Tehran University Medical Journal

Background: Methotrexate (MTX) is commonly used in the hematology-oncology units and is frequently associated with adverse effects. High-dose methotrexate (HDMTX) is indicated in the treatment of acute lymphoblastic leukemia (ALL), osteosarcoma, systemic non-Hodgkin lymphoma and primary central nervous system (CNS) lymphoma. The side effect profile of MTX varies markedly according to dose. The aim of this study was to evaluate the uses and adverse effects of HDMTX in a cancer center in north of Iran.
Methods: This cross-sectional descriptive study carried out in Emam Sajjad Hospital, Ramsar, Iran from June 2016 to July 2017. Doses more than 500 mg/m2 of MTX was considered as a high-dose. Hydration status, evaluation of the renal and hepatic function, blood tests, urine pH, doses and frequencies of leucovorin administration, measurement of serum levels of MTX and side effects were evaluated. Recommendations of UpToDate 2017 were considered as standards of administration of HDMTX.
Results: Forty-four courses of HDMTX were evaluated in this study. HDMTX were prescribed for lymphoma (30 cases), ALL (8 cases) and osteosarcoma (6 cases). In all patients, hydration was done with 1340.9±894 normal saline plus 25 ml sodium bicarbonate 8.4%, one to two hours before HDMTX. The solution used for dilution of MTX was 5% dextrose (1022.7±105.5 ml). Urine pH was not measured in any patient. The frequency of leucovorin administration was 5.64±3.03 times with doses of 17.6±1.7 mg/m2 every 6 hours. Serum levels of MTX were not measured in any patient. Blood urea nitrogen and creatinine measurement was carried out before administration of HDMTX in all patients. The most common adverse effects were nausea (64.4%), anxiety (44%) and headache (43.2%).
Conclusion: The appropriate aspects of HDMTX usage were good hydration, urine alkalinization with bicarbonate and administration of leucovorin in patients receiving HDMTX, whereas monitoring of serum levels of MTX and administration of bicarbonate based on urinary pH were not done in any of the patients.
 

Background: Laparoscopy is an acceptable procedure for cholecystitis in pregnancy. Laparoscopic complications during pregnancy can be unique. Uterine perforation is a rare complication during laparoscopy of pregnant women. Acquaintance with this complication can help surgeons and gynecologist to manage these patients properly. We will report a case of uterine perforation during laparoscopy.
Case presentation: Our patient was a 24-year pregnant woman with gestational age of 28 weeks. She had nausea and vomiting and right upper quadrant tenderness, she was admitted in surgery ward on January 2017 in an academic hospital in Mashhad and candidate for laparoscopic cholecystectomy with diagnosis of cholecystitis. Her fundal height was 28 centimeters. Laparoscopy was done with Hasson technique and three punctures. During abdominal trocar insertion uterine perforation occurred. Amniotic fluid leaked in the abdomen. Perforation repaired immediately and then cholecystectomy was done. Fetal heart rate was normal. After surgery according to stable vital signs and absence of bleeding and contraction, the patient was transferred to the midwifery department. The patient received one course of betamethasone for fetal lung maturation. Antibiotic therapy initiated. During the hospitalization, the patient was monitored daily for vital signs (fever and tachycardia), uterine contraction, vaginal bleeding and vaginal bleeding. Daily fetal heart monitoring was performed. After close prenatal care cesarean section was done in 38 weeks of pregnancy and a healthy baby was born with appropriate Apgar score.
Conclusion: Laparoscopy in pregnant women is usually safe. Pregnancy-specific complications such as uterine injury are not common, but with a series of precautions before and during surgery. These complications can be reduced. Uterine perforation during laparoscopy if properly managed is usually not associated with significant risk.

Background: Probiotics are living organisms that are beneficial for human health. Lactobacillus species has been considered as probiotic bacteria due to their adjustment of human immune responses and therapeutic effects in inflammatory disorders. The aim of the present study was to evaluate the effects of Lactobacillus probiotic strains on toll-like receptors (TLR2 and TLR4) expression in HT29 cell line (a human colon cancer cell line) infected with S. enteritidis.
Methods: This experimental study was done in Food Microbiology Research Center of Tehran University of Medical Sciences, Iran, from March 2016 to February 2017. In this study, two strains of Lactobacillus acidophilus PTCC 1643 and Lactobacillus casei PTCC 1608 were used. HT29 cells were cultured in RPMI medium containing fetal bovine serum and antibiotics. Then, the cells were treated with the Lactobacillus strains, after or before challenge with S. enteritidis. After total RNA extraction and cDNA synthesis, the capacity of probiotic lactobacilli to modulate TLR2 and TLR4 expression on treated and un-treated HT29 cells were assessed quantitatively using Real-time polymerase chain reaction technique with specific primers.
Results: Our findings indicated that after treatment of non-infected HT29 cells, with both the probiotics, the expression of TLR2 and TLR4 genes significantly increased. In contrast, the expression of these two genes in HT29 cells which were infected with S. Enteritidis was significantly reduced before and after treatment with each one of the probiotic bacteria. The anti-inflammatory effect of probiotic lactobacilli on S. enteritidis were confirmed in tests. This study showed that L. acidophilus and L. casei play a major role in boosting the innate immune responses, the TLR2 and TLR4 expression levels also decreased, pre and post-infection with S. enteritidis.
Conclusion: According to the results, both Lactobacillus strains have remarkable anti-inflammatory effect in pathogenicity of S. enteritidis, but L. acidophilus display greater anti-inflammatory activity than L. casei in this work. Additional in vivo and in vitro studies are required to further elucidate the mechanisms underlying this anti-inflammatory effect.

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

Background: Approximately 3% to 5% of obstetric patients will experience postpartum hemorrhage (PPH). Even though the most common reason for postpartum hemorrhage, as the main cause of maternal death, is uterine atony; other complications such as laceration, hematoma, inversion, rupture; retained tissue or invasive placenta; and coagulopathy may result in PPH. The main cause of retained placenta can be traced to the history of manual placenta removal, violent and numerous curettages, uterus anatomical abnormalities, placenta accreta or placenta previa, and history of cesarean section. Here, we have presented a case of retained placenta and uterus septum.
Case Presentation: The patient, a 36 years old female, multigravid 11 live 3 ,death 1 and abortion 6, with a history of four normal vaginal deliveries, and history of preterm premature rupture of membrane since the 16th week of pregnancy, was admitted to Imam Reza hospital, Mashhad University of Medical Sciences due to labor pain in 29th week of pregnancy. After a vaginal delivery, she was transferred to the operating room due to a retained placenta. During the initial diagnosis, the patient’s cervix was dilated and manual placental removal was not possible. The ultrasound results showed an 80mm heterogeneous tissue in the fundus, extending to the left cornu. There was no sign of accreta. During hysterotomy, the retained placenta was removed from underneath a thick layer of Uterine Septum, using sponge forceps. Five days later, the patient returned with severe pelvic pain and signs of peritonitis. Laparotomy and hysterectomy were performed on account of uterine incision necrosis.
Conclusion: The most crucial step in the treatment of retained placenta lies in the early detection of its cause. The treatment includes manual or Surgical removed of placenta which can result in bleeding, infection, and a lengthy recovery.

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo and nystagmus in clinics. Vertigo has many causes and the recurrence of vertigo is unknown. Among a lot of factors, vitamin D deficiency is more important. This study was conducted to determine the effect of vitamin D supplementation on torsional nystagmus in BPPV patients. This study wants to show the deficiency of vitamin D leads to the recurrence of BPPV.
Methods: This case-control study was conducted from April 2017 to May 2018. All eligible patients with BPPV were presented to the Audiology clinic of Babol Rouhani hospital consecutively. Diagnosis of BPPV and the presence of nystagmus were confirmed and serum vitamin D was assessed. Dix-halpike maneuver and videonystagmography (VNG) for assessing nystagmus were done and for serologic assessment, ELISA was performed for analyzing the level of hydroxy 25 vitamin D.Vitamin D sufficient patients (more than 20 ng/ml) with BPPV were considered as the control group and vitamin D deficient patients (less than 20 ng/ml) were as the test group.
  In all the patients of two groups, torsional nystagmus (vertical, horizontal and oblique) were studied and compared.

Background: Developmental delay in preterm infants was estimated to be more common than term infants. Identifying the factors predisposing to developmental delay can help experts and health professionals in this field to prevent developmental delay of the infants, and leads to better management of the condition of them. This study aimed to evaluate and investigate the predisposing factors of developmental delay in preterm infants in the first year of their lives.
Methods: In this analytical cross-sectional study, 87 preterm infants were enrolled in the study by convenience sampling during the period of April 2016 to the end of March 2017 from two educational hospitals of Shahid Beheshti University of Medical Sciences (Imam Hussein hospital and Mahdiyeh hospital). Demographic and other initial data such as age, sex, gestational age, and the data about clinical problems observed at birth were collected through infants' medical records and were recorded in a special form for each infant. Also, the ASQ test was used to assess infants' developmental status at one year of age.

Results: Out of 75 patients, 45 patients were in the exudative pleural effusion group and 30 patients in the transudative group. The mean of hs-CRP in the exudate group was 18.27±10.74 mg/L and in the transudative group 2.98±2.15 mg/L (p˂0.001). The cut-off point for hs-CRP of pleural fluid was calculated to be 5.94 mg / L, which has a sensitivity of 88.9% and a specificity of 93.3%. This marker was also studied in exudative subgroups, and there was a significant difference between pleural hs-CRP levels in two groups of pleural effusion due to malignancy and Parapneumonic effusion (p=0.011).

Results: The study showed that the incidence of sore throat in the magnesium group was lower than ketamine. Comparison of the three groups at the time of recovery (0), 2, 4, and 24 hours after surgery showed that the differences between the three groups were significant in terms of sore throat. Also, the difference in the incidence of sore throat within each group in the four times in all three groups was statistically significant (P=0.001). There was no statistically significant difference between age, gender, body mass index, heart rate, blood pressure, duration of intubation, duration of surgery and anesthesia, size of laryngoscopy insertion and Cormack and Lehane score in the three studied groups. A drop in systolic blood pressure was observed in the both groups half an hour after the operation, which was statistically significant. Changes in diastolic blood pressure were significant only in the magnesium group.

Background: Breast cancer is the most common type of cancer in many countries, accounting for over 18% of all cancers in females. There are more than one million new cases of breast cancer each year. Most women diagnosed with breast cancer are over the age of 50, but younger women can also get breast cancer. About one in seven women are diagnosed with breast cancer during their lifetime. There's a good chance of recovery if it's detected at an early stage. In Iran, breast cancer is the most common cancer among women, making up 21.4% of all female cancers. The mortality rate of this cancer is 4.33 for every 100,000 people. The purpose of this research is to see how often different kinds of early breast cancer come back and how long people live after being diagnosed.
Methods: This retrospective study evaluated the medical records of 500 breast cancer patients at two hospitals in Mashhad, Iran during April 2006 to March 2016. We used SPSS software, version 16 (SPSS Inc., Chicago, IL, USA) to analyze data. A P value less than 0.05 means that the results are considered statistically significant.

Results: We included 230 women with breast cancer. The average overall survival was 130.7 months, with 83.2% of people surviving for five years and 78.8% surviving for 10 years. The stage of the disease is strongly linked to the recurrence (P=0.000). Additionally, the specific type of disease is also strongly related to disease recurrence (P=0.01) or metastasis (P=0.01). Patients who have the triple-negative subtype had the highest chance of the cancer spreading and recurrence compared to patients with other subtypes. Conclusion: The different types of breast cancer are strongly linked to the disease recurrence or metastasis. Patients with triple-negative subtypes had the most cases of cancer spreading to other parts of the body and coming back again, compared to other subtypes. Our findings also showed that patients with the triple-negative disease had the worst overall and disease-free survivals.

Background: Preoperative anxiety assessment allows for better analgesia in the postoperative period and a better experience for the patient. Previous studies have investigated anxiety factors specific to cataract surgery, reporting vision problems, particularly blindness, among the main preoperative fears. However, there is little research that fully and accurately investigates the causes and factors of anxiety in this population. Therefore, in this study, the factors related to anxiety in the elective eye patients.
Methods: In this descriptive-analytical study, the comparison of the level of anxiety in elective eye patients of Shahid Mohammadi Bandar Abbas Hospital in the spring and summer of 2023 was investigated. Patients referred to Bandar Abbas Shahid Mohammadi Hospital were included in the study according to the entry criteria and obtaining informed consent. In this study, after the approval of the research committee of the university, the necessary information was made by the researcher's checklist, which includes gender, age, causes of anxiety, patient's level of education, previous history of eye surgery, previous history of non-eye surgery and other underlying diseases. Was collected and the level of anxiety was measured in 2 stages before and after eye surgery based on VAS criteria.
Results: In this study, 85 (47.2%) patients were male and 95 (52.8%) were female. Also, most of the patients had a diploma-level education. Most patients mentioned a non-ocular surgery history (18.3%). Also, most of the patients (52.8%) noted an unknown cause as an anxiety-causing factor, and the least frequent among the anxiety-causing causes mentioned by the patients was the fear of death due to surgery. The level of anxiety in patients who had a history of non-ocular surgery was significantly lower. Patients who mentioned the unknown cause, the surgery itself, and financial problems as the cause of their anxiety experienced significantly higher preoperative anxiety and postoperative anxiety.
Conclusion: The level of anxiety in patients who have a history of eye and non-eye surgery is significantly lower. Preoperative anxiety and postoperative anxiety are significantly higher in patients who mention the unknown cause, the surgery itself, and financial problems as the cause of their anxiety.

Background: This study was designed to compare the effects of using a laryngeal mask airway (LMA) and endotracheal intubation on airway resistance and compliance in patients undergoing orthopedic surgery under general anesthesia. Evaluating these two methods is crucial for improving respiratory quality and reducing complications related to airway management in patients.
Methods: This analytical cross-sectional study was conducted on 50 patients undergoing orthopedic surgery under general anesthesia at Hospital in Bandar Abbas between May and September 2024. The patients were equally divided into two groups: the first group received a laryngeal mask airway (LMA), while the second group underwent endotracheal intubation under general anesthesia. The primary variables, including airway resistance and compliance, were measured at 0, 15, 30, and 60 minutes after anesthesia induction. Demographic characteristics such as age, gender, and ASA class were also recorded. Data analysis was performed using SPSS version 21, with descriptive statistics (frequency, percentage, mean, and standard deviation) and inferential statistical tests (Mann-Whitney U test and Chi-square test), considering a significance level of P<0.05.
Results: The findings of the present study showed no statistically significant differences between the two groups regarding age distribution and ASA class. A comparison of airway resistance and compliance between genders revealed no significant differences at 0, 15, 30, and 60 minutes. There was no significant difference between the two anesthesia groups (laryngeal mask airway and endotracheal tube) in terms of age distribution. There was no statistically significant difference in ASA classification between the two anesthesia groups. At minute 0 of anesthesia, airway resistance was significantly higher in the endotracheal intubation group compared to the LMA group (P<0.001). At 30 and 60 minutes of anesthesia, airway resistance remained significantly higher in the endotracheal intubation group (P<0.001). Airway compliance was significantly higher in the LMA group at all measured time points (0, 15, 30, and 60 minutes) compared to the endotracheal intubation group (P<0.001).
Conclusion: The results of this study demonstrated that using a laryngeal mask airway (LMA) compared to endotracheal intubation leads to improved airway compliance and reduced airway resistance during anesthesia. These findings may influence the selection of anesthesia methods and enhance postoperative care quality.

Background: Endoscopy is a common medical procedure that often involves the administration of sedative agents to ensure patient comfort and cooperation. Midazolam, a short-acting benzodiazepine, is commonly used as a premedication for its anxiolytic and amnestic properties. Despite its widespread use, there is limited research specifically assessing the occurrence of anterograde amnesia, a potential side effect associated with midazolam administration during endoscopic procedures. Understanding the frequency of this adverse effect is crucial for optimizing patient safety and procedural outcomes.
Methods: In this prospective cohort study After obtaining approval and ethical clearance, patients eligible for endoscopy at Bandar Abbas Shahid Mohammadi Hospital were included in the study. They received 2mg midazolam intravenously before the procedure, followed by propofol for anesthesia maintenance. A memory test involving personal details was conducted before and after the procedure to assess progressive amnesia. Additionally, patients were asked about the procedure 5 minutes before discharge.
Results: 342 endoscopy candidates participated, with an average age of 46.77 years, over half being men. Less than a quarter had a diploma. Average endoscopy time was 2.96 minutes, mostly ASA class 2. Recall scores after midazolam injection and endoscopy were 5.22 and 2.87, respectively. Post-graduate education showed a significant difference in midazolam amnesia. No significant gender difference was observed. Longer endoscopy duration correlated with decreased recall scores. ASA class 2 patients had lower post-endoscopy recall scores than ASA class 1. Recall scores decreased with age, with the highest in the 19-29 age range, a statistically significant finding.
Conclusion: This study In conclusion, this study provided valuable insights into the factors influencing midazolam anterograde amnesia. Key findings include a significant association between higher education levels, particularly post-graduate education, and increased recall scores after midazolam injection. Gender did not show a significant impact on midazolam amnesia, but the duration of endoscopy played a crucial role. Additionally, patients in ASA class 2 exhibited lower recall scores than those in class 1, highlighting the influence of overall health status. Age also emerged as a factor, with the youngest age group showing the highest recall scores after endoscopy. These findings contribute to our understanding of factors affecting midazolam-induced amnesia during endoscopy procedures.

Background: Today, cesarean section is one of the most common surgeries performed in different countries. Shivering after surgery is one of the common complications of spinal anesthesia in cesarean surgery. Many drugs have been investigated to prevent or reduce shivering, but the ideal drug has not yet been finally approved. The purpose of this study is to investigate the effect of dexmedetomidine in preventing shivering after cesarean section surgery under spinal anesthesia in the form of a systematic review.
Methods: In this systematic review, the Persian keywords "dexmedetomidine", "spinal anesthesia", "caesarean" and dexmedetomidine" and the English keywords dexmedetomidine", "Caesarean section", "Spinal Anesthesia" "Dexmedetomidine and "C-Section" in databases PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Clinical Trials.gov and Scopus, SID, Magiran, Medlib and Google Scholar search engine, without time limit Done. Data extraction was performed independently by two authors. Study name, year of study, country, study groups, and incidence of shivering were extracted from the studies. Our primary outcome was the severity of shivering in patients. All disagreements in data extraction were resolved through discussion between the reviewers or, if not possible, by a third reviewer. Data were entered into an Excel file.
Results: In this systematic review, 19 studies were examined. The total number of patients included in the study was 2001 patients. The study range was from 2016 to 2022. The age group of most patients was between 18-45. The drugs studied in combination with dexmedetomidine in the studies included: pethidine, dexamethasone, nalbuphine, ondansetron, and morphine. The most studied drugs were pethidine and dexamethasone in three studies. In 13 studies, dexmedetomidine was more effective in controlling shivering than the other groups studied. Also, in five studies, dexmedetomidine, along with three drugs: pethidine, dexamethasone, and ondansetron, had similar effects in controlling shivering in patients. In one study, dexmedetomidine produced less anti-tremor effects than nalbuphine.
Conclusion: In the review of the studies, the results indicated that dexmedomedin is effective in preventing post-operative shivering in patients undergoing caesarean section. Therefore, it seems that the use of dexmedetomidine to prevent shivering after surgery is useful in these patients.

Background: The use of mesh is considered one of the most effective methods and is considered the method of choice in hernia repair. However, the debate about the choice of mesh type still persists. Therefore, in the present study, the results of using ultra-light Prolene mesh with standard Prolene mesh in hernia repair surgery were compared.
Methods: The present study is a double-blind, randomized, controlled clinical trial that was conducted at Shahid Mohammadi Hospital in Bandar Abbas. Demographic information including age, sex, height, and weight were recorded in a checklist. Patients were randomly assigned to two groups. Each group used Prolene mesh in the first group and ultra-light Prolene mesh in the second group for repair. Hernia repair was performed by the surgeon using the Lebakhstein method.
Results: 119 patients were included in the study. 70 patients (57.4%) had direct hernia and 52 patients (42.6%) had indirect hernia. The mean age of the Prolene group was 43.8±7.49 and the ultra-light Prolene group was 44.32±8.91 years (P=.713). The mean BMI in the Prolene group was 29.94±3.43 and in the ultra-light Parwan group was 29.66±3.76 (P=.673). Wound infection was not observed in either group. Chronic pain was 14.5 in the Prolene group and 10.3 in the ultra-light Prolene group (P=.490). Administrative retention was 6.3 in the Prolene group and 8.5 in the ultra-light Prolene group (P=.738). The recurrence rate 3 months after surgery was 0 in the Prolene group and 1 case (1.7%) in the ultra-light Prolene group (P=.487). The recurrence rate 12 months after surgery was 2 cases (3.2%) in the Prolene group and 3 cases (5.2%) in the ultralight Prolene group (P=. 672). The time to complete recovery was 6.94±1.63 days in the Prolene group and 6.68±1.64 days in the ultralight Prolene group (P=. 368). There was no significant difference in pain intensity at 2, 6, and 24 hours after surgery between the two study groups.
Conclusion:  Both Prolene and ultralight Prolene mesh have relatively similar efficacy in inguinal hernia repair. Although the advantages of ultralight Prolene mesh, such as pain intensity, chronic pain, and faster onset of motion, were slightly different in the ultralight Prolene group, the recurrence rate was slightly higher in the ultralight Prolene group.