Tehran University Medical Journal

Historically, tuberculosis has been the leading cause of death throughout human history. Tuberculosis infection (TB) causes by Mycobacterium tuberculosis that is very dangerous and can affect any parts of the body, especially lungs. Tuberculosis infection still remains a serious threat to human public health due to its contagious nature, capability to stay latent form in host for indefinite time and then appear as active disease. It is estimated that one third of world’s population, nearly 2 billion persons are infected with Mycobacterium tuberculosis. Transmission occurs among people through inhalation of infected droplets. Lungs and especially alveolar macrophage are primary sites of infection. Mycobacterium tuberculosis bacilli by preventing fusion of phagosome with lysosome can remain alive inside the macrophages. Such situation defined as latent infection. In fact, persons with latent tuberculosis infection (LTBI) are only infected with M. tuberculosis without any sign of infectious. Latent infection in compared with active infection is not contagious, but in about 10-5 percent of people will develop active tuberculosis especially in elderly and people who use immunosuppressive drugs. Pulmonary TB is an active form of tuberculosis infection in which bacteria can spread among people by infected droplets. So identifying and treating people with latent TB infection can significantly reduce the progression of latent form to active infection. The tuberculin skin test (TST) is the most widely used test in worldwide that is applied to determine a person who is infected with M. tuberculosis. TST provide valubale information for diagnosis LTBI however its specificity can be reduced by bacillus Calmette-Guérin (BCG) vaccination and infected with non-tuberculous mycobacteria (NTM). In TST test host hypersensitivity responses to Purified protein derivative (PPD) from mycobacterium are evaluated. TST positive reaction indicates the presence of high risk for acquiring TB infection or progression of latent tuberculosis to active form. Previous studies indicated that there is correlation between TST response and subsequent risk of active TB. Experimental evidence has shown that treatment of latent infection in the basis of positive TST reduces the risk of active TB. Although TST is far from gold standard but it's low cost and simplicity make it a suitable laboratory test especially in developing country.
 

Background: Sonography is used for measuring the muscle morphology including length, depth, cross-sectional area, bulk and pennation angle. The supraspinatus is the most common affected muscle among the rotator cuff muscles. There is no study about the reliability of sonographic measurement of supraspinatus thickness in the positions of empty can (EC), full can (FC) and hug up (HU) tests. The present study aims to investigate the intra-rater reliability of the measurement of sonographic thickness of supraspinatus muscle in the rest and positions of the EC, FC and HU tests.
Methods: The present study was a descriptive-analytic study which was carried out in a cross-sectional method on ten healthy women aged: 22.10±2.76 years without any tendon pathology. The study was carried out during four weeks (January to March in 2017). The supraspinatus thickness was scanned during rest and contracted states. The positions of measuring ultrasonic thickness of supraspinatus were as follow: position of EC test: the arm in 90-degree elevation in the scaption plane with the thumb-down, position of FC test: the arm in 90-degree elevation in the scaption plane with the thumb-up, position of HU test: the palm of hand was placed on the opposite shoulder with the elbow flexed using a 0.5-kg weight cuff. Intra-rater reliability of ultrasonic muscle thickness measurements were examined in one day.
Results: All intra-rater reliability values were equal or more than 0.90: the value was 0.90 (95%CI: 0.65-0.97) in the rest position, while for the measurement of ultrasonic thickness of the supraspinatus was 0.96 (95%CI: 0.87-0.99) in the position of EC test, 0.97 (95%CI: 0.90-0.99) and 0.96 (95%CI: 0.86-0.99) in the positions of FC and HU tests, respectively.
Conclusion: Measurement of ultrasonic thickness of supraspinatus muscle is a reliable method in the rest and positions of EC, FC and HU tests. This method can be used to compare the muscle thickness changes in the positions of the above tests.
 

Background: Bloodstream infections are the most important causes of morbidity and mortality in hospitalized patients. Blood culture plays an important role in identifying most of bacterial agents of bloodstream infections. Knowledge about bacterial agents of bloodstream infections and also antibiotic resistance of these bacteria are important. Antibiotic resistance among bacterial agents of bloodstream infection including Acinetobacter, Klebisella, Pseudomonas, Escherichia coli, Enterobacter, Enterococcus, Staphylococcus aureus and Staphylococcus coagulase negative (CoNS) is one of the major challenges faced by physicians in treating. Therefore, this study was aimed to determine the frequency and antibiotic resistant patterns of bacterial isolates from hospitalized patient's blood cultured samples in the hospital, Tehran, Iran.
Methods: This research is a descriptive and retrospective study based on recorded data in Shariati hospital laboratory and under the supervision of Tehran University of Medical Sciences. The bacterial isolates were collected from positive blood cultures from October 2013 to March 2014. The frequency of bacterial isolates were determined by phenotypic and biochemical tests. The antibiotic resistance patterns of isolated bacteria were found by disk diffusion agar method. The diameters of inhibition zone were recorded and interpreted according to Clinical and Laboratory Standards Institute (CLSI) 2013.
Results: The frequency of bacterial isolates was determined among 595 positive blood cultures as followed: 41% Pseudomonas, 20% Staphylococcus epidermidis, 10% Escherichia coli, 6% Acinetobacter lwoffii, 6% Staphylococcus aureus, 5% Stenotrophomonas, 3% Acinetobacter baumannii. The antibiogram test showed that 96.2% of Acinetobacter lwoffii, 92.8% of Acinetobacter baumannii, 66% of Pseudomonas aeruginosa, 85.7% of Staphylococcus epidermidis, 65% of Staphylococcus aureus, 75% of Klebsiella, 73.7% of Escherichia coli, and 50% of Stenotrophomonas were resistant to imipenem, piperacillin, piperacillin, erythromycin, erythromycin, ciprofloxacin, trimethoprim-sulfamethoxazole, and ceftazidime respectively.
Conclusion: The most prevalent bacterial isolate among the blood cultures of patients was Pseudomonas. The patients more than 50 years were more susceptible to blood stream infections. The most bacteria were isolated from the internal medicine department of hospital. The antibiotic resistance was also increasing especially in Acinetobacter, Staphylococcus coagulase negative, Escherichia coil and Klebsiella

Background: Polycystic ovary syndrome (PCOS) is an endocrine disorder and one of the main reasons of infertility in women. PCOS causes many symptoms in women, one of the most important of them is ovulation failure. It affects the women at the age of fertility. Many factors are detected to exacerbate PCOS including insulin, anti-Mullerian hormone, obesity and androgen. The aim of this study was to evaluate endocrine and metabolic factors and its relation with obesity in patients with polycystic ovary syndrome in exacerbation of disease.
Methods: This cross-sectional study was carried out at the Caucasus Infertility Treatment Center of Ardabil from July 2015 to March 2016 and on 321 patients with polycystic ovary syndrome. Blood samples were investigated to measure serum levels of fasting insulin, dehydroepiandrosterone sulfate (DHEAS), 17OHP, fasting blood sugar, sex hormone binding globulin (SHBG), anti-Mullerian hormone, vitamin D, total testosterone, free testosterone, prolactin, FSH, LH and TSH. Also, body mass index (BMI), duration of infertility and age were measured. BMI was evaluated to measure the obesity of patients.
Results: We were able to demonstrate significantly high level of total testosterone and fasting insulin in PCOS women by having weight gain (P< 0.05). Response to drug was significantly increased with reduced weight of these patients (P= 0.02). The level of fasting blood sugar (P= 0.01) and anti-Mullerian hormone (P< 0.05) were increased significantly with access in PCOS. On the other hand, our data showed that duration of infertility was increased by growing the age of patients (P< 0.05).
Conclusion: Insulin resistance, obesity, hyperandrogenism and metabolic syndrome are very important factors in pathogenesis of PCOS. These factors could affect the fertility of women by effecting the reproductive processes. Therefore, it is better in the patients who are older, treatment strategies further underline on reduce these factors (insulin resistance, obesity and hyperandrogenism) to prevent disease progression and increase duration of infertility.

Background: Each toxic agent results in unique presentations, depending on what neurophysiological changes occur following exposure. Scientific understanding of lead toxicity in the organ systems and at low levels of exposure continues to evolve. However, effects of lead poisoning on the thyroid gland function are controversial. In this descriptive study, changes in thyroid hormones in patients with lead poisoning were compared with patients with opioid addiction and healthy individual who were matched for age and sex.
Methods: In this descriptive study, which was conducted from March 2016 to February 2017 in Loghman Hakim Hospital in Tehran, ninety patients were evaluated using convenient sampling method for lead and thyroid hormones levels. The levels of lead and thyroid hormones were evaluated using standard laboratory method, in thirty male patients with lead poisoning, thirty male patients with opioid addiction referring to addiction treatment center and thirty healthy male referring to a blood donation center who were matched for age. Thyroid function parameters in patients with lead toxicity were compared with those of control groups.
Results: The lead level in the lead toxicity group was 57.5±23.5 µg/dl, in the first control group with opium addiction 7.8±3.8 µg/dl and in the healthy male referring to a blood donation center, 5.9±9 µg/dl. Thyroid stimulating hormone (TSH) was significantly lower in patients with lead poisoning (0.2±0.01 Milli-International Units Per Liter (mIU/L) than in the patients with opioid addiction (2.4±1/05 mIU/L) and healthy male referring to a blood donation center (2.3±0.01 mIU/L) (P= 0.04), and thyroxine hormone (T4) was significantly higher in patients with lead poisoning (17.8±2.6 µg/dl) than in the patients with opioid addiction (8.8±1/9 µg/dl) and healthy male referring to a blood donation center (7.4±3.5 µg/dl) (P= 0.02).
Conclusion: Lead toxicity has an effect on thyroid function and it reduces thyroid stimulating hormone and increases thyroxin levels. Clinicians should be aware of the potential hazardous effects of lead on the thyroid and mechanisms through which lead causes these effects on thyroid function need to be elucidated.

Considering the advancement of medical sciences, diagnostic tests have been developed to distinguish patients from healthy population. Therefore, Determining and evaluation of the diagnostic accuracy tests is of great importance. The accuracy of a test under evaluation is determined through the amount of agreement between its results with the results of the gold standard, and this test accuracy can be defined based on sensitivity, specificity, positive predictive value, negative predictive value and the area under the receiver operative characteristic curve (AUC). Gold standard is an accurate and error- free method to determine the presence or absence of disease of interest and classify patients, which is not available in some diseases and situations as this method is costly or invasive. In these cases, reference standard is a best available replacement method to be used by physicians to diagnostic disease. However, in some situation, the acceptable reference standard is invasive or costly and does not exist or unreliable. It can be imperfect and results of the reference standard method are not necessarily error- free and cannot be applied to everyone in the study; all these cases point to the conditions in which the gold standard is not available. The use of reference standard including error causes to incorrect separation of patients from healthy population and thus, it cannot be a comparing measure for other diagnostic tests and its results are inaccurate. Therefore, other alternatives methods are needed for evaluation and determine the diagnostic accuracy tests when the gold standard does not exist. Imputation method, correct imperfect reference standard method, the construct reference standard method, latent class models, differential verification, composite reference standard and discrepant analysis are of these alternative methods. Each of these methods, considering its features, advantages, and limitations can be used to evaluate the accuracy of diagnostic test in the absence of gold standard. The present study gave an overview of methods to evaluation of diagnostic accuracy tests when there is no gold standard and the focus of this study was on explain the concept of these solutions, review and compare them and their strengths and weaknesses.

The purpose of prenatal diagnosis tests is insisting of diagnosis of neonatal disorders, preparing a range of informed choices and making couples at risk to be ready for having children with genetic disorders as well. The aim of this article is to investigate all of the tests in order to determine the best one which has the lowest risk and the highest sensitivity. Screening tests (maternal blood test and ultrasonography for first and second trimester) are testing patients without symptoms who are at low risk. These tests are carried out in the early stages of pregnancy, and the risk of genetic diseases would be estimated. They are safe and also might be helpful in determining whether invasive prenatal genetic tests including chorionic villus sampling, amniocentesis, and percutaneous umbilical blood sampling are needed. Diagnostic test is insisting of invasive tests: amniocentesis, chorionic villus sampling (CVS), cordocentesis, and preimplantation genetic diagnosis (PGD), which is a genetic test on cells removed from embryos to help select the best ones to avoid some of genetic diseases, fluorescence in situ hybridization (FISH), QF-PCR, multiplex ligation probe amplification (MLPA), next generation sequencing (NGS), comparative genomic hybridization (CGH), and non-invasive tests: ultrasound, prenatal sonography, cell free fetal DNA, triple and quadruple screen: alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol (uE3), inhibin-A). These tests are intended for patients who have apparent symptoms and the results of their early stages of pregnancy have been positive. Non-invasive prenatal tests (NIPT), sometimes called noninvasive prenatal screening (NIPS), have features of both screening and diagnostic tests, but, now screening test is more considerable. Small fragments of DNA would be analyzed by this testing in which they are circulating in a pregnant woman’s blood. While most DNA is found inside a cell’s nucleus, these fragments are free-floating and not within cells, at this point, they are called cell-free DNA (cfDNA) which usually contain fewer than 200 DNA building blocks (base pairs). Non-invasive prenatal tests is more sensitive with the high degree of specify to determine trisomy 13, 18 and 21 in women who are at increased risk of having offspring with genetic disorders.

Background: Infective endocarditis occurs due to the presence of microorganisms in the endocardium or the heart valves. Nowadays, infective endocarditis is still a major cause of death with an incidence rate of 5 to 7.9 per 100,000 populations. The aim of the study was to determine antibiotic resistance pattern of bacterial agents isolated from blood culture of patients with infective endocarditis.
Methods: In this retrospective study, infective endocarditis patients who were admitted to Sina and Ekbatan hospitals in Hamadan City, Iran, from March 2005 to February 2014, were enrolled. All demographic data, clinical manifestations, physical examinations and echocardiography reports of the patients were recorded in a check list. For all patients, blood cultures in Mueller Hinton agar and antimicrobial susceptibility testing for ceftriaxone, ceftazidime, oxacillin, cefazolin, vancomycin, imipenem, clindamycin, etc. were done by disk diffusion method. All data analyzed by SPSS statistical software, version 16 (IBM, Armonk, NY, USA).
Results: A total of 61 patients with definitive infective endocarditis were included in the study, 50 of them (82%) were males and 11 patients (18%) were females. The mean age of the patients was 37.45±14.79 (range 17-74) years and 37 (60.7%) of the patients lived in urban areas. The mean duration of admission was 20±13.59 days. In addition, 38 patients (62.3%) were injection drug users (IDUs) and 23 (37.7%) non-IDU. Meanwhile, 54 (88.5%) of them had normal valve endocarditis and 7 cases (11.5%) had a prosthetic valve endocarditis. Moreover, the most common underlying disease in the natural valve endocarditis was rheumatoid fever (6.6%). Blood cultures were positive in 44.3% of the patients. The most common isolated organism was staphylococcus aureus in 15 cases (55.55%), which had the highest resistance to oxacillin. Most patients were managed by antibiotic therapy, but 15 cases (24.6%) underwent cardiac surgery. In follow up patients between 3 months to 9 years, 19.7% of the patients had complete recovery and 8.2% of them died.
Conclusion: According to the findings, antibiotic resistance pattern of bacterial agents isolated from blood culture of patients with infective endocarditis was changed.

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: Colorectal cancer is the second most common cancer in the world which is mainly caused by epigenetic and environmental factors. Among these epigenetic factors, gut microbiota is an important one. Although it has not been proved a unique group of bacteria correlated with colorectal cancer, these findings have generally demonstrated differences between healthy and disease gut microbiome in population. Actually, the identification and investigation of intestinal microbiota in early detection of colorectal cancer have been highlighted in new researches and studies. Herein, in the current study, we aimed to evaluate the number of selected gut bacteria including Lactobacillus and Escherichia coli and Prevotella in the fecal specimens of adenomatous polyposis patients, colorectal cancerous cases in compared to normal participants in terms of estimating important role of gut microbiota during colorectal cancer initiation and progression.
Methods: The current research was a case-control study. Fecal samples were provided from 31 healthy individuals, 42 adenomatous polyposis patients and 20 colorectal cancer cases that were referred to Taleghani Hospital, Tehran, Iran, from August 2016 to August 2017 for colorectal cancer screening tests. Fecal samples were collected to analyze intestinal bacteria including, Lactobacillus, Escherichia coli, and Prevotella by absolute quantitative real-time polymerase chain reaction (PCR). The number of these gut bacteria was precisely determined by this method of real-time PCR.
Results: Higher number of Prevotella with 24.6 CT number (P<0.005) and E.coli with 20.4 CT number (P<0.015) were achieved in colorectal cancer cases and adenomatous polyposis patients in contrast to samples from normal individuals. On the contrary, the opposite range was observed for the quantification of Lactobacillus and greater numbers of bacteria (CT=28.6) were detected in normal, compared to the colorectal cancer cases and adenomatous polyposis (P<0.001).
Conclusion: The gut microbiota composition of individuals with colorectal cancer and adenomatous polyposis differs from that of healthy individuals, and the higher numbers of pathogenic microbiota versus beneficial microbiota present in those with colorectal cancer and adenomatous polyposis. In contrast, healthy individuals have higher numbers of beneficial gut microbiota than pathogenic microbes. These findings need more experimental analysis and investigation to better clarify.

Background: There is some demand for nasogastric tube insertion in unconscious or ICU patients. Nasogastric tubes are generally made of flexible plastic materials, prone to twisting and deviation by the tracheal tube, when passing through the pharynx and esophageal opening, making it difficult to insert the NG-tube properly. We hypothesized that NG-tube insertion with help of guidewire can significantly increase a successful first-try insertion rate in contrast with the conventional "neck flexing" technique in unconscious intubated patients.
Methods: One hundred adult intubated patients, in the emergency ward at Sina Hospital, Tehran University of Medical Sciences were enrolled in this prospective clinical trial study from February 2020 to July 2020. These patients were randomly divided into two groups, with and without use of the guidewire insertion technique. Parameters such as successful NG tube insertion average time, first and second try failure, total failure and occurrence of complications such as kinking, twisting, sticking, moderate hemorrhage and traumatic injuries to the nasopharynx pathway were studied.

Background: For every pregnant woman, it is possible to have a child with chromosomal abnormalities. Although this possibility is not very high, by performing screening tests and considering the mother's background factors, we can largely realize the real extent of this possibility.
Many comorbidities (like high blood pressure, diabetes, and obesity) and high-risk exposures (like alcohol consumption) seem to have an important role in the development of chromosomal abnormalities. This study aimed to determine the predictive factors of a positive first-trimester screening test in the pregnant women.
Methods: This case-control study was done on pregnant women, who were referred to Yas Hospital for their first-trimester screening tests between April 2018 and February 2020. Of those who had positive screening test results, only ones with abnormal biochemical tests, were included in the study regardless of nuchal translucency (NT) examination results and were considered as cases, and the women with normal screening test results were considered as controls.

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.

Methods: This was a cross-sectional study. In this study, in a period of three years from (March 2016 to March 2019), all patients admitted to the PICU of Tehran Bahrami Children's Hospital were examined. The sample size was calculated 380. Demographic information, diagnosis during hospitalization, underlying disease, and initial tests during the first 24 hours of hospitalization were recorded in the checklist. To evaluate the demographic findings between patients with and without UGIB, chi-square and Fisher tests were used. A p-value of less than 0.05 was considered significant. Results: 462 patients were studied, of which about (58%) were male. The mean age of the samples was 48 months and the average length of hospital stay in PICU was ten days. In general, (21.21%) of patients had gastrointestinal bleeding on the first day and (12.12%) on the second day of hospitalization. Gastrointestinal bleeding occurred in 50 patients (10.82%). Use of ventilator, pulmonary diseases, coagulation and blood diseases were significantly more common in patients with gastrointestinal bleeding than in children without gastrointestinal bleeding. Cardiac, neurological, hepatic, and renal disease were not significantly different in patients with gastrointestinal bleeding compared to children without gastrointestinal bleeding. Conclusion: The occurrence of gastrointestinal bleeding in critically ill patients admitted to the PICU is a serious risk. The most important risk factor for upper gastrointestinal bleeding is mechanical ventilation. Other risk factors of gastrointestinal bleeding are lung disease, coagulation diseases, hematologic and oncologic disease.

Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan.
Methods: In this cross-sectional study, out of 5800 patients who were admitted to Al-Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings.

Results: Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070). Conclusion: The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.

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: Acute gastrointestinal bleeding is one of the critical emergencies with good prognosis if properly managed. Combination of drug has had the best possible clinical results to stabilize the hemodynamic status of these patients. Therefore, in this study, the short-term consequences of simultaneous administration of vasopressin and tranexamic acid were compared.
Methods: In this double-blind clinical trial study that was conducted from November 2018 to November 2019 at Valiasr Hospital in Arak 120 eligible patients with acute gastrointestinal bleeding were included. Patients were divided into four groups of 30. In the first group (TXA) the common treatment with tranexamic acid was first infused at the rate of 10mg/kg as an initial dose over 20 minutes and then received to 1mg/kg per hour as a maintenance dose for up to four hours. The second group (VP group) received common treatment with infusion of 30 units per hour for six hours. The third group (R group) received only conventional treatments and the fourth group (TXA+VP group) received both tranexamic acid and vasopressin along with conventional treatment. The amount of light blood lose and vital signs including blood pressure and heart rate and Hg, BUN , CR , NA, K, BS, PT, PTT, INR were checked.

Results: In this study, the vasopressin group had a greater decrease in hemoglobin (p≤0.05), the increase in blood urea was less in the two groups that received vasopressin than the other two groups (p≤0.05). The group of tranexamic acid had much better conditions than the group of vasopressin, in terms of hematochezia or hematemesis interruption, need for blood transfusion, re-bleeding, need for endoscopy and emergency surgery, and adding vasopressin to tranexamic acid also led to improved outcomes (p≤0.05). Conclusion: It seems that the concurrent use of tranexamic acid and vasopressin in upper gastrointestinal bleeding improves renal function and stops bleeding and reduces the risk of re-bleeding, the need for blood transfusion and endoscopic and surgical intervention. Its long-term results need further study.

Background: Although the respiratory system is the main element involved in the disease of COVID-19, nevertheless, there are reports of the involvement of other organs and their lesser symptoms. This study was conducted with the aim of investigating the frequency of gastrointestinal symptoms in patients with COVID-19.
Methods: This cross-sectional descriptive study was conducted on all patients diagnosed with COVID-19 hospitalized in Imam Khomeini Hospital from April to September 2021 by census method. The data was collected using a checklist that included demographic information. After the data was collected, it was entered into SPSS software, version 18 (IBM SPSS, Armonk, NY, USA) and analyzed with the help of descriptive statistics.

Results: In this study, the results showed that out of 2580 hospitalized patients, 54% were women and 46% were men. And the average age of the patients was 58.67±17.68. The highest frequency of people was in the age range of 40-59 years (925 people). 64% of patients had at least one gastrointestinal symptom, Each of the symptoms had a different prevalence, Anorexia 40% with a preference for men (57%) and the highest frequency in the age range of 40-59 years (430 people), gastrointestinal bleeding 10% with a preference for men (80%), And the highest frequency in the age range of 60-79 years (112 people), abdominal pain 8% with preference for women (65%) with preference for frequency in the age range of 40-59 years (65 people), vomiting 3% with preference for women (51%) with abundance in the age range of 80-99 years (58 people), diarrhea 1.5% with preference in men (51%) with abundance in the age range of 60-79 years (18 people) and constipation in 0.2% with preference Women (67%), all of whom were over 60 years old. Conclusion: The findings of this study showed that the COVID-19 disease can not only involve the respiratory system but also the digestive system in the course or beginning of the disease.