Tehran University Medical Journal

Background: One common symptom of diabetes is diabetic retinopathy, if not timely diagnosed and treated, leads to blindness. Retinal image analysis has been currently adopted to diagnose retinopathy. In this study, a model of hierarchical self-organized neural networks has been presented for the detection and classification of retina in diabetic patients.
Methods: This study is a retrospective cross-sectional, conducted from December to February 2015 at the AJA University of Medical Sciences, Tehran. The study has been conducted on the MESSIDOR base, which included 1200 images from the posterior pole of the eye. Retinal images are classified into 3 categories: mild, moderate and severe. A system consisting of a new hybrid classification of SOM has been presented for the detection of retina lesions. The proposed system includes rapid preprocessing, extraction of lesions features, and finally provision of a classification model. In the preprocessing, the system is composed of three processes of primary separation of target lesions, separation of the optical disk, and separation of blood vessels from the retina. The second step is a collection of features based on various descriptions, such as morphology, color, light intensity, and moments. The classification includes a model of hierarchical self-organized networks named HSOM which is proposed to accelerate and increase the accuracy of lesions classification considering the high volume of information in the feature extraction.
Results: The sensitivity, specificity and accuracy of the proposed model for the classification of diabetic retinopathy lesions is 98.9%, 96.77%, 97.87%, respectively.
Conclusion: These days, the cases of diabetes with hypertension are constantly increasing, and one of the main adverse effects of this disease is related to eyes. In this respect, the diagnosis of retinopathy, which is the same as identification of exudates, microanurysm and bleeding, is of particular importance. The results show that the proposed model is able to detect lesions in diabetic retinopathy images and classify them with an acceptable accuracy. In addition, the results suggest that this method has an acceptable performance compared to other methods.

Background:  Some studies show that frozen shoulder is due to the pathologic changes in the muscles around the shoulder. Measurement of the ultrasonic thickness of a muscle is a method for measuring the muscle changes. There is no study about the reliability of measurement of the muscle’s ultrasonic thickness around the shoulder in patients with frozen shoulder. The present study aims to investigate the intra-rater reliability of the ultrasonic thickness measurement of the supraspinatus, deltoid and upper trapezius muscles in women with frozen shoulder and healthy women.
Methods: This study was carried out during 4 months (June to October 2017). Twenty women consisted of 10 patients with frozen shoulder (mean age: 51.6±9.41 years) and 10 healthy subjects (mean age: 35.5±8.22 years) participated in this study. The patients from some clinics and hospitals in Tehran, and healthy subjects consisted of some personals and students in the School of Rehabilitation of Shahid Beheshti university of Medical Sciences participated in the present study. Measurements of ultrasonic thickness of the upper trapezius, supraspinatus and deltoid muscles in rest position carried out by the same rater two times in 48 hours. Ultrasonography instrument with linear probe (frequency: 7.5 MHz) were used for measurement of muscle thickness in millimeter.
Results: Reliability of the ultrasonic measurements of the muscle thickness in patients and healthy subjects was respectively as follow: The upper trapezius muscle (0.81, 0.81), the supraspinatus muscle (0.90, 0.92) and the middle deltoid muscle (0.93, 0.96). The reliability of the ultrasonic measurements of the muscle thickness for the upper trapezius muscle and the supraspinatus muscle was higher in healthy subjects compared to the patients with frozen shoulder. The reliability of the ultrasonic measurements of the middle deltoid thickness for the patients and healthy subjects was similar.
Conclusion: It seems that ultrasonography is a reliable method for measuring the thickness of the muscles around the shoulder in patients with frozen shoulder and healthy subjects.

Background: The average age of women with breast cancer in Iran is at least 10 years lower in comparison to developed countries and the incidence of the disease in Iranian women is on a rise. According to studies, diets that are diverse in food groups can play a role in protecting against chronic diseases including cardiovascular diseases and cancer. Diet diversity score is an indicator used to measure diversity between and within food groups. This study aimed to assess the relationship between diet diversity score and breast cancer risk.
Methods: This case-control study was carried out from April 2014 to February 2015 at Shohada Hospital in Tajrish, Tehran. Demographic and anthropometric data of 298 participants including 149 breast cancer cases and 149 apparently healthy women were collected. A valid food frequency questionnaire containing 168 food items was completed to assess usual dietary intake through face to face interviews. Energy was calculated using Nutritionist 4 software (First Databank Inc., Hearst Corp., San Bruno, CA, USA) and diet diversity score was calculated using five food group scoring. Odds ratios with 95% confidence intervals were obtained using logistic regression test to evaluate the association between breast cancer risk and diet diversity score tertiles.
Results: There was no significant difference in weight, height, body mass index between the two groups, but physical activity level and daily energy intake showed a significant difference (P<0.001). After adjusting for the effect of confounding variables including energy, body mass index, physical activity, menopause status, family history of breast cancer, contraceptive use, number of pregnancy, age of menarche and smoking, the risk for developing breast cancer was 86% lower in those in the highest tertile of diet diversity score compared to those in the first tertile (OR=0.14, 95% CI=0.06-0.31). An inverse and significant association was found between breast cancer risk and diversity scores of fruits and milk groups (P<0.001).
Conclusion: Higher diet diversity score is associated with reduced risk of breast cancer.

Background: Obesity is one of the causes of onset and exacerbation of rheumatoid arthritis. However, limited studies have examined the association between body composition and severity of disease. The aim of this study was to evaluate the association between severity of rheumatoid arthritis with various types of obesity and the comparison of anthropometric indices between patients with rheumatoid arthritis and healthy subjects.
Methods: This case-control study was conducted on 95 patients (48.8±10.4 years) with rheumatoid arthritis as a case group and 95 healthy people (46±9.3 years) as a control group carried in Golestan Hospital, Ahvaz, Iran, from April 2016 to February 2017. Weight, height, waist circumference (WC), hip circumference (HC) and body fat percentage (BFP) were measured. The anthropometric indices were calculated. The disease severity was calculated according to disease activity score 28 (DAS28).
Results: There was no significant difference between two groups regarding their gender ratio (1:1), age (P=0.16) and height (P=0.58). The weight, body mass index (BMI), body fat (BF), WC, HC, waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and other obesity indices include a body shape index (ABSI), body adiposity index (BAI), abdominal volume index (AVI), body surface area (BSA) and Conicity index (CI) in patients with rheumatoid arthritis are significantly higher than healthy subjects (P<0.05). No difference in fat free mass was observed between two groups. Waist to height ratio and BAI compared with other indicators had the highest correlation with the DAS28 score. In addition, prevalence of obesity by waist circumference (82% vs. 61%), obesity by BMI (47% vs. 33%), and obesity by BFP (91% vs. 83%) was higher in patients with rheumatoid arthritis than healthy subjects. The risk of rheumatoid arthritis in people with central obesity by waist circumference (OR=2.92, 95% CI 1.50-5.70) was greater than obesity defined by BMI (OR=1.77, 95% CI 0.98-3.18) or BFP (OR=2.37, 95% CI 1.01-5.53).
Conclusion: The results of present study indicate association of rheumatoid arthritis disease severity with obesity types (especially central obesity) and anthropometric indices.
 

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: Prostate cancer has been reported as a worldwide important kind of cancer and the second most common cause of cancer-related mortality among men. Prostate-specific antigen (PSA) serum level is one of the most important markers of prostate cancer diagnosis. While PSA level helps predict the risk of prostate cancer development, researchers still looking for ways to increase the accuracy of prognostic models. To increase the specificity of PSA and decrease of unnecessary biopsies and morbidity, PSA-related parameters such as PSA doubling time (PSADT) have been used. In this study, the relationship between this factor and the severity of prostate cancer was evaluated.
Methods: In this retrospective study, the data of patients who were subjected to transrectal ultrasound-guided (TRUS) biopsy of the prostate and referred to Imam Khomeini Hospital, Tehran, between 2009 and 2017 were reviewed. We enrolled the men with at least two consecutive elevated PSA level within three months to calculate PSADT. Based on the pathology report, primary and secondary Gleason score (GS) were determined. Correspondingly, considering GS, the patients were divided into two groups with high-grade and low-grade tumor (GS<7 considered as low-grade and GS>7 considered as high-grade tumor).
Results: Totally, 1712 cases of TRUS biopsy of the prostate were studied. Among them, 547 (32.3%) had prostate cancer, of whom 73 cases were eligible based on inclusion criteria and were consented to enroll in the study. According to the data obtained, we found a significant difference in PSADT between the two groups of patients with high-grade and low-grade malignancy (mean±SD PSADT, 9.8±14.2 vs. 16.1±14.9 respectively, P=0.004). Considering the seven months as the cut-off point for PSADT in determining malignancy, there was a significant difference between the two groups according to Fisher's exact test (P=0.01).
Conclusion: In our study, PSADT cut-off of 7 months provided the greatest accuracy for differentiation between low-grade and high-grade malignancy, and PSADT has acceptable accuracy for the diagnosis of high-grade tumors.

Background: Medical errors are those mistakes committed by healthcare professionals due to wrong execution of a planned healthcare action or execution of a wrong healthcare action plan whether or not it is harmful to the patient. Medical errors may cause patients to suffer and have huge financial costs for the healthcare system. Identifying and measuring medical errors and adverse events are essential for improving patient safety. The objectives of this research were to measure medical errors and adverse events rates, to identify their severity and also analyze their underlying causes in a general educational hospital in Tehran, Iran by using The Global Trigger Tool.
Methods: A descriptive, cross-sectional, and retrospective approach was used in this study. The medical records of 377 hospitalized patients between April 2015 and March 2016 were examined using simple random sampling method. Patient’s records were reviewed by a nurse using The Global Trigger Tool. Then, a physician authenticated the findings of the adverse events and rated their severity. The causes of adverse events were identified using brain storming and Ishikawa Cause And Effect Diagram.

Background: The bronchopulmonary carcinoid tumor accounts for 1-2% of all adult malignancies of the lung and 20-30% of all carcinoid tumors. Cushing’s syndrome is the result of chronic exposure to increased concentration of exogenous or endo-genus cortisol hormone, and it is generally associated with central obesity, metabolic syndrome, and hypertension. Treatment is based on decreasing cortisol levels in the blood, through medical or surgical approaches. Surgery is considered the main treatment for ectopic ACTH-secreting tumors. Paraneoplastic Cushing’s syndrome due to bronchopulmonary carcinoid tumor is a rare clinical occurrence, which has been reported in only a few case reports and case series. An average of 71% of typical carcinoid tumors were found to be central. 79% of patients with a peripheral carcinoid tumor and evidence of mediastinal node enlargement are likely to have an atypical carcinoid.
Case Presentation: A 45 Years old male with a history of ectopic Cushing’s syndrome over the last two years was admitted to our department (Department of thoracic surgery, Teahran, Iran). He had a positive Octreotide scan of the hilar lymph nodes of the left lung at last evaluations. During the surgery, in the left lower lobe was resected (because a small nodule with tumoral appearance was seen in left lower lobe) with hilar and mediastinal lymph node dissection. Pathology indicated a typical carcinoid tumor with mediastinal lymph node metastasis. Plasma cortisol and ACTH were normalized following the surgery.

Background: Intravenous (IV) injection of drugs is one of the most common methods of drug prescription in hospitals, which is a complex, potentially hazardous and erroneous method; accordingly, it requires control methods to reduce the potential risks. This study focused on determining the frequency and types of different medication errors while preparing and administering mostly used IV drugs in three intensive care units (ICU) and one general department in AL-Zahra hospital, Isfahan, Iran.
Methods: This cross-sectional observational study was conducted for 6 months from September 2017 to March 2018. To determine the frequency of different medication errors, a quoting sampling method was applied to select and observe 400 cases of IV drug administrations. All nurses from any studied department were included in this study. Different stages of preparation and administration of the observed drugs were compared to an instructed checklist prepared by the clinical pharmacist.

Life expectancy has increased throughout the world and, as a result, the population of the elderly is also rising. From the age of 30 years old, the human body mass loses about 0.1 to 0.5% of its skeletal muscle mass annually, which is accelerated after the age of 65 years old. Aging is characterized by a decrease in the progression of musculoskeletal and physical activity known as sarcopenia. Sarcopenia has a complex molecular pathogenesis that includes age-related changes in muscles’ neuromuscular activity, muscle protein replacement, the hormone levels and the related sensitivity of human body to these mentioned factors. The pathogenic conditions and other disorders in sarcopenia are the chronic inflammatory states that include oxidative stress and changes in behavioral factors, especially in nutritional status and physical activity. By definition of the European Working Group on Sarcopenia in Older People (EWGSOP), the diagnosis of sarcopenia is determined by the presence of two main factors which are low muscle mass and low muscle function. Besides, specific sarcopenia-related biomarkers have been identified for early diagnosis and accurate identification of the main pathophysiology mechanisms involved in the development of the disease. Since sarcopenia has adverse outcomes on public health in terms of behavioral factors, frailty, hospitalization and mortality of people, it is an important necessity for the social health system to plan some therapeutic approaches to prevention. The main and more important of these therapeutic approaches have known as exercises, nutritional supplements and hormonal therapies. Also, other new therapeutic strategies are under investigation to be introduced in the future. However, currently, it has been shown that only physical exercise has a positive effect on the controlling and prevention of sarcopenia and its adverse effects on human and public health. However, the role of appropriate nutrition is also effective. Therefore, carefully designed studies in terms of better utilization of physical activity are needed to achieve useful therapeutic results for sarcopenia management. Thus, this survey aims to review the other considerable studies on the pathogenesis, appropriate evaluation of the disease and treatment options for sarcopenia.

Background: Neurosurgery practice conflicts with many challenges during the COVID-19 pandemic; Including the lack of beds in intensive care units, as well as the use of some methods such as drills and trans-nasal and trans-oral approaches that produce aerosols or are directly in contact with patient discharge. Due to these challenges, developing a clinical guideline to help neurosurgeons and medical staff in decision making and improving patients and medical staff safety during the COVID-19 pandemic is the purpose of this study.
Methods: First, all of the relevant clinical guidelines to neurosurgical practice during the COVID-19 pandemic were extracted from the data centers. Finally, five clinical guidelines were selected. The questions and the items were designed according to these guidelines. The answers to each of the questions were extracted from these guidelines. The complementary evidence was extracted by searching in the data centers again. Finally, the answers were edited and the edited answers were considered as the recommendations. These recommendations were sent to 4 experts in the Neurosurgery field and 2 experts in the infectious diseases field. The appraisers evaluated the recommendations according to the AGREE-REX instrument.  This instrument has 9 items and 3 domains including clinical applicability, values and preferences, and implement ability. Recommendations with above 80% agreement were considered as the final recommendations.

Background: Appendicovesical fistula in patients suffering from cystic fibrosis is a rare condition. Although this situation is so rare it should be considered in the differential diagnosis, dealing with a patient with cystic fibrosis and chronic abdominal pain with no response to primary management. To the best of our knowledge, this is the third case of appendicovesical fistula in a patient with cystic fibrosis.
Case presentation: In this paper, we are reporting a bladder lesion of a nine-year-old Iranian girl, a known case of cystic fibrosis, who was referred to pediatric urology clinic, Children’s Medical Center, Tehran University of Medical Sciences. The girl is a known case of cystic fibrosis on regular follow-up who had chronic abdominal pain for about one year. While primary management had been failed for her, further workups were done by her pediatric pulmonologist. In her pelvic sonography, the radiologist reported a bladder lesion so she was referred to our clinic. Cystoscopy was done for her, but transurethral biopsy/resection was impossible according to the lesion location. The non-papillary nature of the lesion raised our concern about the possibility of genital rhabdomyosarcoma with bladder invasion. So, an Abdominopelvic CT scan and a pelvic MRI were also done for her. Intact uterus and vagina with an enhancing lesion at the dome of the bladder with some degree of inflammation/attachment around the adjacent GI tract were detected on her images. The urachal inflammatory/tumoral process could not be ruled out. So open surgical exploration was planned. During the attempt for surgical exploration and partial cystectomy, at the Children’s Medical Center in December 2021, we found that the mass, is actually her appendix which has invaded the urinary bladder, and presented as a bladder lesion.
Conclusion: Abdominal pain is a relatively common complaint of patients with cystic fibrosis. Every caregiver or physician should consider rare conditions, dealing with a cystic fibrosis patient whose abdominal pain does not respond to common management.

Results: No RBC was detected in microscopy. The majority of the leucocytes were lymphocytes with rare accompanying platelets. The radiolabeling efficiency of the procedure was higher than 40%. The viability test indicated more than 80% of viable cells. The radiochemical purity of the final product was more than 95%. Two to four hours after injection, low background images were acquired. The liver and spleen were target organs with low-grade urinary, thyroid, and GI activity. Conclusion: Employing multi-stage centrifugation, Tc-HMPAO labeled leucocyte scan could be efficiently performed.

Conclusion: The concurrent prevalence of upper respiratory tract disorders with gastrointestinal infections of H. pylori was observed to be almost equal and significant in elderly and young patients. Due to the fact that the simultaneous occurrence of two types of infections and diseases in people is very dangerous, screening of patients with each of these infections is necessary to identify the other infection and prescribe appropriate drugs.

Background: Among diseases causing acute lower abdominal pain in women, isolated fallopian tube torsion is a rare cause that occurs mainly in women of reproductive ages and if left untreated can lead to fertility problems. Immediate diagnosis and timely surgery are urgent and necessary to preserve the fertility of females. Successful pregnancy with simultaneous involvement of isolated fallopian tube torsion is one of the rare operations in the world.
Case Presentation: The reported case is a 37-year-old pregnant woman (Gravid 2, with 33-week gestational age) with nausea, vomiting and abdominal pain in August 2020 who presented to the Maryam Hospital in Karaj in August 2020. The patient was examined in the operating room under anesthesia, and pain in the right and lower abdomen was observed. There was no anorexia, and on examination, there was severe tenderness in the right lower quadrant (RLQ) area. There was no pain in other parts of the abdomen. Ultrasonography in the patient's tenderness showed an image of a tubular and cystic structure measuring 30×10 mm. In CBC test, leukocytosis with high PMN (Polymorphonuclear), (WBC: 11700 mm3 and Neutrophil: 78%) was observed. During laparotomy, isolated torsion of the right fallopian tube observed, half of which was cyanotic. Due to the confirmation of fimbriae necrosis during surgery, preservation of uterine tube integrity, fallopian tube detorsion, excision of cyanotic fimbriae and hemorrhagic cyst of fimbriae, intra-abdominal fluid suction and fimbriae repair performed. The patient discharged in good condition after two days and gave birth to a healthy baby at 38 weeks of gestation by cesarean section.

Conclusion: Isolated fallopian tube torsion should be considered as a potential differential diagnosis in patients that have acute lower abdominal pain in women of reproductive ages and even adolescents. Early diagnosis and early surgical intervention are critical to maintaining the fallopian tube and fertility in the future. Laparoscopy is one of the main diagnostic tools for assessing, management and maintenance isolated torsion of the fallopian tube.

Results: Then bacterial colonies were counted, contamination reduction was measured, and the shelf life of the solution was determined according to the standards.  Results showed that a 60-to-90-second scrub with an alcohol-based disinfectant is the best way to reduce hand contamination and, thereby, nosocomial infections. Conclusion: Based on the study findings, alcohol-based solutions can be recommended for surgical scrubs, according to WHO guidelines.

Background: Athletes are seeking ways to enhance sports performance and protect themselves from the long-term effects of exercise. One potentially effective solution is the administration of colostrum supplements. Evidence suggests that it can support immune system function by maintaining the integrity of the intestinal barrier. The aim of this study is to evaluate the impact of colostrum supplementation on athletes' immune system performance.
Methods: This systematic review searched English and Farsi databases including Medline, Scopus, Embase, ScienceDirect, Scientific Information Database, Islamic World Science Citation, Cochrane, and Google Scholar website without a time limit until November 2023. Eighteen randomized clinical trials, following the Cochrane protocol, were analyzed to assess the effects of colostrum supplementation on athletes' immune systems. The studies measured various factors, such as the amount of cytokines, concentration of serum immunoglobulins, salivary immunoglobulin, white blood cell count, neutrophil oxidative reactions, and the rate of respiratory system-related diseases in athletes during the consumption of colostrum supplements or its derivatives. The potential risks of bias in the studies were evaluated using the Cochrane Risk of Bias 2.0 tool for randomized controlled trials.

Results: The findings of these studies indicate that daily consumption of 3.2 grams of colostrum for 24 weeks can decrease the production of inflammatory cytokines caused by exercise and increase anti-inflammatory cytokines. Additionally, a daily intake of 20 grams of colostrum supplement can protect against the reduction of neutrophil function and immune responses resulting from long-term exercise. The group receiving colostrum experienced fewer upper respiratory tract diseases compared to the placebo group in studies that investigated this indicator. No significant effects on leukocyte count were observed with any dosage of supplementation, and the results of studies on other immune indicators were inconsistent. Conclusion: Bovine colostrum can improve athletes' immune system performance by regulating immune parameters and mitigating the negative effects of intense exercise. However, the contradictory results of existing studies call for further research that examines different doses of colostrum in various sports.

Background: Rectal prolapse, characterized by the extrusion of the rectal mucosa through the anal sphincter, is a relatively rare condition in children. This condition can be attributed to several anatomical and functional factors. This study aimed to investigate defecation habits in children with rectal prolapse.
Methods: This retrospective study was conducted from 2017 to 2021 in Akbar and Sheikh children's hospitals. The study population included 50 children under the age of 14 who were diagnosed with rectal prolapse and visited the hospitals. Data were collected using pre-prepared checklists and analyzed using SPSS version 24. Inclusion criteria were children under 14 years diagnosed with rectal prolapse, while exclusion criteria included incomplete data or other severe unrelated health conditions.

Results: The results showed that 67.4% of the sample were boys, and the most affected age group was children under 2 years (38.8%). A total of 57.1% of the children had daily bowel movements, and 68.2% reported consistently hard stools. Additionally, 48% of the children experienced pain or burning during defecation. Conclusion: The findings of this study indicate that children with rectal prolapse often face challenges related to stool consistency and defecation pain, despite having frequent bowel movements. These results emphasize the need for targeted interventions to improve stool consistency and manage pain to effectively prevent and treat rectal prolapse.