Tehran University Medical Journal

Background: Asymptomatic hemorrhagic transformation infarct (AHTI) is known as a complication of ischemic attack and maybe occurs in the entire stroke. However, the role of AHTI in the result of the treatment is still not clear, because it is based on the definition of an asymptomatic and not identifiable. The aim of this study was assessment and evaluation frequency of AHTI in acute ischemic stroke patients.
Methods: This prospective cross-sectional study was done in Neurologic Department, Tehran University of Medical Sciences, Tehran, Iran, from April 2015 to April 2016. Second evaluation was done about new neurologic signs and symptoms ten days after stroke. In addition, brain CT scan was used to diagnose of hemorrhagic event in infarct area. If the hemorrhagic event was occur in different area, the patient was consider as a non-hemorrhagic transformation and excluded from the study. Other exclusion criteria include intracranial hemorrhage (ICH), trauma to the head during admission, cerebral vein thrombosis, coagulation disorder, anti-coagulant (heparin, warfarin) administration, induced transformation within 10 days of onset of ischemia, lacunar ischemic and unobservable in thirty T-brain scan, patient's lack of referral for examination and CT scan 10 days after the onset of symptoms, died before CT was considered.
Results: Three hundred and eighty seven patients had inclusion criteria. 249 cases were excluded due to lost following, vein thrombosis of the brain, lacunar ischemia, anti-coagulants recipient (heparin, warfarin), asymptomatic hemorrhagic transformation and death. Finally, 138 cases (86 men, 52 women) with 66.61±9.37 years (50-101 years) were participated in data analysis. Frequency of positive CT scan was evaluated for ischemic stroke evidence in two stages. Of the 138 patients who participated in the study, 75 (54.3%) were positive in the first and 63 (45.7%) cases in the second time. 27 cases (19.6%) had AHTI.
Conclusion: Coronary artery bypass graft (CABG) had significant correlation with ATHI in acute ischemic attack. However, stroke history correlated with decreasing of ATHI. Concerning smoking and consuming the results showed that smoking did not affect the asymptomatic hemorrhagic transformation. Also, the results showed that the use of aspirin and Plavix also had no significant effect on increasing the incidence of ATHI.

Background: Trauma is one of the main causes of maternal mortality and morbidity in societies, which annually causes millions of deaths worldwide and imposes a high financial burden on health facilities, the purpose of this study was to determine the frequency of physical trauma and its associated factors during pregnancy.
Methods: All data for this cross-sectional study were collected from medical records of pregnant women, who referred to the Mahdeeyeh Hospital in Tehran, Iran, as a result of trauma through 2015. Information related to the pregnant women with trauma was extracted from their medical records based on a researcher-made collection form. All patients who meet criteria for entering the study (based on entry and exit criteria from the study) were selected as samples. The significance level of the tests was considered as P<0/05, the Spearman correlation coefficient tests and Chi-square were used.
Results: A total of 68 people were enrolled on the basis of selected criteria, meanwhile, the mean age of subjects was 26 years and 100% had no history of abortion. In all cases the trauma was blunt and included 63% abdominal, 24% lower back, and 14% flank trauma. Abortion was reported in 3% and 8% of the cases with abdominal and lower back trauma, respectively. Also, according to the results of this study, in cases where the placental abruption (six cases) were lateral face pairs, in all of them physical trauma was also posed. It is necessary in the traumatic pregnant women referring with placental abruption symptoms and sign, due to the legal importance of doing a thorough examination and sonography, the type of placental abruption (lateral or central) is made sure and then documented in patients' files.
Conclusion: Physical trauma also is common in the pregnant women and the lateral aspect placental abruption can be one of the obvious evidence for physical trauma.

Background: Methotrexate is an anti-metabolite drug and one of the folic acid analog that it can play an important and functional role in the treatment of many malignancies and inflammatory diseases. However, the development of petechiae (maculopapular rash) is a very rare complication.
Case Presentation: The patient was a 77 years old woman, Aryan race, who was known a case of severe and progressive rheumatoid arthritis. She previously was treated by multiple drugs such as salicylates, gold, corticosteroids, because of unresponsiveness to these drugs, physician prescribed methotrexate once a day, but patient misunderstands and use three times per day for days. Patient with this history referred to a poisoning emergency. In a physical exam, she had oral and throat erythema and swelling of mucosa. In the funduscopy of eyes, bottom of the eyes was normal and conjunctival eyes were prurient she had multiple petechiae at the upper part of chest and base of neck and shoulders and arms with no swelling around petechiae. The lesion had no itching. She had no other sign besides laboratory analysis showed a high level of creatinine, leukopenia, decreased the level of platelets, patient with high suspicious of methotrexate poisoning underwent to granulocyte-macrophage colony-stimulating factor (GM-CSF) and folic acid treatment. After treatment all of her signs recovered and laboratory tests became normal.
Conclusion: At the time of taking methotrexate by the patient, even with appointment of a specialist physician, with any skin signs such as maculopapular rash without itching, we should consider poisoning with methotrexate, and think appropriately about it. This suggests that methotrexate can cause side effects even at low doses.

Background: Medical malpractice is one of the most important legal issues in medicine committed more or less by physicians. The medical staff has inadequate or deficient awareness of medical errors and their importance. Therefore, this study investigated the frequency of medical malpractices/errors resulting in death in files referred to the Iranian Legal Medicine Organization.
Methods: The study population in this descriptive cross-sectional research consisted of all doctors who had been sued in Tehran's Legal Medicine Organization (Forensic Committees of Tehran Province) from the first day of July 2018 to the end of December 2018. The study was carried out in and under supervision and support of the Legal Medicine Research Center. Data were collected using a checklist of the files from Tehran's Legal Medicine Organization.
Results: The results showed that most medical errors are of organizational types. Major medical failures occur in university-affiliated hospitals among the male technical staff aged 41-50 years with a work experience less than 6 years. Most complaints were recorded against general practitioners, general surgeons, and anesthesiologists, respectively. The smallest percentage of the complaints related to orthopedics, urologists, and ear, nose, and throat (ENT) specialists.
Conclusion: The results of the study indicated that most of medical failures have of an organizational nature and occur in university hospitals among male technical officials who are in the fifth decade of life with a low work experience. So, paying attention to these issues can help the better selection of technical officials. The technical authorities of the hospitals must be careful about the responsibilities given to them. In order to reduce the failure of the technical authorities of the hospitals, doctors with a high standard of service should be appointed as technical officers. These doctors ought to possess legal knowledge and be familiar with the course of complaints filed in the judiciary.

In 2019 a newly emerged coronavirus was detected by the Center for disease control (CDC) in China. Nucleic acid sequencing from nose and throat swab samples of patients revealed that it was like severe acute respiratory syndrome coronavirus (SARS-CoV). World Health Organization (WHO) named it coronavirus disease 2019 (COVID-19) and reported more than 100000 positive tests until March 2020 for COVID-19. During the past 20 years, the world has been affected by three coronavirus epidemics, SARS-COV, Middle East respiratory syndrome coronavirus (MERS-CoV), and COVID-19 that make world attention. The mortality rate of COVID-19 was more than other coronaviruses, but because of more people affected by it, it seems that it has a less fatality rate compared with MERS- CoV. Initial data showed that more than 80% of patients did not have any symptoms or may had light symptoms. 15% showed severe pneumonia, 5% became critically ill, and developed multiorgan dysfunction and septic shock. Due to the epidemic of emerging viruses and the lack of information about it, this study aimed to provide a quick overview of the most recent studies in the world. To perform this review, keywords such as COVID-19, severe acute respiratory syndrome coronavirus 2, and Angiotensin-converting enzyme 2 were retrieved using the medical subject headings (MeSH) system and then searched in English in PubMed, Scopus, Google Scholar, and Web of Science databases.
COVID-19 virus enters its genome into the cells by binding to Angiotensin-converting enzyme 2 in some organs such as the lungs. Although the transmission route is unclear, it enters the body through respiratory droplets. The clinical symptoms includ fever, cough, dyspnea, myalgia, confusion, headache, sore throat, rhinorrhea, chest pain, diarrhea, nausea, vomiting, malaise, and convulsion. The standard diagnostic method is Real-time polymerase chain reaction (RT-PCR), but due to the time-consuming and sensitivity and the existing errors in this technique, chest CT and hematologic data are preferred. No definitive cure for the virus has been suggested so far, but antiviral drugs such as Oseltamivir, Ganciclovir, Lopinavir, Ritonavir and Remdesivir, and the anti-malarial drug Chloroquine phosphate and Interferon are in use until the discovery of the vaccine.

Background: one of the leading clinical problems for premature neonates especially with very low birth weight is the type and amount of feeding. The authors aimed to compare outcomes of slow versus rapid feeding in premature neonates hospitalized in Al-Zahra hospital, Rasht.
Methods: This is a clinical trial that was conducted on 62 premature neonates aged less than 35 weeks of gestation who were referred to Al-Zahra Hospital from April 2015 to April 2016. They weighed 1000-2000 gr at birth. Samples were randomly assigned to intervention or control groups. The intervention included neonatal feeding with breast milk or formula with feeding advancement of 30 cc/kg/day which was compared with the routine method of slow feeding (20 cc/kg/day). Neonates were assessed until discharge or the occurrence of Necrotizing enterocolitis. Data were reported by descriptive statistics including mean, standard deviation, frequency, and percent, and analyzed by independent samples t-test and chi-square test in SPSS software, version 22 (IBM SPSS, Armonk, NY, USA).

Results: In the group of children with tic disorders, the highest number of patients were girls and in the group of children who were healthy, the highest number of patients were girls. The average age of patients in the case group was 10.37±0.31 years old and the average age of patients in the control group was 10.06±0.41 years old. The average age difference between the children with tic disorders and healthy children was not statistically significant (P=0.971). The average body mass index (BMI) in the case group was 16.98±0.35 and the average BMI in the control group was 16.0±84.56. The average body mass index difference between the children with tic and healthy children was not statistically significant (P=0.838). The mean serum Vit 25(OH) D3 levels in the control group were higher than the average serum level of vitamin D in the case group. The mean serum vitamin D level difference between the children with tic disorders and healthy children was statistically considerable (P=0.036). Conclusion: The results showed that the average serum level of vitamin D in children with tic disorders was significantly lower than in children who were healthy. To investigate and confirm this relationship, more long-term studies with a larger number of patients are needed.

Background: The training and education of competent and qualified surgeons have been one of the challenges of the surgical profession. The concept of surgical competence has been affected widely due to a series of developments in the new disease emergence, various surgical techniques and the introduction of advanced tools and equipment into the operating. The development of surgical competence and achieving this goal requires accurate identification and analysis of the dimensions of competence. This study was done to explain the concept of surgical competence using the 8-step Walker and Avant approach.
Methods: This study is a qualitative study that was conducted from May- October 2016 at Shahid Beheshti University of Medical Sciences. The present study is a qualitative and conceptual analysis study, which is done with Walker&Avant's eight-step approach to determine the defining characteristics of the concept of surgical competence. A systematic search was conducted between 1990 and 2020 by keywords search such as surgery, surgical, operation OR laparoscopy AND competence competency development competency proficient, proficiency, expertise, clinical, in the database like Google Scholar, PubMed, SID, Magiran, Scopus, Web of Science. Twenty articles were included in the study based on inclusion and exclusion criteria. Moreover, the defining features of the concept were extracted from it.

Results: Based on the results of this study, the concept of surgical competence was defined and the four dimensions of elements, goals, components and the process of developing surgical competence were identified. Then, by clarifying the characteristics of surgical competence, a model of surgical competence development was drawn. Surgical competence development depends on the acquisition of specialized knowledge and numerous skills that are acquired through experience and deliberated practice under the supervision of others in the surgical community of practice and over time. Conclusion: Surgical competence is a set of observable and measurable skills that allows a surgeon to manage the surgical process independently pbt while maintaining the patient's safety. It includes specialized knowledge, communication skills, cognitive and technical skills, and basic surgical skills.

Background: In addition to heart disease, ECG also changes in non-heart disease, which due to its similarity, can lead to misdiagnosis of heart disease in patients. ECG changes in brain lesions such as ischemic and hemorrhagic strokes, brain traumas, etc. and have been studied in many articles, but the effects of brain midline shift on ECG changes have not been studied. In this study, we want to examine these changes.
Methods: This is a prospective cross-sectional descriptive study. Patients with brain tumors who were referred to Al-Zahra and Kashani hospitals in Isfahan from April 2019 to March 2021 were selected. Patients with a history of heart disease, patients receiving medications that cause ECG changes, patients with ECG changes due to non-cardiac and cerebral causes, and individuals under 15 years of age were not included in the study. Patients whose ECG changes were due to electrolyte disturbances or acute heart problems were also excluded from the study. After obtaining informed consent from patients, a CT scan or brain MRI was taken and patients were divided into two groups with and without midline shift. Then the ECG was taken and ECG changes (T wave, ST segment, QTc Interval, QRS prolongation) were compared in two groups of brain tumors with and without midline shift.
Results: 136 patients were included in the study. Of these, 69 patients were in the without midline shift group and 67 patients were in the midline shift group. In the midline shift group, 3% of patients had ST segment changes and 23.9% had T wave changes, which were 1.4% and 10.1% in the without midline shift group, respectively. The mean QTc Interval in the two groups without and with midline shift was 338.26 (4 28.438) and 388.66 (37.855), respectively, and the mean QRS in the without midline shift group was 86.09 (88.9.88) ms and in the midline shift group was 94.63 (±12.83) ms.
Conclusion: Brain midline shifts can cause QRS widening, QTc interval prolongation, and T-wave changes in patients' ECGs.

Background: The objective of this study was the transcultural adaptation of the Rotator cuff quality of life (RC-QOL) questionnaire and the determination of the reliability and validity of the questionnaire in the Persian-speaking population with rotator cuff disease.
Methods: This study was conducted in Isfahan from April 2022 to February 2023. The participants consisted of 56 people with rotator cuff pathology. The process of adapting and translating the questionnaire was done with the methodology presented previously by Beaton et al. Content validity was first tested by a group of orthopedic and physical medicine and rehabilitation specialists and then through a pilot study consisting of 15 Persian-speaking patients with rotator cuff disease. Test-retest reliability was established with an intraclass correlation coefficient. Internal consistency was calculated using Cronbach's alpha. The measurement's error estimation was calculated with the standard error of the measurement. Reproducibility evaluation was measured with a 3-day interval between the completion of the test-retest questionnaire.

Results: The age range of the participants was 34 to 68 years (55% men and 45% women). The mean (standard deviation) of the total score of the RC-QOL questionnaire was 44.33(10.81) and ranged from 17.35 to 70.88. Cronbach's alpha was 0.971, which showed high internal consistency. The intraclass correlation coefficient was 0.99, indicating high test-retest reliability. The mean values (standard deviations) of the DASH and SPADI questionnaires were equal to 77.66(13.69) and 66.66(18.25), respectively. The results of the study showed excellent and significant convergent validity of the RC-QOL questionnaire with both the DASH and SPADI questionnaires. The correlation value with the DASH and SPADI questionnaires was equal to 0.907 and 0.941, respectively. Conclusion: The Persian version of the RC-QOL questionnaire is a valid and reliable tool to evaluate the quality of life in patients diagnosed with rotator cuff injuries.

Case Presentation: A 35-year-old man who had a history of Wolff-Parkinson-White syndrome from 8 years ago and suffered from dilatation and reduced left ventricular ejection fraction in recent years was presented with a pre-excited atrial fibrillation attack at the emergency department. The initial surface ECG showed positive delta wave in all precordial leads and negative QRS complexes in interior leads with QRS duration of about 200 ms. He had undergone electrophysiology study and ablation at the left postero-lateral accessory pathway. After ablation of accessory pathway within the months (from November 2022 until June 2023), left ventricular function was gradually improved and the symptoms of the patient's shortness of breath were also decreased. Conclusion: The existence of heart failure in patients with Wolff-Parkinson-White syndrome can be due to various reasons including the presence of an accessory pathway and the dyssynchrony of intraventricular contraction which is caused by premature excitation of the connected part of the left ventricle by accessory atrioventricular pathway. Although in order to rule out the possibility of the incidental association of the accessory pathway with primary dilated cardiomyopathy and to investigate the segmental dyskinesia, it is necessary to perform diagnostic measures such as echocardiography and cardiac computerized tomography and magnetic resonance imaging, ablation of such accessory pathway not only controls arrhythmic attacks but also leads to the improvement of the left ventricular systolic function even in a middle age patient.

Background: Preterm premature rupture of membranes (PPROM) significantly impacts perinatal mortality and maternal-fetal outcomes. The purpose of this study is to investigate the frequency of maternal risk factors, maternal and fetal outcomes and the role of care in the occurrence of outcomes.
Methods: This retrospective cross-sectional study involved 317 pregnant women with premature rupture of membranes (PPROM) at Shahid Beheshti Hospital in Isfahan, between April 2020 and April 2022. Data were collected from medical records, including demographic information, risk factors, and maternal and neonatal outcomes. Patients were categorized into two groups: those receiving care (24-34 weeks of gestation) and those undergoing pregnancy termination (less than 24 weeks or more than 34 weeks). The chi-square test was used for qualitative variables, while the T-student test was applied for quantitative variables.

Results: In this study, the average age of patients was 29.42±6.56 years. The most common risk factors for PPROM were 20.2% for abortion records, 20.2% for urinary infections, 18% for cervical insufficiency, and 13.6% for gestational diabetes. Comparing maternal outcomes between the two groups revealed that chorioamnionitis occurred more frequently in the care group (18% vs. 2%, P=0.0001), as did emergency cesarean sections (37% vs. 4.5%, P=0.0001) and NICU hospitalization (71% vs. 17%, P=0.001). In the next stage, a regression test identified the independent effects of variables on maternal and newborn outcomes without intervention or confounding factors. The analysis indicated that mothers in the care group experienced significantly more complications than those in the pregnancy termination group, and their babies also faced significantly more complications. Conclusion: The study results indicate that a history of abortion, urinary infections, cervical insufficiency, and gestational diabetes are significant risk factors for PPROM. Expectant management of PPROM is associated with more neonatal and maternal complications than pregnancy termination. Thus, timely identification of these risk factors allows healthcare providers to educate mothers and potentially prevent and manage them, significantly reducing the incidence of PPROM and its complications.