Tehran University Medical Journal

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Background: The rabies is a deadly disease and if its symptoms break out in a person, he will certainly die. However, the deaths caused rabies can be prevented by post-exposure prophylaxis (PEP). Methods: In this study, subjects were recruited through census and with respect to in-formation which gathered from Fars Province health centers, Pasteur institution and previous studies In Iran. The mortalities for age groups and by sex type have been cal-culated. The decision tree model using probabilities, which the effectiveness of PEP treatment after getting bitten by an animal suspected, persons to receive specified. Dis-ability adjusted life year score (DALY) was applied to estimate the DALYs saved from PEP. In this study it was assumed that if a person suffering with rabies, a few days af-ter the onset of symptoms, death is compulsory. Therefore YLD rabies was considered zero. Finally, to increasing the accuracy and because inherent uncertainty of the data, and the increase the power of analysis, one-way sensitivity analysis was used. Results: From March 2011 to March 2012, in Fars Province, total cases of animal bites were reported and received PEP treatment. The cases were 5394 (75.85%) male and 1717 (24.15%) female. PEP generally prevented from 177.076 deaths which 134.096 (75.72%) were men and 42.98 (24.27%) of them were women. The age distribution of suspected animal bites in youth more than adults, and in men higher than women. Also due to prevented mortality caused by PEP, it is prevented from 4455.71 DALYs. Based on the sensitivity analysis DALY prevented, except for dogs and cats, there was no change in the other animals. Conclusion: The implementation of PEP for animal bitten people remarkably reduced the burden of disease in community. Calculations with primitive cost estimations im-plicitly revealed that this intervention is a most cost-effectiveness program.

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Growing and developing are influenced by genetic, social and environmental factors and it's most important and initial phase step is formed of the early life of the fetus and infant. According to the world health organization, the incidence of preterm birth and low birth weight are increasing in most countries that most of it related to developing countries. Low birth weight (LBW) and preterm birth are one the most important causes of death in the world and therefore are considered as one of the major health problems that can affect growing and developing so that it can threaten public health. Advances in medical technology in recent decades at intensive care unit, increased survival of premature infants and high-risk specialist care is needed, but failed, to reduce the complications of premature birth but it couldn’t reduce complications of preterm birth. There is also an increased recognition of the potential disconnect between perinatal outcomes and long-term outcomes. The administration of oxygen and postnatal steroids are prime examples of interventions that may have immediate positive effects but negative long-term effects. Many premature babies will be encounter with mobility problems, cognitive, neurosensory impairments, cerebral palsy, cognitive and language delays, neuromotor developmental delay, blindness and hearing loss, behavioral and psychosocial disorders, learning difficulties and dysfunction in scholastic performances in the future. These disadvantages appear to persist into adulthood and therefore have broad implications for society. Without a doubt, one of the tragedies of the world is people with physical or mental damage caused by premature birth, many of these disorders are not early diagnosed and the prediction of long term complications of infants discharged from the NICU is difficult. Although nourodevelopmental follow-up of these babies is a necessary part of the neonatal assessment but there is no standard process for it. The present review article aims to introduce the care process and tools that is used for following-up these babies, also introduces the application of screening tools for neuro-developmental care.

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Background: Sacrococcygel region is the most common site for pilonidal sinus and surgery is the most common treatment for it. Numerous operative techniques have been described for management of this disease but a technique with low recurrence and complication rates is the best treatment option. Karydakis has been introduced as a method with less recurrence rate, but it seems that surgeons debate on complications and it is not a common technique in our country. In this article, we will discuss Karydakis procedure and its results after a prospective follow-up in our patients. Methods: This is a prospective single cohort study on the patients with sacrococcygeal pilonidal disease. Cases evaluated in this study included patients underwent Karydakis procedure for their pilonidal sinus from 23 September 2006 to 22 September 2013. Patients were followed-up prospectively after their discharge within the first week, first month and third month for early complications and then annually for recurrence. The length of follow-up ranged from 3 to 77 months (median 36 months). Results: Of 141 patients, 119 (84.4%) were male and mean operating time was 55.52 (35-120) minutes. Mean time to healing wound with no need to dressing was 15.92 (range: 2-120) days and mean time to return to work was 14.44 (range, 1-35) days. Overall rate of early post-operative complications was 21.3% that most of them treated conservatively. Wound breakdown within the caudal part was the most common complication detected in 12.1% of patients and infection was detected in 5.8%. Hematoma, seroma and complete wound breakdown were seen in one patient each. The mean score of patient's satisfaction after one year was 4.91 out of 5. Recurrence was appeared in 1.42% of patients. Conclusion: Karydakis procedure for sacrococcygeal pilonidal disease is associated with low complications, short healing time and return to work, and reasonable recurrence rate.

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Background: Inguinal hernia is a common surgical problem which increases with aging especially in men. A common method for treatment is surgical repair using prosthesis, Lichtenstein technique. One frequent complication after inguinal herniorrhaphy is soft tissues seroma. There are several methods to prevent or to drain seroma. Some surgeons suggest the insertion of closed suction drainage system but others disagree. Methods: In this clinical trial study, 42 patients who are candidate for hernia repairing (Lichtenstein technique), referred to Amir Al-Momenin Hospital in Semnan, Iran, from 2011 to 2012, were randomly divided into two groups. So that, the list of eligible patients in the study, were numbered, and then using the patients' code, patients, who assigned an odd number in the registration list, were allocated to group 1, the remainder were placed in group two. The two first numbers in registration list (1 or 2), were randomly assigned to groups. Group 1 underwent hernia surgery without closed suction drainage and the second group underwent hernia surgery with closed suction drainage. The patients were evaluated for seroma, hematoma or wound infection after 24 hours, during days 4 to 7 and days 10 to 15 following surgery. Results: No adverse event including hematoma, seroma or wound infection occurred in either group with or without closed suction drainage in the first 10 days after surgery. Only one patient carried wound infection during days 10 to 15 following operation who was in the group with closed drainage (P=1.00). Conclusion: In this study, Seroma and hematoma was not observed in patients with and without closed suction drainage. To avoid drains' complications, indiscriminate use of antibiotics, prolonged hospital stay, we do not recommend the use of drains in this type of surgery.

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Background: Last decades, we have observed major improvements in treating infertility by using microinjection. However, reduction in abortion or increase in fertility has not been significant. It seems use of corticosteroids improves clinical outcomes during assisted reproductive technology (ART) techniques. Therefore, this study tried to show how corticosteroids therapy improves the results of intracytoplasmic sperm injection (ICSI). Methods: This semi clinical trial study without control group was included infertile women with more than one year’s infertility and were candidate to ICSI which were referred to Kosar Infertility Center, Urmia University of Medical Sciences from April 2011 to September 2013. Patients received prednisolone which was started 20 mg/day from one day before embryo transfer to 7 days, then for 2 days more 1 tablet and stopped. Pregnancy outcomes were chemical and clinical pregnancy, ectopic pregnancy, multiple pregnancy and rate of abortion before 20 weeks. Beta human chorionic gonadotropin (HCG) test was performed. Patients with positive pregnancy test were followed by sonography in 6, 12 weeks and 20 weeks of pregnancy. Results: One hundred and eighty one patients entered to the study. The mean± SD of age and fertility duration were 30.42± 6.07 and 7.69± 5.54 years. The mean± SD of transferred embryo was 4.60± 1.10 and embryo grading was 138 (44.7%) grade A, 124 (40.1%) grade B, 47 (15.2%) grade C, respectively. There were no significant difference between fresh/frozen embryo transfer in pregnancy outcomes (P> 0.05 in all of outcomes comparison). The incidence rate of biochemical pregnancy was 48.1% (87), clinical pregnancy rate with appearance of fetal heart was 44.2% (80), incidence rate of abortion before appearance of fetal heart (6 weeks) in women with intra-uterine pregnancy was 5.9% (5), incidence rate of abortion before 20 weeks was 12.9% (11). Incidence rate of ectopic pregnancy was 2.3% (2) and rate of multiple pregnancies was 32.5% (26). Conclusion: Our study suggests that the infertile patients who receive prednisolone in ICSI cycle, had improved pregnancy outcomes. Additional confirmatory studies are needed.

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Background: Sciatic pain in association with lumbar disc herniation may require surgical intervention in the form of lumbar discectomy. Yet, the optimal time for this operation has not been specified in medical literature. Methods: In a Cross-sectional study, 147 patients (100 men and 47 women) with radiological and clinical signs of L4-L5 or L5-S1 disc herniation were entered to our registry prior to March 2009. They were all examined, diagnosed and operated on (lumbar discectomy) in Ghaem General Hospital, Mashhad, Iran. Patients were all subsequently followed for one year. The follow-up continued in a number of 126 cases, whose satisfaction was rated via phone interview for an extra year. The patients’ assessments were implemented employing three scaling systems, both before and following lumbar discectomy, to name the Modified Oswestry Disability Index (MODI), Visual Analogue Scale (VAS) and Prolo Functional Economic Outcome Rating Scale (PORS). The former two were used for pre-operative and post-operative assessments whereas the latter was applied during the first year of follow-up. The focus of the investigation during second year was on patients’ satisfaction. Results: Mean age of our cases were 34±7.4 years. According to the duration of the sciatica, patients were divided into 4 groups. <3 months, 3 to <6 month, 6 to <12 months and >12 months. Statistical analysis revealed a significant difference between patients having undergone lumber discectomy with a history of sciatica for less and more than three month before the operation in terms of pre-and post-operative visual Analogue Scale (P= 0.022). However, there could be found no such disparity in other clinical scores (P= 0.63 for MODI, P= 0.85 for Prolo scale and P= 0.73 for satisfaction). Conclusion: Patients with less than three months of sciatica may seem to enjoy a better clinical outcome after one year, there could be found no correlation between the duration of sciatica and the satisfaction after two years.

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Background: The relationship of the base of appendix to the cecum remains constant, whereas the tip can be found in a retrocecal, pelvic, subcecal, preileal, or right pericolic position. These anatomic considerations have significant clinical importance in the context of acute appendicitis. The knowledge about the correct anatomical position of appendix may facilitate in generating an accurate diagnosis of appendicitis as well as assist in achieving a better prognosis and early treatment. The present study aimed to determine the anatomical location of the appendix in Iranian cadavers. Methods: This descriptive cross-sectional study was conducted on 200 cadavers who were referred to the Forensic Center of Tehran from March to September 2013. The data including age, sex, weight, and appendix length and position were collected and analyzed using SPSS software, version 16 (SPSS, Inc., Chicago, IL, USA). Results: In the present study, 200 cadavers were evaluated accidentally, of which 173 (86.5%) were males and 26 (13%) were females, and the mean age was 39.96 years±16.31 (SD). The mean wall thickness of the appendix was 9.78 cm±16.31 (SD). The mean appendix length was 9.86 cm±1.79 (SD) in men and 9.30 cm±1.56 (SD) in women. The appendix height was long in 20 cadavers (10%), short in 3 cadavers (1.5%), and moderate in 177 cadavers (88.55%) cadavers. The appendix position was posterior in 120 (60%), ectopic in 32 (16%), and pelvic in 48 (24%) cadavers. Conclusion: Majority of appendices examined in the present study were positioned at the posterior (Retrocecal) of pelvis. According to different positions of appendices in different populations and different races, the knowledge of appendix position in various populations is necessary for early diagnosis and treatment and fewer complications for related disease.

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Background: Pregnancy in women with systemic lupus erythematosus (SLE) is still introduced as a major challenge. Consulting before pregnancy in these patients is essential in order to estimating the risk of undesirable maternal and fetal outcomes by using appropriate information. The purpose of this study was to develop an artificial neural network for prediction of pregnancy outcomes including spontaneous abortion and live birth in SLE. Methods: In a retrospective study, forty-five variables were identified as effective factors for prediction of pregnancy outcomes in systemic lupus erythematosus. Data of 104 pregnancies in women with systemic lupus erythematosus in Shariati Hospital and 45 pregnancies in a private specialized center in Tehran from 1982 to 2014 in August and September, 2014 were collected and analyzed. For feature selection, information of the 149 pregnancies was analyzed with a binary logistic regression model in SPSS software, version 20 (SPSS, Inc., Chicago, IL, USA). These selected variables were used for inputs of neural networks in MATLAB software, version R2013b (MathWorks Inc., Natick, MA, USA). A Multi-Layer Perceptron (MLP) network with scaled conjugate gradient (trainscg) back propagation learning algorithm has been designed and evaluated for this purpose. We used confusion matrix for evaluation. The accuracy, sensitivity and specificity were calculated from the confusion matrix. Results: Twelve features with P<0.05 and four features with P<0.1 were identified by using binary logistic regression as effective features. These sixteen features were used as input variables in artificial neural networks. The accuracy, sensitivity and specificity of the test data for the MLP network were 90.9%, 80.0%, and 94.1% respectively and for the total data were 97.3%, 93.5%, and 99.0% respectively. Conclusion: According to the results, we concluded that feed-forward Multi-Layer Perceptron (MLP) neural network with scaled conjugate gradient (trainscg) back propagation learning algorithm can help physicians to predict the pregnancy outcomes (spontaneous abortion and live birth) among pregnant women with lupus by using identified effective variables.

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Background: The incidence rate of gastric cancer in Western countries has shown a remarkable decline in recent years although it is still the almost common cancer between men in Iran. The proto-oncogene MYC, located at 8q24.1, regulates almost 15% of human genes and is activated in 20% of all tumors. MYC amplification and overexpression of its protein product are observed in 15-30% of gastric neoplasia. The objective of this study was to find the preference of CISH or IHC in the diagnosis and prognosis of gastric cancer. Methods: In this cross-sectional investigation, 102 paraffin blocks samples of Iranian patients with gastric cancers were studied. All the patients had undergone primary surgical resection at the Cancer Institute Hospital, Tehran University of Medical Sciences from 1987 to 1993. CISH and IHC techniques were applied to the samples. CISH was carried out on 3-µm-thick tissue sections and with a ZytoDot CISH Implementation Kit (ZytoVision GmbH, Germany). IHC was down using the HRP method with the monoclonal antibody. A universal peroxidase-conjugated secondary antibody kit was used for the detection system. All samples were gastric adenocarcinoma and were selected randomly. Results: Our data revealed that both diffuse and intestinal types of gastric cancer occurred significantly in men more than women. Our results showed an indication of some correlation between grades and CISH results, although the difference was not significant. Our data also showed that CISH+ patients (43.1%) were more frequent in comparison with IHC+ patients (14.7%). There was a correlation between CISH and IHC. This result revealed that there was a significant difference between grades and IHC. There was also no statistically significant difference between CISH amplification in diffuse and intestinal types. Conclusion: Our conclusion is that for the treatment, management of stomach cancer, and monitoring of progress and prognosis of the tumor that is almost important for patients and clinicians, CISH test is a better and feasible to IHC test, with regards to sensitivity and specificity.

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Background: Chorionic villus sampling refers to a procedure in which small samples of placenta are obtained for prenatal genetic diagnosis, generally in the first trimester of pregnancy in 11 weeks till 13 weeks+6 days. This procedure provides prenatal diagnosis in pregnancy. Amniocentesis is a technique for windrowing amniotic fluid from the uterine cavity using a needle via a trans abdominal approach. Amniocentesis and chorionic villus sampling are invasive prenatal procedure. Their complications are fetal loss vaginal bleeding, rupture of membrane chorioamnionitis and limb reduction. There are some probable predictors of fetal loss after chorionic villus sampling and amniocentesis including maternal age, gestational age, number of needle insertion, previous miscarriage, and placental location. The aim of this study was to compare procedure related complications of amniocentesis and chorionic villus sampling in a tertiary referral hospital in Iran.

Methods: This retrospective cohort study was done in pregnant women who were high risk in genetic screening tests. The pregnancy outcome of women who underwent amniocenthesis and chorionic villus sampling was assessed in Yas Women General Hospital (Mirza Kuchak Khan), Tehran, Iran, from 2001 to 2011. Group one, pregnant women who underwent amniocentesis, was compared with group two, pregnant women that underwent chorionic villus sampling. The statistical analyses were performed with SPSSv.20 using a significant level of α<0.05.

Results: There were no significant differences between the two groups in procedure related fetal loss before 24th weeks of pregnancy (1.1% in chorionic villus sampling group versus 0.6% in amniocentesis group, P=0.318). A significant relationship between the number of needle insertion in the chorionic villus sampling group and fetal loss before 24th weeks of pregnancy was seen P<0.028. There were no significant differences between the two groups in the occurrence of vaginal bleeding, rupture of membrane, pre-term birth, placenta location, low birth weight and very low birth weight. The risk of chorioamnionitis was higher in chorionic villus sampling group (P=0.019). No significant difference was observed between the liquid and bloody amniotic fluid and pregnancy complications.

Conclusion: There was no significant difference between the procedure related complications of amniocentesis and chorionic villus sampling.

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Background: We retrospectively compared the clinical outcome of post-cardiac surgery tracheal extubation between patients extubated with a lower than normal pH and patients extubated according to our routine institutional protocol. Our main goal was to clarify that strict adherence to the current criteria is dispensable. Methods: In this retrospective cohort study, we recruited 256 patients who met our study criteria and divided them into the exposed group (n= 95) and the control group (n= 161). The inclusion criteria consisted of coronary artery bypass grafting alone and age> 18 years. The exclusion criteria comprised the use of corticosteroids in the preceding 2 weeks, Serum creatinine (SCr)> 2 mg/dL, uncontrolled diabetes, liver dysfunction, Glasgow coma scale <13, and acetazolamide and sodium bicarbonate use. The arterial blood gas (ABG) characteristics before and 6 hours after extubation, extubation failure rate, length of stay in the in ICU, length of stay in the hospital and mortality were compared between the two groups. Results: In the control group, the males outnumbered the females and the ejection fraction was higher relative to that in the exposure group (P= 0.01 and P= 0.02, respectively). There were more patients with chronic obstructive pulmonary disease in the exposure group (P< 0.005) and also the euroSCORE was higher (P< 0.002). There were no significant differences between the groups regarding the ABG values at the time of ICU admission. Significantly higher levels of FiO2 and PaCO2 (P< 0.001 for both) as well as lower HCO3 and pH (P< 0.001 for both) were observed in the exposure group immediately before extubation. Following extubation, there was a significant increase in pH and a significant reduction in FiO2 need in the exposure group (P< 0.001 for both). The extubation failure rate, length of stay in the in ICU, length of stay in the hospital, and mortality rate were not different between the 2 groups.

Conclusion: The patients with a lower than normal pH, tracheal extubated at the discretion of the ICU anesthesiologist did not have a clinical outcome worse than that of the patients extubated in accordance with our routine institutional protocol.

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Results: The results showed that the ES and SRM of the Persian OSS were 1.73 and 1.79, respectively. The correlation between the Persian OSS and the VAS scores was 0.69 and between the Persian OSS and the DASH scores was 0.89. The correlation between the Persian OSS changes and GRC was not statistically significant (r=0.25, P=0.18). However, a significant moderate correlation was identified between the VAS and DASH with the GRC scores (r=0.43, r=0.42, respectively).  Conclusion: The Persian OSS has internal and external responsiveness for the assessment of subjects with shoulder pain. The Persian OSS, as a responsive instrument, can be used to investigate the effectiveness of interventions in the clinical settings and research to detect the changes in patients with shoulder pain. Further study with larger sample of patients with shoulder pain is warranted to confirm the findings and to estimate the minimally clinically important change.

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Background: The use of the traditional method for saphenous vein harvesting is associated with wound complications and not on-time patient mobilization. This has caused the improvement of minimally invasive vein harvesting techniques, together with general bridging. This study was designed to compare the therapeutic results of large saphenous vein harvesting with conventional and standard bridging techniques for lower extremity vascular reconstruction in patients with chronic lower extremity ischemia. Methods: In this randomized clinical trial study, 66 patients with chronic lower extremity ischemia were randomly divided into two groups: large saphenous vein harvesting by conventional technique (continuous longitudinal incision) (n=30) and standard Bridging technique (small and multiple incisions) (n=36). Pain score (VAS), graft patency, wound complications, surgery results and patient satisfaction was recorded. The follow-up period was six months. (IRCT20190511043562N1). Results: Graft patency (P=0.353), and Amputation-free Survival (P=0.397) did not show a significant difference between the two groups. Changes in pain score at rest (P=0.846) and movement (P=0.380) at different times did not show a significant difference between the two groups. One week after the operation, the incidence of infection in the bridging technique showed a significant decrease (P=0.045). During the six months of follow-up, the wound healing rate, ischemic pain relief, and claudication improvement were better in the bridging technique but did not show a significant difference with the conventional technique (P<0.05). Patient satisfaction was higher in the bridging technique but did not show a significant difference between the two groups (P<0.05). Conclusion: It seems that the use of the bridging technique in venous resection large saphenous vein harvesting is associated with reducing wound complications and pain, reducing the length of hospital stay, increasing the speed of wound healing, and improving patient satisfaction. The duration of graft patency and Amputation-free Survival were similar in the two groups. We believe that each technique has advantages and disadvantages that should be considered by the patient and surgeon when choosing a surgical procedure. Keywords: chronic limb-threatening ischemia, saphenous vein, treatment outcome.

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Background: Despite the progress of medical science and organ transplantation, lung transplantation is associated with significant complications and mortality. In Iran, the first lung transplant was performed in 2000 at Imam Khomeini Hospital in Tehran. So far, there has been no assessment of the patients. The main purpose of this study is to investigate the status of lung transplantation status at this center.
Methods: In this retrospective longitudinal study, all lung transplant patients referred to the Lung Transplantation Center of Imam Khomeini Hospital in Tehran from April 2000 to March 2022 were examined. Demographic and clinical data, and information related to their current status, including pulmonary function tests, transplant-related complications, pharmacotherapy, and drug-related adverse events were recorded. Appropriate statistical analysis was applied.

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