Tehran University Medical Journal

Background: A major problem in surgical procedures is postoperative pain. The effectiveness of prescribing preoperative tizanidine in reducing postoperative pain is not clear. The aim of this study was to determine the efficacy of tizanidine as a premedication in reducing pain after septoplasty.
Methods: This double blind clinical trial study was performed in 71 patients aged from 18 to 50 years, undergoing septoplastic surgery for the first time, who were classified in ASA (American Society of Anesthesiologists) classes 1 and 2 in the Ear, Nose, and Throat (ENT) Department of Shafa Hospital, in Kerman, Iran from April 2014  to March 2015. Patients were randomly assigned into two groups using numbers from a randomization table. A dosage of 4 mg of tizanidine was administered orally to the patients two hours before the surgery (septoplasty) in the intervention group. In the control group, placebo pills which were 100 mg vitamin B1 were prescribed. The severity of pain was measured and recorded after 4 and 8 hours, and the morning after the surgery.
Results: 62 patients (87.32%) were male and 9 (12.68%) were female. The mean age of the subjects was 24.6±7.5 years. The two groups were similar in regard to age (P=0.54), but the duration of surgery was different in the two groups (P=0.038) and was longer in the group that received tizanidine. The mean of pain was different between the two groups, after 4 hours and was significantly higher in the group that received tizanidine (P=0.043). The mean of pain was not significantly different between the two groups after 8 hours (P=0.95) or one day after surgery (P=0.79).
Conclusion: Although some researchers have reported that taking tizanidine before some surgeries may reduce postoperative pain, in this study the administration of tizanidine before surgery was not effective in reducing pain after septoplasty. 

Background: Skin cancer is one of the most common forms of cancer in the world and melanoma is the deadliest type of skin cancer. Both melanoma and melanocytic nevi begin in melanocytes (cells that produce melanin). However, melanocytic nevi are benign whereas melanoma is malignant. This work proposes a deep learning model for classification of these two lesions.   
Methods: In this analytic study, the database of HAM10000 (human against machine with 10000 training images) dermoscopy images, 1000 melanocytic nevi and 1000 melanoma images were employed, where in each category 900 images were selected randomly and were designated as the training set. The remaining 100 images in each category were considered as the test set. A deep learning convolutional neural network  (CNN) was deployed with AlexNet (Krizhevsky et al., 2012) as a pretrained model. The network was trained with 1800 dermoscope images and subsequently was validated with 200 test images. The proposed method removes the need for cumbersome tasks of lesion segmentation and feature extraction. Instead, the CNN can automatically learn and extract useful features from the raw images. Therefore, no image preprocessing is required. Study was conducted at Shahid Beheshti University of Medical Sciences, Tehran, Iran from January to February, 2020.
Results: The proposed model achieved an area under the receiver operating characteristic (ROC) curve of 0.98. Using a confidence score threshold of 0.5, a classification accuracy of 93%, sensitivity of 94%, and specificity of 92% was attained. The user can adjust the threshold to change the model performance according to preference. For example, if sensitivity is the main concern; i.e. false negative is to be avoided, then the threshold must be reduced to improve sensitivity at the cost of specificity. The ROC curve shows that to achieve sensitivity of 100%, specificity is decreased to 83%.
Conclusion: The results show the strength of convolutional neural networks in melanoma detection in dermoscopy images. The proposed method can be deployed to help dermatologists in identifying melanoma. It can also be implemented for self diagnosis of photographs taken from skin lesions. This may facilitate early detection of melanoma, and hence substantially reduce the mortality chance of this dangerous malignancy.

Background: Nonpuerperal uterine inversion is a rare medical condition that many gynecologists might not be encountered even with one case during their entire medical practice. It refers to the expulsion of uterine corpus from the dilated cervix resulting in uterus being turned inside out. There are two kinds of uterine inversion, puerperal and non-puerperal, which the second condition is less common. Acute uterine inversion usually presented by crampy abdominal or pelvic pain, vaginal bleeding, anemia, and even symptoms of severe sepsis. We describe a case of uterine inversion in a postmenopausal woman.
Case Presentation: A 66 years old grand multiparous woman (6 normal vaginal delivery) who was menopause since 15 years ago, was referred to the emergency unit of an academic hospital of Mashhad University of Medical Sciences at October 2016 due to postmenopausal uterine bleeding, cramp-like abdominal pain and mass protrusion from the vagina. The vital sign was stable at the first visit but a big non-necrotizing red vaginal mass was protruded from vaginal opening that connected to other soft intravaginal mass. Abdominal ultrasonography revealed the dilated vaginal cuff and some air-fluid levels in the uterine cavity. The patient referred to the operative room and vaginal myomectomy was done with diagnosis of pedunculated submocusal leiomyoma. Then, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed after the correction of uterine inversion by abdominoperineal approach.
Conclusion: Acute uterine inversion is a potentially dangerous condition (due to vaginal bleeding, severe abdominal or pelvic pain, and the possibility of uterine necrosis and even systemic infection). This condition should be considered as an important differential diagnosis as a vaginal mass in the post-menopausal period.

The highly contagious new coronavirus virus, SARS-CoV-2, was first appeared in Wuhan, China in late 2019. The virus has spread to 216 countries, including Iran, until 7 September 2020. So far, the number of people infected by the new corona virus and died from the disease is 27032617 and 881464 worldwide, respectively. Therefore, it is necessary to introduce the available treatments for this virus, as a global dilemma. Articles for this review study were selected from Embase, Medline and Google Scholar. Published full articles in English, English full articles published from 1st December 2019 to 23rd July 2020, were included. The search terms included combinations of COVID-19, SARS-COV-2, chloroquine, convalescent plasma, antiviral, antibacterial, Remidesivir, hydroxychloroquine, chloroquine phosphate, vaccines and monoclonal antibodies. There were no restrictions on the types of study eligible for inclusion. Different available therapies generally can be divided into small molecules and biological products. Among the small molecule drugs used for COVID-19 patients Remdesivir, Favilavir, and hydroxychloroquine have been associated with considerable success in disease control. Separation and transfusion of plasma from blood of improved COVID-19 patients to new patients and the use of recombinant Angiotensin converting enzyme 2 (ACE2) have been two very successful biological therapies in the treatment of COVID-19 disease. However, many efforts are being made by researchers around the world to make other effective and promising biological products. The development of a safe and effective vaccine can lead to great success in eradicating the disease. Also, the production of anti-SARS-CoV-2 monoclonal antibodies and using of stem cell-based therapeutics can be a great success in treating the disease. In addition, according to the miRNA properties, many efforts have been made to inhibit the production of viral proteins using natural miRNAs or artificial siRNAs. It has been proposed that aptamers derived from SELEX can be used for the diagnosis and treatment of COVID-19. Subsequently, since the size of miRNAs is at the nanometer level, they can easily incorporate to the targeted exosomes and be delivered via circulation in human blood to the infected cells such as lung cells. Interestingly, miRNAs can be delivered into the lung by inhalation.

Background: Alzheimer dementia as the most common cause of dementia is a chronic, progressive, irreversible and incurable disease. The second most common cause of dementia after Alzheimer is vascular dementia. One of the systems involved in dementia is the visuospatial system and visual evoked potential (VEP) can be one of the diagnostic methods for this disease. Therefore, the present study aims to compare visual evoked potential changes in Alzheimer dementia, vascular dementia and patients with minimally conscious impairment (MCI) with healthy people.
Methods: A case-control study was performed on referred clients to Shariati Hospital, Tehran, Iran, from April 2015 to September 2016. Patients with cognitive impairment went through Montreal cognitive assessment (MOCA) test and divided into three groups of Alzheimer dementia, vascular dementia and patients with minimally conscious impairment. Subjects with normal cognition were included in the control group. The visual evoked potential test was performed on all participants in two Methods: pattern shift visual evoked potential (Ps-VEP) and flash visual evoked potential (f-VEP) and results were compared between groups.

Conclusion: This study showed that only Alzheimer was associated with a significant increase in visual evoked potential P100 latency. On the other hand the other hand, there was no significant difference in flash visual evoked potential variables including P1, N2, P2 and N3 between different groups which shows that flash visual evoked potential cannot differentiate between Alzheimer dementia, vascular dementia, patients with minimally conscious impairment and normal people.

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: Oxford Shoulder Score (OSS) is a specific questionnaire for the assessment of pain and function in subjects with shoulder pain. The reliability and validity of the Persian version of this questionnaire have been shown previously. But its responsiveness has not been investigated yet. This study aimed to determine the Persian OSS responsiveness in subjects with shoulder pain.
Methods: This was a prospective cohort study design conducted in the Physiotherapy Clinic, School of Rehabilitation, Tehran University of Medical Sciences in 2018.  Thirty-one subjects with shoulder pain (20 females and 11 males) with a mean age of 50±15.3 participated in this study. They completed the Persian OSS, Disability of Arm, Shoulder & Hand (DASH) questionnaire, and Visual Analog Scale (VAS) before and after 10 physiotherapy sessions. After the 10th session, the Global Rating of Change (GRC) was also completed. The statistical analysis included the Effect Size (ES), Standardized Response Mean (SRM), and the Spearman or Pearson correlation coefficients.

Background: CNS infection can be focal or generalized. Meningitis, besides other etiologies, can occur after a viral infection or viral vaccine. Although meningitis can occur in at any age but it is more common in children less than five years old. Aseptic meningitis and meningoencephalitis are two of the most common complications of mumps (wild type or vaccine). As a result of their serious complication, we decided to obtain more information about clinical manifestations and laboratory findings after the injection of the Hoshino MMR vaccine in a group of children in an Iranian referral hospital.
Methods: In this cross-sectional study, performed from March 2013 to February 2015 on 73 children with meningochemical symptoms of meningitis, children who have been diagnosed with aseptic meningitis followed by an MMR vaccine in an infectious ward or emergency department of the Children’s Medical Center were enrolled in the study and their information was recorded from their files. A questionnaire was provided for children with diagnostic criteria of aseptic meningitis and their data were collected.

Background: The health of pregnant mothers is one of the most important health indicators of each country. The midwifery clinic is one of the first places in which pregnant mothers become familiar with at the time they arrive. Providing health services at a desirable level and improving the quality of services in the midwifery clinic require an accurate understanding of the situation and its complications. This study aimed to assess how well pregnant mothers were satisfied with the midwifery services that they have received at midwifery to improve their quality.
Methods: This cross-sectional study was performed on 364 pregnant women who were referred to the midwifery clinic of Shariati Hospital in Tehran in August and September in 2018. Data were collected using a validated, pre-designed questionnaire and were analyzed using chi-square and multivariate logistic regression.
Results: Among the pregnant women referred to the clinic, 70.2% were satisfied with the care services received and 29.8% of them were not satisfied. This satisfaction level had a significant relationship with pregnancy (P=0.009) and mothers' age (P<0.001) while decreased by the increment in the number of pregnancies and age. Also, in this study, the least satisfaction was related to the crowds and waste of time and lack of access to the parking spot (P<0.001). In this research, the least satisfaction was due to crowding and waste of time, which can be addressed by improvement in the health services in the residential areas, appropriate referrals, informing about the expected time of arrival, and providing information on the alternative of the new hospitals in areas around the city with less traffic congestion and better parking sites.

Conclusion:  The results of our study showed the detailed patient satisfaction factors of an educational medical hospital. In overall the satisfaction.

Background: Marital satisfaction is considered to be the feelings and understanding of the couple about their marital relationship and their two-way relationship. Many factors play a role in creating marital satisfaction, and on the other hand, marital satisfaction is one of the concepts that cause sexual health in a person. Sexual health has many dimensions and includes coordination and adaptation of physical, emotional, intellectual, and social aspects of sexual affairs in humans. This study was conducted to assess the marital satisfaction of working women in Iran through meta-analysis.
Methods: In this meta-analytic study, the issue of marital satisfaction amongst Iranian working women which has been published in local articles was evaluated. To find pertaining studies, Magiran, IranDoc, SID, Iranmedex, and Pubmed websites were used. Statistical society in this research consists of all studies in Iran in regard to the relationship between being a working woman and having marital satisfaction that has been accomplished since 2001-2018 and was indexed in one of the scientific informative websites.
  To access desired articles we used the English keywords of ‘Sexual dysfunction’, ‘Iran’, ‘Sexual function’, ‘Marital satisfaction’, ‘Working women’ and ‘women’ and their Persian equivalents. After the selection process of articles related to the research objectives, 10 articles were selected and assessed as final samples.

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.

Background: Given the huge mental, psychological, and economic impact imposed on patients with chronic renal failure, it seems quite necessary to study life satisfaction in such individuals in to order to provide the necessary information and plan for appropriate services. In form of a systematic review and meta-analysis, the present study was conducted in to order to compare the quality of life in two groups of patients, one undergoing hemodialysis and the other recipients of a kidney transplant.
Methods: In order to fulfill the objective of the present study, among innumerable researches carried out in this field, through the implementation of a meta-analysis checklist nine researches were found to be qualified for the final meta-analysis (specific consideration was given to the following criteria: hypothesis, research method, statistical population, sample size, sampling method, measurement tool, and statistical analysis method). All related studies conducted from June 1995 to July 2016 in Iran.

Background: Despite years of continuous research, maternal mortality due to preeclampsia is still a serious threat. Researchers believe that preeclampsia is a multifactorial disease and proposed many risk factors including immunological factors for it. Given the description of preeclampsia as an excessive response of the immune system, the relationship between preeclampsia and immunological changes is of particular importance. Genetic polymorphisms are considered to be one of the causes of immunological defects. Due to the role of immunologic and inflammatory factors in the etiology of preeclampsia, in the present study, the association of rs1028181-513T/C polymorphism of interleukin 19 gene with preeclampsia in the patient and control groups who were referred to Valiasr hospital in Kazerun, was compared.
Methods: The present case-control study was conducted at Islamic Azad University of Kazerun from December 2016 to May 2017. 150 preeclampsia patients and 150 healthy pregnant women who were referred to Valiasr hospital in Kazerun, were enrolled. Genotypes of participants for the -513T/C (rs1028181) variant were determined by the Tetra Primer ARMS-PCR method. SPSS software and Chi-square statistical test were used for data analysis.

Background: Early diagnosis of patients in the early stages of Alzheimer's, known as mild cognitive impairment, is of great importance in the treatment of this disease. If a patient can be diagnosed at this stage, it is possible to treat or delay Alzheimer's disease. Resting-state functional magnetic resonance imaging (fMRI) is very common in the process of diagnosing Alzheimer's disease. In this study, we intend to separate subjects with mild cognitive impairment from healthy control based on fMRI data using brain functional connectivity and graph theory.
Methods: In this article, which was done from April to November 2020 in Tehran, after pre-processing the fMRI data, 116 brain regions were extracted using an Automated Anatomical Labeling atlas. Then, the functional connectivity matrix between the time signals of 116 brain regions was calculated using Pearson correlation and mutual information methods. Using functional connectivity calculations, the brain graph network was formed, followed by thresholding of the brain connectivity network to keep significant and strong edges while eliminating weaker edges that were likely noise. Finally, 11 global features were extracted from the graph network and after performing statistical analyses and selecting optimal features; the classification of 14 healthy individuals and 11 patients with mild cognitive impairment was performed using a support vector machine classifier.

Conclusion: Combining the features of brain graph and functional connectivity by the mutual information method with a machine learning approach, based on fMRI imaging analysis, is very effective in diagnosing mild cognitive impairment in the early stages of Alzheimer’s which consequently allows treating or delaying this disease.

Classifying patients with low back pain into homogeneous and distinct categories by organizing similar manifestations among individuals can be helpful to attain better results for treatments. Providing homogenous categories of patients with low back pain would improve benefits produced by treatments. To gain a greater understanding of the proposed multi-stage process and validate diagnostic categories, the current research was designed to conduct a review about this process. We aimed to validate movement system impairment (MSI) based categories of people with chronic low back pain. MSI-based classification uses a standardized approach for classifying people with low back pain into 1 of 5 subgroups. For the present narrative review, computerized databases of EMBASE, Google Scholar, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed and Science Direct were searched for articles published between January 1990 and December 2018. For electronic searches, keywords and terms used were: “Reliability”, “Validity”, “Classification”, “low back pain" and “Human Movement System”. Fourteen full-text research reports that have been undertaken to add clinical, laboratory and outcome validity to MSI-based classification of low back pain were included in the review. Five studies were categorized as clinical validity studies which investigated the accuracy of examinations for patients with low back pain, 5 studies categorized as laboratory validity studies and 4 studies categorized as outcome validity studies which included randomized control trials. The results of this review revealed that novice users can learn the diagnosis algorithm of MSI-based categories of low back pain and by practicing, their inter-tester reliability and precision in applying the classification algorithm would be comparable to that of described for experienced expert raters. The laboratory-based tests, including 3D motion analysis, indicated that there are differences in movement patterns of the lumbar spine between low back pain subgroups. Also, for people with low back pain, classification-specific treatments based on the MSI model resulted in better outcomes. In conclusion, this review indicated the validity of the MSI classification system in people with chronic low back pain.

Background: The preparedness and safety of hospitals in disasters are essential to maintain the health and survival of the community. Numerous studies have shown that the level of preparedness of Iranian hospitals is moderate and low. Lack of comprehensive hospital standards for disaster preparedness is one of the reasons. This study aimed to develop hospital accreditation standards for hospital disaster risk management.
Methods: This comparative study was conducted between April and September 2016. Hospital disaster risk management accreditation standards were extracted from the hospital accreditation standards of 11 countries including the United States, Canada, Australia, Malaysia, India, Thailand, Egypt, Turkey, Saudi Arabia, Denmark and Iran. Overall, 27 hospital disaster risk management accreditation standards were introduced. The opinions of 22 disaster risk management experts were used to assess the content validity of the proposed disaster risk management accreditation standards.
Results: Differences were observed in the quality and quantity of those countries’ disaster risk management standards. The national accreditation standards of the United States, Australia, and Canada had comprehensive standards and covered all aspects of the disaster risk management cycle. Finally, 27 standards were proposed for developing Iranian hospitals’ disaster risk management accreditation standards. The CVI & CVR validity of the proposed standards were acceptable.
There were significant differences in the quantity and quality of hospital disaster risk management accreditation standards in selected countries. The most comprehensive standards belonged to the US National Standards (12 standards and 113 sub-standards), followed by the Australian and Canadian accreditation standards. The accreditation standards of the developing countries and Iran were not comprehensive and did not meet the international goals of disaster risk management. The proposed hospital disaster risk management accreditation standards had high content validity.
Conclusion: Disaster risk management accreditation standards in Iran and developing countries need to be revised and upgraded. Comprehensive standards based on international experiences and expert opinions were introduced in this study that can be used to develop hospital accreditation standards in Iran and other countries.

Background: Time management is effective in controlling stress especially for medical residents. Time management in the surgical field and residential education is very important as they are directly involved in treating patients. Proper time management will help decrease work-related stress and increase efficacy, although there is no time management in medical courses. There are few studies in Iran in this field. So, we designed this study to assess the effects of time management on improvement of educational and therapeutic services in surgical residents of Imam Hospital.
Methods: This before–after study was done in Imam hospital between February-March 2015. In this before-after study, 18 surgical residents of Imam Hospital (residents of 1-4 years), were enrolled. Their activities were evaluated in 11 scopes. To evaluate the effects of this self-evaluation, 5 scopes were assessed by the staff. The time during two weeks spent on each item was claimed as a percentage of 336 hours in two weeks. The self-assessment results and their effects on their scores were considered. Data regarding age, sex, and marital status were also gathered. Data were analyzed using SPSS software.

Background: Healing involves complex processes that are not yet fully known. The wound healing process consists of three stages. In all these stages, normal wound healing requires platelet activation, release of cytokines and growth hormones, and chemotaxis and cell differentiation. Platelets play a key role in homeostasis and wound healing and growth factor production of more than 30 carried out by them. Platelets regulate the healing process with their chemotactic effect. Antilogous PRP platelet count in about 3 to 5 times increase and consequently also increases the number of growth factors, for this reason, they are being used in surgical procedures and clinical therapy.
Methods: At Ilam Medical Center in Imam Khomeini Hospital, 20 patients with two similar donor graft sites were gradually selected to participate in a clinical trial from January to March 2017. The two regions have the same skin graft patients, an area of Honor conventional and other areas with the topical administration of platelet-rich plasma That immediately after surgery and in the days after the fifth and eleventh, eightieth and after washing the wound with a topical serum Physiology rubbed on the wound and thus treated The rate of wound healing clinically and using X-ray photo-checked and compared.