suggested a benign colon tumor likely to be a leiomyoma. To facilitate a more accurate diagnosis, immunohistochemical analysis was recommended, which confirmed the diagnosis of leiomyoma.
Conclusion: Colonic leiomyomas can present with various symptoms depending on their size and location. Due to the difficulty in differentiating leiomyomas from malignant colonic tumors, particularly when they are larger, surgical intervention is often recommended. This case highlights the importance of early diagnosis and appropriate management strategies for these tumors to prevent potential complications.

Background: Intestinal lymphangiomatosis is a rare benign disorder of the gastrointestinal tract characterized by abnormal proliferation and dilatation of lymphatic channels within the intestinal wall and mesentery. It accounts for less than 1% of gastrointestinal tumors and predominantly affects the small intestine, particularly in pediatric patients. Clinical manifestations vary widely depending on the size, location, and extent of the lesions, ranging from asymptomatic presentations to acute complications. Due to its rarity and nonspecific features, early diagnosis is often difficult. Imaging modalities, especially ultrasonography, computed tomography, and magnetic resonance imaging, are crucial for initial evaluation and preoperative planning.
Case Presentation: We report an infant who presented with failure to thrive, progressive abdominal distension, and acute symptoms of gastrointestinal obstruction. The patient was admitted to Imam Reza Hospital, Bojnurd, in February 2024. A detailed clinical assessment and laboratory evaluation were performed, followed by abdominal ultrasonography, which revealed a multiloculated cystic mass originating from the small bowel, highly suggestive of a lymphatic malformation. Due to complete small bowel obstruction and worsening clinical status, urgent exploratory laparotomy was undertaken. Intraoperative findings demonstrated a cystic lesion involving a segment of the small intestine, causing total luminal obstruction. Segmental resection of the affected bowel with primary anastomosis was performed, and the resected specimen was submitted for histopathological analysis. The postoperative course was uneventful, with gradual resolution of abdominal distension and successful reintroduction of enteral feeding. Histopathological examination confirmed intestinal lymphangioma, showing dilated lymphatic channels lined by endothelial cells within the intestinal wall, with no evidence of malignancy. During follow-up, the patient demonstrated satisfactory weight gain and normalization of gastrointestinal function, without recurrence or postoperative complications.
Conclusion: Although rare, intestinal lymphangiomatosis should be considered in infants presenting with failure to thrive and signs of bowel obstruction. Timely imaging, particularly ultrasonography, is essential for early diagnosis. Surgical resection remains the definitive treatment in symptomatic cases and is associated with favorable outcomes. Increased clinical awareness can help prevent delayed diagnosis and minimize associated morbidity.

 

Background: Subarachnoid hemorrhage (SAH) is a life-threatening emergency condition often accompanied by severe, sudden-onset headache. The main causes are head trauma and aneurysm rupture. Pain management in these patients remains challenging, typically requiring opioids which carry significant adverse effects. As anti-neuropathic agents, gabapentin and pregabalin may serve as suitable alternatives to opioids. This systematic review aimed to evaluate the efficacy and safety of gabapentin and pregabalin in managing SAH-associated headaches.
Methods: Following PRISMA guidelines, we conducted comprehensive searches in PubMed, SCOPUS, Web of Science, and EMBASE through May 2025. Key search terms included "Gabapentin," "Pregabalin," "Subarachnoid Hemorrhage," and "Headache." After initial screening, we selected English or Persian-language articles investigating these medications' effects on SAH-related headache. After removal of duplicates and screening, four eligible studies (including randomized controlled trials and cohort studies) were included for final analysis. Data on study type, sample size, type of interventions, headache management-related outcomes, as well as safety and tolerability profiles were extracted.
Results: Pregabalin demonstrated significant efficacy, showing a statistically significant reduction in pain intensity compared to placebo before anesthesia induction (P≤0.004) and up to 24 hours post-operatively (P=0.007). Additionally, patients receiving pregabalin required significantly fewer rescue analgesics (P≤0.005). In contrast, gabapentin did not produce a statistically significant reduction in pain intensity or morphine equivalent requirements compared to placebo, although a non-significant trend toward decreased pain was observed. Safety profiles were favorable for both medications; no serious adverse events leading to drug discontinuation were reported.
Conclusion: Pregabalin appears to be an effective, safe, and well-tolerated option for managing SAH-related headache, significantly reducing both pain intensity and opioid requirements. Current evidence for gabapentin remains limited and inconclusive, warranting further large-scale, randomized controlled trials to confirm its potential role in this setting.