Iranian Red Crescent Medical Journal
Volume:18 Issue: 4, Apr 2016

Context: The feeling of abdominal fullness, bloating, and movement of gas in the abdomen is a very uncomfortable sensation termed flatulence. Since flatulence is one of the most common gastrointestinal symptoms that is bothersome to patients, it is important to identify effective methods to resolve this issue. In modern medicine, management of flatulence is often not satisfactory. On the other hand, traditional systems of medicine can be considered good potential sources to find new approaches for preventing and treating flatulence. The aim of this study is to review flatulence treatments from a traditional Persian medicine (TPM) viewpoint.
Evidence Acquisition: In this study, the reasons for flatulence and methods for its prevention and treatment are reviewed in traditional Persian medicine (TPM) texts and then related with evidence from modern medicine by searching in databases, including PubMed, Scopus, Google Scholar, and IranMedex.
From a traditional Persian scholar viewpoint, one of the most important causes of flatulence is an incorrect manner of eating; valuable advice to correct bad eating habits will be illustrated. In addition, traditional practitioners describe some herbs and vegetables as well as herbal compounds that are effective food additives to relieve flatulence. The anti-flatulent effect of most of these herbs has been experimentally verified using modern medicine.
Attention to TPM can lead to the identification of new preventive and curative approaches to avoid and treat flatulence. In addition, Persian viewpoints from the medieval era regarding flatulence are historically important.

Outcomesforcystic fibrosis patients are improving rapidly. The demographic factors are notable variables inoutcomes, which can be evaluated and modified.
This study was designed to investigate the association between outcome and demographic factors in patients with cystic fibrosis.
Patients and This was a cross-sectional study and data were gathered for 331 patients using the census method, from March 2001 to September 2014 in Iran. Data was analyzed using logistic regression analysis, chi-square test, and independent sample t test using SPSS 18. Odds ratio with confidence intervals of 95% and P There were 85 (25.7%) deceased patients and 246 (74.3%) living patients at the time of the study. Of the 246 living CF patients, 202 (82.2%) were less than nine years of age, and 77 (90.6%) out of the 85 deceased CF patients had died younger than four years of age. There was a significant difference between outcome and location of residence. The risk of mortality was 50% less in urban patients than in rural patients (P = 0.03). The risk of mortality was approximately two times higher in patients with a positive family history than in those with a negative family history (P = 0.02). The proportion of mortality was approximately two times, or 94%, higher for those in a consanguineous marriage than for those in a non-consanguineous marriage (P = 0.01).
The results demonstrated that the mortality rate was higher in CF patients with a positive family history, a consanguineous marriage, and residence in a rural area. Therefore, demographic factors play an important role in the outcome of cystic fibrosis. Unfortunately, these parameters, which can be managed easily and with low cost, have been overlooked.

Persistent infection with high-risk human papillomavirus (HPV) has been recognized as a major cause of cervical cancer. Distribution of HPV genotypes may differ according to the geographic region and the severity of the cervical lesion. Determining HPV genotypes’ specific distribution is useful for HPV surveillance and control programs. However, little is known about the distribution of HPV genotypes in Iranian women.
The aim of this study was to determine the distribution of HPV genotypes in Iranian women with different grades of cervical lesions.
Patients and From 2011 to 2013, a total of 436 Iranian women with convenience sampling strategy were included in this cross-sectional study. In detail, 287 women negative for intraepithelial lesion or malignancy, 32 with atypical squamous cells of undetermined significance (ASCUS), 50 with low-grade squamous intraepithelial lesion (LSIL), 44 with high-grade squamous intraepithelial lesion (HSIL), and 23 with cervical cancer were evaluated in this investigation. HPV genotypes were determined by INNO-LiPA HPV Genotyping Extra assay.
In total, HPV infection was detected in 45.4% of the cases. The most common high-risk HPV (HR-HPV) genotype was HPV-16 (32.8%), followed by HPV-53 (9.1%). Within low-risk (LR-HPV) genotypes HPV-6 (22.2%) and HPV-44 (6.1%) were the most prevalent. HPV-16 was the predominant genotype in cases with cervical cancer (56.5%), ASCUS (34.4%), and HSIL (34.1%). HPV-6 was the most common genotype in normal cases (9.1%) and LSIL patients (18%). The prevalence of HPV positivity was significantly higher in cases with high-grade lesions (≥ HSIL) (64.2%) than in normal/LSIL (37.3%) (P = 0.033). The rate of HR-HPV infection was significantly higher in ≥ HSIL cases (61.2%) than normal/LSIL (27.9%) (P = 0.003).
This study describes robust information on the distribution of HPV genotypes among Iranian women with and without cervical lesions. The present data may be of importance for designing future public health strategies, including HPV vaccination programs.

Oral mucositis is one of the irritating side effects of chemotherapy in patients undergoing bone marrow transplantation. However, up until now, the common methods of oral mucositis therapy have failed to show significant effects.
The aim of this study was to investigate the effects of local cryotherapy on the intensity of chemotherapy-induced oral mucositis in autologous bone marrow transplantation patients.
Patients and In this single, blinded, randomized clinical trial, 29 patients undergoing stem cell transplantation in Iran were selected by convenience sampling, and randomly allocated to control (n = 13) and intervention groups (n = 16). In the intervention group, cryotherapy was applied, while the control group received a normal saline mouthwash. The severity of the mucositis and neutrophil rate were investigated in five periods, based on the world health organization (WHO) scales. The data were analyzed using descriptive statistics, the Mann-Whitney test, repeated measures analysis of variance (ANOVA), and linear regression.
In both groups, the mucositis reached its peak intensity on the 7th day, and the least intensity was obtained on the 21st day. The neutrophil rate reached the minimum value on the 7th day, then increased up to the 21st day. The two groups showed no significant differences between the mucositis severity on the 14th and 21st days (P = 0.164), while the severity of the mucositis in the cryotherapy group was significantly less than that in the saline mouthwash group (1.81 The results showed that cryotherapy is more effective than the saline mouthwash in reducing the severity of mucositis. This method is recommended for the prevention of mucositis in bone marrow transplantation.

Propylthiouracil (PTU) is commonly used to treat hyperthyroidism and can induce antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Although this is a rare side effect, ANCA-associated vasculitis can progress to severe disease if its diagnosis and treatment are delayed, leading to a poor prognosis.
A 43-year-old woman with Graves’ disease developed pulmonary vasculitis and diffuse alveolar hemorrhage (DAH) associated with ANCA against myeloperoxidase and proteinase-3 that was confirmed by computed tomography (CT) and bronchoscopy and treated with PTU. The symptoms and signs of alveolar hemorrhage were rapidly resolved after PTU withdrawal and treatment with corticosteroids. After 6 months of follow-up, the patient maintained complete ANCA-negative clinical remission status, as confirmed by normal CT and bronchoscopy findings. To our knowledge, this is the first documented case of bronchoscopic comparison of PTU-induced DAH before and after steroid treatment.
Patients treated with PTU should be closely monitored and followed up, even if the drug has been used for several years. When patients develop progressive dyspnea with alveolar opacities on chest imaging that cannot be explained otherwise, alveolar hemorrhage should be an important differential diagnosis while investigating the case. Early diagnosis and prompt discontinuation of the PTU treatment are essential for improving patient outcomes.

Small cell carcinoma constitutes the most aggressive type of lung cancer, with the greatest propensity for early disseminated disease. Although commonly neglected due to its rarity and the presence of other comorbidities, cases of iris metastasis from small cell lung cancer have been reported in the literature.
We present the case of a 76-year-old female. Once diagnosed, the patient already had disseminated disease with metastatic foci found in the spleen, liver, and brain. The patient received six cycles of combination carboplatin/etoposide chemotherapy, followed by cranial irradiation. After an initial response, two months after the completion of cranial irradiation, the patient complained of visual impairment and was referred to an ophthalmologist. A diagnosis of secondary glaucoma was made, caused by metastasis to the left iris.
Physicians should be aware of this rare site of metastasis. Early diagnosis is of paramount importance in order to effectively prevent the significant morbidity this condition can cause if left untreated.

Marital satisfaction is one of the deepest and the most basic human pleasures and should be established within the family environment; if not, couples might suffer emotionally. Several factors are involved, including attachment and lifestyle.
The purpose of this study was to investigate the relationship between styles of attachment and lifestyle with marital satisfaction.
The population in this study included all of the Bandar Abbas oil refining (BAOR) company employees, for a total of 292 people (146 couples). They were selected by multistage random sampling. The enrich marital satisfaction scale was used to measure marital satisfaction, the Collins and read’s revised adult attachment scale (RAAS) for adult attachment to determine attachment style, and the life style questionnaire (LSQ) for lifestyle. This research was a descriptive-correlative one, and for the data analysis, we used Pearson’s correlation factor and multivariable regression.
The results indicate that attachment style and lifestyle factors can predict marital satisfaction. There was also a meaningful negative relationship between insecure attachment avoidant and insecure attachment anxious-ambivalent styles and marital satisfaction. However, there was no meaningful relationship between secure attachment style and marital satisfaction.
The results showed that the early relationship within the family environment supports a certain attachment style and the effects of the avoidant insecure and ambivalent insecure styles affect the interpersonal relations of the couples in adulthood. The effect of attachment styles on interpersonal relations is far greater than that of lifestyle.

Angiogenesis is an important biological process involved in the proliferation of endothelial cells, tumor growth and metastasis. Vascular endothelial growth factor (VEGF) is considered as a prominent regulator of angiogenesis which exerts the aforementioned effect(s) through its respective receptors (VEGFR1 and VEGFR2). VEGF receptors are targeted as a therapeutic candidate for cancer growth inhibition. RNAi as a new and promising strategy has provided a useful means to specifically suppress gene expression in cancer cells.
The current study aimed to down-regulate expression of the VEGFR1 using siRNA.
This experimental study designed specific siRNAs against VEGFR1. Total RNA was extracted from human umbilical vain endothelial cell (HUVEC) and subsequently cDNA was synthetized. PCR was performed using specific primers to amplify the target gene. After double digestion and purification, the gene was cloned into pEFGP-N1 expression vector. Then, AGS cells were transfected with recombinant pEGFP-N1 using lipofectamin. The gene expression and down-regulation were evaluated by fluorescence scanning, reverse transcription PCR (RT-PCR) and Western blot techniques.
Fluorescent scanning, RT-PCR (27.68%) and western blot analysis (31.06%) showed that the expression of VEGFR1 was suppressed effectively.
The results of the current study showed that specifically designed siRNA can be considered as an appropriate strategy to suppress gene expression and might be a promising tool to prevent angiogenesis.

Road traffic accident (RTA) victims also suffer from different types of injuries and disabilities, which can affect their quality of life. They usually face with various physical, mental, and social problems. Most traffic accident victims had difficulty to return to normal life.
This study aimed to understand the experiences of return to normal life in RTA victims.
Patients and This qualitative study with content analysis approach was conducted on 18 Iranian patients with disability in the upper or lower limbs caused by traffic accidents, who had passed a time between 3 months till 2 years. A purposeful sampling method was applied until reaching data saturation. Data were collected using semi-structured interviews. Afterwards, the gathered data were analyzed through conventional content analysis.
By analyzing 498 primary codes, four main categories, including supportive needs, adaptation to the new situation, seeking information, and transition from functional limitation, were extracted from traffic accident victims’ experiences of reintegration to normal life.
The results of this study may help policy-makers to take steps toward health promotion and recovery of RTA victims. Considering the results of this study, it is a need for further research to investigate RTAs victims’ needs for reintegration to home and community. Access to training and supportive facilities like strong therapeutic, nursing and social support, and the possibility to participate in self-care activities is essential for reintegration to community in RTA victims.

When a country’s health system is faced with fundamental flaws that require the redesign of financing and service delivery, primary healthcare payment systems are often reformed.
This study was conducted with the purpose of exploring the experiences of risk-adjusted capitation payment of urban family physicians in Iran when it comes to providing primary health care (PHC).
This is a qualitative study using the framework method. Data were collected via digitally audio-recorded semi-structured interviews with 24 family physicians and 5 executive directors in two provinces of Iran running the urban family physician pilot program. The participants were selected using purposive and snowball sampling. The codes were extracted using inductive and deductive methods.
Regarding the effects of risk-adjusted capitation on the primary healthcare setting, five themes with 11 subthemes emerged, including service delivery, institutional structure, financing, people’s behavior, and the challenges ahead. Our findings indicated that the health system is enjoying some major changes in the primary healthcare setting through the implementation of risk-adjusted capitation payment.
With regard to the current challenges in Iran’s health system, using risk-adjusted capitation as a primary healthcare payment system can lead to useful changes in the health system’s features. However, future research should focus on the development of the risk-adjusted capitation model.

Brucellosis is a zoonosis disease which is widespread across the world.
The aim of the present study is the evaluation of culture-negative blood samples.
A total of 100 patients with suspected brucellosis were included in this experimental study and given positive serological tests. Diagnosis was performed on patients with clinical symptoms of the disease, followed by the detection of a titer that was equal to or more than 1:160 (in endemic areas) by the standard tube agglutination method. Blood samples were cultured by a BACTEC 9050 system, and subsequently by Brucella agar. At the same time, DNA from all blood samples was extracted by Qiagen Kit Company (Qia Amp Mini Kit). A molecular assay of blood samples was carried out by detection of eryD transcriptase and bcsp 31 genes in specific double PCR reactions. The specificity of the primers was evaluated by DNA from pure and approved Brucella colonies found in the blood samples, by DNA from other bacteria, and by ordinary PCR. DNA extraction from the pure colonies was carried out by both Qiagen Kit and Chelex 100 methods; the two were compared.
39 cases (39%) had positive results when tested by the BACTEC system, and 61 cases (61%) became negative. 23 culture-positive blood samples were randomly selected for PCR reactions; all showed 491 bp for the eryD gene and 223 bp for the bcsp 31 gene. Interestingly, out of 14 culture-negative blood samples, 13 cases showed positive bonds in PCR. The specificity of the PCR method was equal to 100%. DNA extraction from pure cultures was done by both Chelex 100 and Qiagen Kit; these showed the same results for all samples.
The results prove that the presented double PCR method could be used to detect positive cases from culture-negative blood samples. The Chelex 100 method is simpler and safer than the use of Qiagen Kit for DNA extraction.

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological analgesic method used to control different types of pain.
The aim of this study was to evaluate the effects of preoperative TENS on post inguinal hernia repair pain.
Patients and This randomized, double-blind, placebo-controlled clinical trial was performed on 66 male patients with unilateral inguinal hernias who were admitted to the Shahid Beheshti hospital in Kashan, Iran, from April to October 2014. Participants were selected using a convenience sampling method and were assigned to intervention (n = 33) and control (n = 33) groups using permuted-block randomization. Patients in the intervention group were treated with TENS 1 hour before surgery, while the placebo was administered to patients in the control group. All of the patients underwent inguinal hernia repair by the Lichtenstein method, and pain intensity was evaluated at 2, 4, 6, and 12 hours after surgery using a visual analogue scale. Additionally, the amounts of analgesic administered by pump were calculated and compared between the two groups.
The mean estimated postoperative pain intensity was 6.21 ± 1.63 in the intervention group and 5.45 ± 1.82 in the control group (P = 0.08). In the intervention group pain intensity at 2 and 4 hours after surgery were 3.54 ± 1.48 and 5.12 ± 1.41 (P TENS can reduce postoperative pain in the early hours after inguinal hernia repair surgery.

Leiomyosarcoma is a rare gynecologic malignancy that accounts for less than 1% of gynecological malignancies. Leiomyosarcoma of the broad ligament is an even rarer condition. According to Gardner’s criteria, the diagnosis is made when the mass is completely separated from the uterus and adnexa. So far, 23 cases of primary leiomyosarcoma of the broad ligament have been reported in the literature published in English.
In September 2014, a 55-year-old, gravida 3, para 3 woman with a BMI of 30 and a chief complaint of fever and dizziness was admitted to the infectious-diseases ward of the Pars general hospital affiliated with Iran University of Medical Sciences in Tehran, Iran. Her symptoms had begun two weeks before. The results of a fever workup and examination for infectious, metabolic, and immunologic problems were all negative. Imaging modalities revealed an endometrial polyp, two calcified myoma in the body of the uterus, and a solid, heterogeneous 70-mm mass in the right para-cervical space, posterior to the broad ligament, and far from the ovary. After surgery, a histologic report revealed leiomyosarcoma.
Although a leiomyosarcoma of the broad ligament is rare, practitioners should consider it when dealing with masses in the region of the broad ligament. If there is any suspicion of malignancy, especially in the presence of fever, it is recommended to avoid morcellation during laparoscopy.

Patient satisfaction is a key determinant of the quality of medical care. Moreover, satisfaction can be used as a criterion for examining the adequacy of the care, health, and competency of personnel.
This study was conducted to determine the satisfaction of patients receiving trauma care in the emergency department of a hospital affiliated with Isfahan University of Medical Sciences.
Patients and This simple clinical trial was performed on 104 patients admitted for traumatic injury to an emergency department in Iran. Given that patients frequently enter an emergency department for care, the sampling of patients in the department was done on days that were randomly assigned to the study group. The experimental group received trauma intervention in four areas from their admission to the emergency department to their discharge from the hospital, and the control group received routine nursing care. The data were collected through a questionnaire that asked for demographic characteristics and then went on to ask about patient satisfaction. The satisfaction questionnaire was completed after the trauma intervention at the end of patients’ stay in the hospital. The data were analyzed using SPSS 22 software and descriptive statistical tests and analytical tests (independent t and Chi-square).
The mean score for total satisfaction after trauma intervention in the experimental group (45.6 ± 3.69) was significantly different from that of the control group (32.01 ± 7.78) (P In this study, trauma intervention increased satisfaction in patients admitted to the emergency department. Therefore, managers and personnel of hospitals and healthcare training centers are urged to implement trauma intervention in their hospitals or healthcare training centers.

Body temperature is a critical criterion of health. Drugs and a variety of poisons can affect body temperature in poisoned patients, causing hyperthermia and hyperpyrexia.
Our previous study’s findings in patients poisoned with organophosphate led us to the goal of this study: obtaining the initial tympanic temperature in patients poisoned by a variety of toxins.
A cross-sectional study reviewed the records of poisoned patients who were admitted to the toxicological intensive care unit (TICU) at Loghman Hakim hospital poison center (LHHPC) from February 2014 to February 2015. The data collected included gender, age, type of poisoning, the season during which poisoning occurred, vital signs, initial tympanic temperature (first four hours), presence of seizures, white blood cell (WBC) count, creatinine phosphokinase (CPK), length of stay and patient outcome. We determined the mean (SD) for normally distributed continuous variables, the median and interquartile range for non-normally distributed continuous variables, and the absolute and relative frequency (%) for categorical variables. All were determined using SPSS version 16.
Data were collected from 310 eligible patients. The mean patient age was 32.65 (with a standard deviation of 14.40). Of the patients in the study, 183 (59%) were male. Intentional poisoning in an attempted suicide was documented in 253 (81.6%) patients. The most prevalent poisoning agent was aluminum phosphate (18.70%), followed by methadone (10%) and opium (10%). Seventy percent of the patients (n = 217) were diagnosed and classified with fever or hyperthermia. A temperature ≥ 40°C was detected in just three cases. The highest mean temperature was found in patients poisoned with amphetamine, organophosphate and tramadol. Patients with alcohol and phenobarbital poisoning were included in the sample, but these patients were not diagnosed with hypothermia. WBC ≥ 10,000 cells/mL and CPK ≥ 975 IU/L were recorded in 57.7% and 13.2% of subjects, respectively.
Body temperature changes in human poisonings are a matter in need of special attention. A literature review did not reveal any controversy over hypothermia, but poisoning cases exhibit a variety of patterns of fever and hyperthermia. If there are no limits to the diagnosis of fever and hyperthermia, all cases with a poor prognosis which fail to respond to treatment could be categorized as drug-induced hyperthermia. Therefore, a different approach is needed for poisoning cases.

Inversion of chromosome 9 had been widely discussed among geneticists and evolutionary biologists because of its significant impact on various hereditary disorders and in the evolution of man. The role of such inversions in human disease evolution is an area hitherto unclear.
We present the case of a chronic myeloid leukemia (CML) patient who showed intermittent relapse on treatment, with a rare appearance of clones with dual inversion (9) breakpoints [inv(9)(p22q34); inv(9)(p11q21)]. We also present the first report of inv(9)(p11,q13) as the sole abnormality in a patient with chronic myeloproliferative disorder(CMPD). Both the patients registered in 2012 and were from Kerala, India.
Both the cases discussed in our study have inv(9) as the sole abnormality and are found to confer a relatively poor prognosis.

Hospitalized premature babies often undergo various painful procedures. Kangaroo mother care (KMC) and swaddling are two pain reduction methods.
This study was undertaken to compare the effects of swaddling and KMC on pain during venous sampling in premature neonates.
Patients and This study was performed as a randomized clinical trial on 90 premature neonates. The neonates were divided into three groups using a random allocation block. The three groups were group A (swaddling), group B (KMC), and group C (control). In all three groups, the heart rate and arterial oxygen saturation were measured and recorded in time intervals of 30 seconds before, during, and 30, 60, 90, and 120 seconds after blood sampling. The neonate’s face was video recorded and assessed using the premature infant pain profile (PIPP) at time intervals of 30 seconds. The data was analyzed using the t-test, chi-square test, Repeated Measure analysis of variance (ANOVA), Kruskal-Wallis, Post-hoc, and Bonferroni test.
The findings revealed that pain was reduced to a great extent in the swaddling and KMC methods compared to the control group. However, there was no significant difference between KMC and swaddling (P ≥ 0.05).
The results of this study indicate that there is no meaningful difference between swaddling and KMC on physiological indexes and pain in neonates. Therefore, the swaddling method may be a good substitute for KMC.

Homocystinuria is a hereditary disease caused by a defect in the enzymes involved in metabolizing methionine. Homocystinuria can influence many systems and may be mistaken for other diseases, including Moyamoya disease. Here, we report the case of a 10-year-old male patient with a diagnosis of Moyamoya disease who had been monitored for that for an extended period. The patient’s diagnosis was changed to homocystinuria as a result of lens subluxation and cataract findings.
A 10-year-old male patient presented with vomiting, headache, lethargy, muscular weakness, and eye redness. The patient was mentally retarded, his right pupil was hyperemic, and he had muscle weakness on his left side. In addition, his blood pressure was high. The patient’s history included a diagnosis of Moyamoya. A neck and cranial computed tomography (CT) angiography showed no flow bilaterally past the bifurcation of the carotid artery. The patient’s bilateral internal carotid arteries were determined to be occluded. It was considered that his eye findings could be compatible with a metabolic disease. On metabolic screening, the patient’s homocysteine level was very high. In addition, a heterozygous A1298C mutation was identified in MTHFR. Therefore, the patient was started on a diet free from homocysteine and methionine. In addition, his treatment regimen included vitamins B12 and B6. With these treatments, the patient’s complications regressed.
In cases of unusual vascular lesions, metabolic diseases must be considered. In homocystinuria, early diagnosis and treatment are important. Blood homocysteine levels can be returned to normal, and some complications can be prevented.

Diazinon is an organophosphate that is broadly used as a pesticide to control insects and environmental pollutions. This toxic material is absorbed via inhalation, contact, or digestion and affects different tissues.
This research was a histomorphometric and immunohistochemical study of the fetal liver of mice after exposure to Diazinon.
Twenty-five pregnant BALB/c mice (25 - 30 gr) were divided into five equal groups in the animal lab of Baqiyatallah University of Medical Sciences, Tehran, Iran. The normal group was without any intervention, and two sham groups received an emulsifier as 0.52 and 5.2 μL/volume (5000 cc in desiccator) and two experimental groups received Diazinon 1.3 and 13μL/volume from the seventh to eighteenth days of pregnancy every other day via forty minutes of inhalation. The pregnant mice were killed on the eighteenth day of gestation and their fetuses were removed and evaluated for fetal growth and liver development. Five fixed fetuses were dehydrated through a series of graded ethanol, embedded in paraffin wax and their whole bodies were sectioned sagittally and stained via the hematoxylin-eosin method. Quantitative computer-assisted morphometric studies were done on the fetal liver tissues occupied by hepatocytes, blood islands, liver sinusoids, and apoptosis.
The mean crown-rump of the fetuses and their mean weight were increased in the experimental group as compared to the sham and normal groups, but the differences were not significant. The mean percentage of the hepatocyte area significantly increased in the experimental group as compared to the sham and control groups (P Our data showed that inhalation of Diazinon during pregnancy increased the hepatocyte area and hepatocyte apoptosis while it decreased the sinusoid area of the fetal liver.

Neuroretinitis (NR) is considered to be an inflammatory condition which is characterized by optic disc edema and, as a result, formation of a macular star figure. NR is an atypical presentation of toxoplasmosis infection, and such cases are quite rare.
A 13-year-old girl presented with painless subacute visual loss in her right eye for a week at Khatam-Al-Anbia eye hospital in Mashhad, Iran. Following comprehensive evaluation, a diagnosis of toxoplasmic NR was made. The NR favorably responded to classic anti-toxoplasmosis treatment. A juxtapapillary retinochoroidal scar appeared after disc swelling resolution.
Although toxoplasmosis NR is rare, it should be considered in the differential diagnoses of NR.

Children suffering from thalassemia have higher levels of depression and lower levels of self-concept.
The aim of this study was to determine if group play therapy could significantly increase self-concept among children with thalassemia major ages 7 to 11 years old in teaching hospitals of Golestan province, Iran, in 2012.
Patients and In this randomized, controlled clinical trial, 60 children with thalassemia major were randomly assigned to intervention (30 children) and control (30 children) groups. The intervention included eight 45 to 60 minute sessions during four weeks, during which the intervention group received group play therapy. The control group received no interventions. Self-concept was measured three times using the Piers-Harris children’s self-concept scale: before, immediately after, and a month after the intervention.
For the intervention group, results showed that the mean self-concept score was significantly higher at the second point in time compared to the baseline (P 0.05).
The results showed that group play therapy improves self-concept in children suffering from thalassemia major.

Placenta accreta is an increasingly common complication of pregnancy that can result in massive hemorrhage.
We describe two cases of placenta accreta, with successful conservative management in a referral hospital in Tehran, Iran. In both cases, two procedures were performed: compression suture (B-Lynch) and a perfusion-decreasing procedure (bilateral uterine artery ligation). We also present the results of a narrative literature review.
The double B-Lynch and uterine arterial ligation procedure in cases of abnormal placentation might be strongly considered in fertility preservation, coagulopathy, coexisting medical disease, blood access shortage, low surgical experience, distant local hospitals, and no help.