مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و ششم شماره 4 (پیاپی 208، تیر 1397)

Today, nanoscience has grown and developed in various medical and therapeutic areas, including cancer treatment. On the other hand, cancer and its types have been rumored and inclusive and many people suffer from this fatal and deadly disease. Currently, existing therapeutic method, including chemotherapy, radiotherapy, and etc., along with the therapeutic effect, cause complications that are unpleasant for patients. Hence, scientists and researchers are looking to develop and improve treatment options and methods to deal with this serious disease. Today, nanoscience and nanotechnology have become widespread, and its various fields, including nanoparticles, are widely used for a variety of applications, especially for delivery of drugs and diagnostic items and imaging cases. Nanotechnology-based release systems have a significant impact on the release of cancer drugs. Advances in bio-materials and bio-engineering are contributing to new approaches to nanoparticles that may create a new way for the improvement of cancer patients. Nano-technology in the drug release system has had a great impact on the selection of cancer cells, the release of a targeted drug, and overcoming the limitations of conventional chemotherapy. At the present many drug delivery systems are now made of nanoparticles, and various substances have been used as drug-stimulating agents or as a reinforcing agent to improve the efficacy of the treatment and durability and stability and also the safety of anticancer drugs. The materials used to release cancer drugs are divided into various categories such as polymer, magnetic, biomolecules. In the meantime, polymer nanoparticles have been organized in the carriers of anti-cancer nanoparticles due to the process of easy production, biocompatibility, and biodegradability. Although the loading of hydrophilic compounds is still confronted with limitations, due to the diversity of nanoparticle structures, it is possible to encapsulate various molecules. Also, surface changes and modification such as binding to antibodies and target ligands can also be applied to these materials, to act as target drug delivery to increase the effectiveness of treatment process. In this article, we will have an overview of cancer disease and cancer drugs and also nanoparticles and their contribution to cancer treatment.

Cancer is one of the most dangerous health problems of today modern societies which has an increasing rate especially in developing countries. There are many diverse ongoing treatment attempts trying to defeat cancer. Despite that, scientists have been unable to find a permanent cure for this disease. In many cases although there is a successful first response in patients, cancer cells are finally able to withstand therapeutic procedures and even use chemo-resistance to take advantage of treatments to facilitate tumor growth, resulting in cancer remission. Therefore, and mostly in recent two decades, scientists have been trying to choose their treatments just as smart to be able to conquer cancer. One of the best methods of this smart defense is to target weak points of neoplastic cells and use them for designing drugs. In this case it would be most probable for cancer cells not to have a chance to confront and cause chemo-resistance. Total endeavors to fulfill this goal are named “targeted cancer therapy”. This therapeutic approach is mostly consisted of two different procedures: 1- designing and using specific drugs to target cancer cells’ mutated genes; which will be defined by checking the genetic background of tumor cells for each specific cancer type. EGFR, RAS, VEGF and HIF-1α are among the pathways that have already been used as targets. 2- The other procedure could be methods that would carry drugs directly to unhealthy cells to prevent further side effects for normal cells of patients. It would be possible by designing specific antibodies to target antigens of neoplastic cells. Ribonucleic sequences (miRNAs and siRNAs) are also very promising as new drugs and nanoparticles have enabled us to increase drug concentration in tumors. The ultimate goal of these new experiments is to suggest specific drugs for each patient based on the nature of one's disease and genetic background, which will bring about "personalized medicine" era. Using valid new references, this review article first presents targets that are currently being used for this targeted therapy, their logic of choice and the drugs that have already been produced for clinical trials. Smart methods of drug delivery are also presented and discussed afterwards.

Children's health, preserving and promoting it is a health priority of any society. Malnutrition affects all age groups, but malnutrition in children is one of the most common nutritional problems that can delay body growth, shortened height, frequent infections, mental retardation, the prevalence of mental disorders, lack of academic achievement and reduced efficacy. Because of the importance and impact of this issue in children, the purpose of this study was a systematic review and meta-analysis of the prevalence of underweight in Iranian children, in order to highlight the importance of this issue to health policy-makers.
A meta-analysis was performed for relevant articles in scientific databases including Scientific Information Database (SID), ScienceDirect, PubMed and Google Scholar. Entrance criteria included cross-sectional studies (March 1996 to February 2017) that had a low incidence of underweight in Iranian children in different parts of Iran. Non-relevant articles included review articles, interventions, cohorts and case studies, and studies that looked at obesity, overweight and the relationship between these factors and other diseases, excluded from the study list. Reference lists of identified articles were reviewed for additional articles. Heterogeneity of study was checked using I2 index and the possibility of publication bias by funnel plot and Begg and Mazumdar's rank correlation test and a significance level of 0.1. Data were analyzed using the comprehensive meta-analysis software, version 3 (Biostat, Englewood, NJ, USA).
In 26 articles reviewed in the study, total number of participants was 142938 persons at the age of 1 month to 12 years. The overall prevalence of underweight in Iranian children was 15.5% (Cl 95%: 12%-19.7%) during 1996 to 2017. The highest prevalence of underweight in was recorded in Birjand city in 2006 and Zahedan city in 2009, 68.6% (Cl 95%: 63.3%-72.9%) and the lowest prevalence of underweight in was found in city of Jahrom in 2013, 1.8% (Cl 95%: 1.2%-2.9%).
According to the results of this study, the prevalence of low-birth-weight in the country is high and requires interventional measures.

Labor induction is one of the most public ways carried out global for delivering mothers. The aim of labor induction is to encourage uterine contractions before the spontaneous onset of labor, resultant in vaginal delivery misoprostol is used off-label for a variety of indications in the practice of obstetrics and gynecology, including medication abortion, medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage. Regarding the importance and lack of similar researches in Iran, this research was done to compare the efficacy of buccal and sublingual misoprostol for labor induction in pregnant women.
This study was conducted as a randomized double-blind clinical trial from March 2017 to February 2018. In this survey, 200 women were randomly assigned to receive 50 µg buccal misoprostol and sublingual (100 buccal and 100 sublingual) in Kosar Hospital, Qazvin University of Medical Sciences, Iran. The maternal and fetal complications, Bishop score, and time of pain onset and its interval with labor were monitored in two groups and the findings were analyzed.
Research variables were age, gestational age, BMI, number of previous pregnancy, neonatal weight, total dose, Bishop score 1, Bishop score 6, oxytocin, and delivery type. The results showed that there were no differences between Bishop score 6 (P=0.07), and 1 (P=0.36), total dose (P=0.58), neonatal weight (P=0.43), number of pregnancy (P=0.67), BMI (P=0.67), and pregnancy weak (P=0.108) of sublingual group and buccal group. About 43 patients (43%) in buccal and 64 (64%) in sublingual group had vaginal delivery (P=0.05). The frequencies of maternal and fetal complications were similar between two groups.
It can be concluded that there is no difference between efficacy of sublingual and buccal misoprostol in pregnancy results, maternal, and fetal complications, however, it seems that the sublingual group is more effective than buccal group due to the significant amount of vaginal delivery, achieving vaginal delivery in less than 24 hours, and less need for oxytocin.

The role of high levels of parathyroid hormone in the development of anemia either directly or by mediating mechanisms is unclear, and there is a controversy about the pathophysiological role of parathyroid hormone (PTH) in the development and intensification of anemia associated with renal disease. The aim of this study was to investigate the relationship between anemia and parathyroid hormone and dialysis adequacy in chronic hemodialysis patients.
A cross-sectional study was performed in patients undergoing dialysis in Soodeh Hemodialysis Center, Vavan city, Tehran province, Iran, in two years (September 2013 to September 2015). Patients with age>18 years who underwent dialysis for at least three months were enrolled. Anemia was calculated based on the absolute amount of hemoglobin, hematocrit, and the percentage of patients who achieved the hemoglobin treatment goal of more than 11 g/dL. Parathyroid hormone levels were measured intact PTH and enzyme immunoassay (EIA) method.
176 patients who had entry criteria participated in this study. Patients included 102 males (58%) and 74 women (42%). The mean age of the patients was 54.14±13.98 years (18-85 years). The mean weight of patients was 68.07±14.17 kg (36-120 kg). 23 (13.1%) of the patients had a previous history of kidney transplantation. Of the 176 patients, only one had a history of parathyroidectomy (0.6%). The mean dialysis time in the patients was 6.38±5.29 years (1-28 years). The type of dialysis access in 132 patients (75%) was AV fistula and in 44 patients (25%) was Shaldon catheter. The mean erythropoietin intake of patients was 10,000 units per week. The mean of hemoglobin, hematocrit and PTH were 10.73 g/dl 33.6% and 403 pg/ml, respectively.
The findings of the study showed that there was no significant correlation between hemoglobin and hematocrit levels with parathyroid hormone levels and dialysis adequacy. Increased levels of serum iron, total iron binding capacity (TIBC) and resistance to erythropoietin were associated with a decrease in hematocrit levels due to decreased hemoglobin levels and resistance to erythropoietin.

The study of their knowledge, attitude, and behavior toward health is an essential step for health planning. In the urban area, there are several concerns about environmental pollution, health status, the dangers of insecurity, and bad dietary habits. The aim of the study was the determination of knowledge, attitude, and behavior of Tehran citizens in order to plan better municipal services.
This descriptive, cross-sectional study was conducted on 13000 participants between 15-84 years in 22 districts of Tehran, Iran University of Medical Sciences, in August and September of 2011. Cluster sampling and self-administered reliable and valid questionnaire were used for data gathering. The inclusion criteria are all of citizens of Tehran. Age, sex, marital and job status, obesity, physical activity, hypertension, myocardial infarction, accidents, diabetes, nutrition, stroke, psychological behavior, smoking, addiction and drugs, musculoskeletal, sexual behavior, anemia, physical environment, fat blood, cancer, chronic obstructive pulmonary disease, dietary habits and socioeconomic status were measured under standard protocols and by using calibrated instruments.
From 13000 participants in the study, 11753 (90%) was fulfilled the questioners. Nonresponse rate from 11753 participants was 8.6%. The proportion of obesity/overweight was 50% and 29.5% of people had appropriate physical exercise, 37.6% reported a tobacco consumer in their family and 4.5% reported an experience of substance misuse. Also, 29.2% and 24.8% from these had anomalistic consuming of salt and soft drink, respectively. Of the participants, 44.8%, 89.1% had a good knowledge and attitude, respectively. Cronbach alpha coefficient was 0.82 and 0.79 for knowledge, attitude and behavior, respectively. In additional, the correlation coefficient between test and re-test questions was 0.91.
This study was a comprehensive study to measure the knowledge, attitude and practice of Tehran citizens using reliable and valid questionnaires about general health status. A considerable percentage of Tehran citizens suffering from overweight, obesity, hypertension, diabetes, high blood lipids and smoking consuming and using anomalistic from TV and computer. The results can be used as a framework and guide to prioritize problems and planning health education interventions in Tehran.

Burns are one of the most devastating forms of trauma worldwide. In the elderly, flame and scald burns, or scalds alone, are the major causes of burns, occur at home, particularly in the kitchen and bathroom. Because elderly burned patients suffer from greater morbidity and mortality than younger patients with similar burn extents, preventing burns is paramount to continuing functionality and quality of life. Burns are largely explainable by characteristics of both the individual and the physical environment. Our study aims to analyses the epidemiologic characteristics of burn in the elderly (above 60 years old) in Iran.
Records of elderly patients (aged 60 and older) admitted with acute burns to the Burn Center of the Shahid Motahari Hospital, Tehran, Iran, between March 2007 and March 2014 was carried out. Patient demographics, etiology of burn, mechanism of injury, burn extent, mortality, severity of burn, length of stay in hospital, and outcomes were reviewed. The information was analyzed by SPSS software, version 18 (SPSS Inc., Chicago, IL, USA). T-test, oneway anova and K square were used.
A total of 374 elderly patients were admitted. Majority of the patients were men 231 (61.8%) and the number of women were 143(38.2%). The most common etiologies were scalds (20.3%) and (oil-benzine-gasoline) (19.8%). The mean age of the patient was 71.5 years, which was average in women (72) and men (70.5 years). There was a statistically significant difference between the mean age in both male and female groups, so that the mean age of women was significantly higher than men (P=0.004). There was a significant correlation between gender and (etiology, hospital stay-mortality) and between treatment outcome and (etiology and motivation) and between motivation and etiology (P Boiling water was the main cause of burning in older women. Diminished senses, concentration disorders, slower reaction time, reduced mobility, and bedridden states may decrease elder's ability to identify fire and also to escape harm.

Tariff setting in healthcare is an important control knob affecting the quality, access and cost of services. As part of Iran Health Transformation Plan (HTP) in 2014, the relative value of health care and services was increased to motivate healthcare providers to deliver high quality services. This study aimed to examine the impact of HTP on health services tariffs.
This descriptive and cross-sectional study used the data from California Tariff Book (2013 edition) and the new relative value book (2016 edition). The weighted average of the relative value of the anesthetic and surgical services in both books was calculated and compared.
The California book and the new relative value book had 5281 and 3448 service codes respectively in 13 major medical specialties (34.7 percent reduction of service codes in the new tariff book). Overall, 64985.9 K and 125133.6 K were considered in the California book and the new relative value book (92.6% growth). The California book and the new relative value book considered 25,976 K and 22,307 K for anesthesia services, respectively in those 13 medical specialties (14.1% reduction). The HTP has increased the relative value of healthcare services tariff by 1.9 times in average.
The HTP has doubled the tariff of healthcare services. A rise in the relative value of healthcare services has incurred financial burden on Iranian public health insurance companies and made it difficult to finance health system of the country. A sustainable health financing system should be developed as well a change should be applied in provider payment system to control the cost and increase the health system efficiency.

Various prediction models have been developed aiming to estimate risk-adjusted mortality, morbidity and length of intensive care unit stay following cardiac surgeries. The European system for cardiac operative risk evaluation II (EuroSCORE II) is a prediction model which maps 18 predictors to a 30-day post-operative risk of death. The objective of this study was to evaluate the performance of the EuroSCORE II risk-analysis predictions among patients who underwent heart surgeries.
A prospective cross-sectional study was conducted to collect required variables for all consecutive patients underwent heart surgeries in Emam Reza hospital, Mashhad, Iran, from March 2014 to March 2015. Once the patient was hospitalized a cardiologist or a general physician evaluated pre- peri- and post-operative state to fill out the pre-designed structural paper form. Comparing the observed and expected mortality, the sensitivity, specificity, area under the receiver operating characteristic curve (AUC) and finally the discrimination power of the model for our patients were calculated and reported. The model value was calculated using the online tool.
A total of 1337 patients (60% males) were included, the observed mortality rate was 3.2%. Although the overall performance was acceptable, the model showed poor discriminatory power (AUC=0.667, CI 95%: 0.648-0.685) and accuracy with sensitivity=61.88% and specificity=66.23%.
Our single-center study, based on consecutive patients who underwent cardiac surgery showed that EuroSCORE II demonstrated a moderate statistical overall performance with poor discrimination and calibration measures remain as concerning issues regarding 30-day post-operative mortality prediction after adult cardiac surgery. Poor performance measures for this system show the need for reformulating this risk stratification tool aiming to improve post cardiac surgery outcome predictions in Iran.

Acute leukemia is one of the most common types of childhood malignancies and one fourth of malignancies in this age group is acute leukemia. Acute leukemia may be myeloid or lymphoid. Acute lymphoblastic leukemia is characterized with abnormal proliferation of lymphoid cells and symptoms related to this are acute and if disease is not treated appropriately, it progresses rapidly and end up to death. Diagnosis of these types of malignancies is easily made with evaluation of bone marrow and peripheral blood cells by an expert hematologist. One of the primary sites of leukemic involvement in childhood is oral cavity which is caused by infiltration of leukemic cells in this area. This causes signs and symptoms, for instance, oral lesions gingival hemorrhage and swelling.
We present a 13-year-old girl who was referred to local physician due to toothache and gingival lesions. Some medications were prescribed for her without any improvement. Then excision of this painful gingival lesion was done and diagnosis of acute lymphoblastic leukemia was confirmed. After diagnosis and start of appropriate medical therapy, patient developed many different complications of acute lymphoblastic leukemia and its related therapies. What make this presented case as an outstanding and interesting one is the mentioned complications which were more significant with multiple organ involvement in comparison with similar cases. These complications were treated by appropriate managements.
With new advance in treatment of ALL, survival rate of patients is increased but unfortunately morbidity rate is significant. These complications may be managed by appropriate therapies and close follow-up.