دکتر ملیحه کدیور

Cellulases and xylanases are hydrolytic enzymes that randomly cleave the β-1, 4 backbones of the cellulose and arabinoxylans of wheat flour and are widely used in the bakery industry as a dough texture improver in the formulations of flour products. Creating novel sources of a microbial strain using induced gamma irradiation can increase enzyme production for bakery industrial usage. According to this, Co60 gamma irradiation has been used to develop a mutant strain of Trichoderma afroharzianum. Trichoderma mutants were isolated, and the qualitative and quantitative screening were used to evaluate the extracellular enzyme production with the wheat bran waste as a substrate. The best Trichoderma mutant isolate was identified using the DNA barcoding method. The highest xylanase activities were observed in the superior mutant isolate of Trichoderma afroharzianum NAS107-M82, which is approximately 3.3 times higher than its parent strain. The electrophoretic pattern of proteins showed that the exo-glucanase I, endo-glucanase III, and the xylanase I enzymes hydrolyzed the wheat bran, synergistically. Overall, gamma irradiation-induced mutation could be an expedient technique to access such superior mutants for the bioconversion of wheat bran wastes to xylanase enzyme.

Widespread use of smartphones among health care professionals, and increasing audiovisual recording of patients with the aim of clinical and non-clinical purposes has emerged serious ethical, legal and social issues. To address such issues several guidelines have been developed in many countries. However, providing a practical and easily accessible ethical guideline with respect to national values seems necessary. Therefore, we developed an ethical guideline for making and using audiovisual recordings of patients with special attention to Iranian culture, social principles and Islamic commands.

This study was conducted at Tehran University of Medical Sciences in 2017-2019 and the guideline was developed through four phases:  Literature review, focused group discussions, Expert panels, Assessing stakeholders’ views.

The final draft of this guideline consisted of 43 items of "General Regulations" and 25 items of "Specific Regulations". The "General Regulations Section" covered the considerations before, during and after audiovisual recordings of patients. The "Specific Regulations Section" included ethical principles on audiovisual recordings of children and adolescents, cadavers, and patients with impaired decision making capacity as well as the ethical issues on broadcasting the recordings on public media.

Developing an ethical guideline for making and using audiovisual recordings of patients with respect to social, cultural and religious considerations will be helpful to address the emerging ethical, legal and social issues in this regard.

Altered concentrations of cerebrospinal fluid (CSF) and blood amino acids may be related to epilepsy or the severity of the seizure. In the present study, we assessed the concentrations of amino acids in CSF and plasma in neonates with refractory seizures.

In this prospective cohort study, 27 neonates aged 1 to 56 days with refractory seizures were included. Blood and CSF samples were collected from each neonate within 24 hours after receiving 2nd antiseizure medications. All plasma and CSF samples were sent to the laboratory to measure amino acid concentrations. The associations between CSF and plasma amino acid levels with different variables were evaluated.

Except for leucine (P=0.15) and isoleucine (P=0.07), the levels of all amino acids were significantly higher in plasma than CSF. Significant associations were observed between types of seizure and plasma citrulline (P=0.008) and leucine concentrations (P=0.04). The mean of CSF glutamic acid was also statistically different among neonates with different EEG results (P=0.02).

Our findings indicate that several plasma and CSF amino acids could be candidate biomarkers for neonatal refractory seizures. Further studies with larger sample size are to confirm our findings.

Peripherally inserted central catheters (PICCs) have long been used to provide intravenous therapy to premature neonates. The advantages of PICCs for neonates include avoidance of the pain and handling associated with repeated peripheral intravenous cannulation as well as the ability to safely deliver concentrated parenteral fluid or nutrients. Malpositioned PICC line tips can cause life-threatening complications. There are different intra- or post-procedural techniques to confirm line-tip placement to decrease the potential complications. These include plain radiographs, fluoroscopy, ultrasonographic detection, digital imaging, computed radiography, and intra-cavitary/ trans-esophageal/ and thoracic electrocardiographic monitoring. Each method has advantages and disadvantages and some methods have benefits in specific situations. The present study provides a literature review of common methods developed for detection of PICC tip positions over the last two decades.

Seizure is a common sign in neonates hospitalized in the neonatal intensive care units (NICU) that may lead to morbidity and mortality. Most neonatal seizures are subclinical. Conventional EEG (cEEG) is the gold standard for detecting and monitoring seizures but is not widely available. Amplitude-integrated electroencephalography (aEEG) has been used for over a decade to evaluate infants with seizures. In this study, we tried to determine the efficacy of aEEG as
a widely available diagnostic tool in diagnosing seizures.

All cases with seizures or suspicious seizures were admitted to the NICU of the Children’s Medical Center for one year. cEEG and aEEG were performed for these infants. aEEG was recorded for at least six hours with a description of the tracing. Clinical information, outcomes, and questionnaires (patient information) were recorded in detail. The obtained data were analyzed with the SPSS version 24 software.

Eleven out of twenty-five aEEG recordings were abnormal; other patients showed normal aEEGs. The most common clinical and neurological manifestations were seizure (68%) and hypotonia (28%); the mortality rate was 12%. No significant correlation was observed between aEEG findings and gender, age, familial relation, outcome, ultrasound result, type of seizure, and underlying disease.

Caustic ingestion in the pediatric population usually occurs accidentally in children under five years due to insufficient care or negligent household depositing of caustic substances. Neglectful behavior of parents while preparing formula for a neonate can lead to this rare condition in newborns.

We are reporting the case of a four-day-old newborn that was accidentally given house cleaning liquid mixed with formula by his mother, who mistook it for water to dilute the milk. This led to the development of extensive oral and esophageal lesions. 

This report highlights the importance of providing education for parents on how to prevent such accidents and avoid neglectful behaviors while caring for their children.

 Patent ductus arteriosus (PDA) is a disease presenting on the first days of birth, associated with unpleasant complications such as exaggerated respiratory distress and increased mortality, requiring prompt treatment.

 This study evaluated the relationship between perfusion index and the recovery of patients diagnosed with PDA.

 In this cross-sectional study, 22 neonates with PDA (as the case group) and 22 healthy neonates (as the control group) were selected. The difference in perfusion index (PI) before and after arterial duct closing was determined, and also the relationship between pre-ductal and post-ductal PI in the case and control groups was evaluated. Data were analyzed by SPSS version 21.

 The results showed a significant difference in the mean scores of pre-ductal and post-ductal PI before and after arterial duct closure (P = 0.004). Also, pre-ductal and post-ductal PI scores were significantly lower in the case group than in the control group (P < 0.001)

 According to our findings, PI in infants with PDA is low at presentation and increases after treatment. Therefore, PI can be used as an indicator to evaluate response to treatment during follow-up, particularly when repeated echocardiography is not accessible.

Echocardiography (ECHO) is a non-radiation real-time technique for evaluating Peripherally Inserted Central Catheter (PICC) tips that could overcome the limitations of plain radiographs, including the static and single image and exposing neonates to radiation. This study compared the accuracy of ECHO and radiography for PICC tip positioning in neonates.

This cross-sectional pilot study was conducted in the neonatal intensive care unit (NICU) of the Children's Medical Center in Tehran, Iran. Ultrasonography was used to visualize the end of the catheter in the vessels. After insertion of the catheter, a chest x-ray along with the ECHO was performed by a pediatric cardiologist blinded to the preliminary radiographic reports, and the results were compared and interpreted.

Forty infants with mean gestational ages of 35.4±3.3 weeks were enrolled in this study which was conducted during 12 months, from 2019 to 2020. The radiography results confirmed the correct PICC location in 29 infants (72.5%), which was simultaneously confirmed by ECHO in 28 infants (70.0%). The ECHO results indicated inappropriate placement in 12 infants (30%), and radiographs indicated correct placement in 11 infants (27.5%). This confirmed the higher accuracy of ECHO compared to radiography. ECHO had a sensitivity of 100%, specificity of 96.55%, PPV of 91.67%, NPV of 100%, and diagnostic accuracy of 97.5%. Both methods were appropriately correlated regardless of the demographics characteristics, sex, birth weight, gestational age, and catheter insertion site.

The findings confirmed that ECHO was more accurate than radiography for visualizing PICCs tip placement. ECHO does not require radiation exposure, has fewer complications, and is faster than radiography; thus, it should be considered as an alternative to standard radiography for line tip confirmation.

Neonatal seizure is a significant problem in this life course, and its timely and effective treatment is crucial. In this study, we compared the efficacy of levetiracetam versus phenytoin for treating the acute phase of neonatal seizures.

In this single-blind case-control study, 60 consecutive children with neonatal seizures referred to the Children’s medical center in Tehran, Iran, in 2018 were studied. Those neonates who had at least 30 minutes of seizure after Phenobarbital treatment were assigned to receive either phenytoin (20 mg/kg) or levetiracetam (initial dose of 40-60 mg/kg) through block randomization. The efficacy and safety of the two drugs were compared between the groups.

The response rate was 83.3% and 86.7% in phenytoin and Levetiracetam groups, respectively, which was not significantly different between groups (P=1.000). Adverse effects were nearly similar between groups (6.7% in the phenytoin group and 3.3% in the Levetiracetam group, P=1.000).

Levetiracetam and phenytoin are both practical and safe for treating neonatal seizures.

The present study aimed to assess the correlation of spiritual well-being with parental stress and coping strategies in mothers with preterm neonates hospitalized in neonatal intensive care units (NICUs).

This prospective cross-sectional study assessed Spiritual Well-Being (SWB), parental stress, and coping strategies in mothers (n=200) of preterm infants admitted to NICUs. Mothers were further divided based on socio-demographic characteristics, such as mother’s age, gestational age, average scores at school, mothers’ literacy level, the birth rank, cesarean or vaginal delivery, number of children, job, and duration of hospital stay.

The results pointed out that 46.6% and 53.4%of mothers had moderate and high levels of SWB, respectively. Moreover, the religion domain (53.30±7.33) had a higher score, in comparison with the existence domain (46.03±7.15). The planful problem-solving was the most frequently used (46.02±11.46) strategy. Religion domain had a significant positive and negative correlation with planful problem-solving strategy (r=0.439**; P≤0/000) and emotional-driven coping strategy (r=-0.420**; P≤0/000), respectively. There was a significant negative correlation (r=-0.322**; P≤.0/000) between the existence domain and the emotional-driven coping strategy.

Regarding the close interrelationship between mothers and NICU nursing staff, it is clear that nurses can help mothers to cope with stress more quickly and efficiently using accurate assessment and appropriate intervention in terms of their spiritual and religious beliefs.

Child Abuse and Neglect (CAN) is a major health problem with serious consequences. Since health care professionals play an important role in identification, management, and reporting CAN cases, they should have precise knowledge on this subject. The aim of this study is to investigate the level of knowledge, attitude and practice of the pediatricians, pediatric residents, and nurses regarding CAN issues as well as their possible needs for any educational programs in this regard.
130 pediatric nurses and physicians working at two pediatric tertiary centers, in Tehran, Iran participated in this descriptive cross-sectional study. An anonymous validated and standardized self-report questionnaire was used as the study instrument. The questionnaire consisted of five sections on demographic information, knowledge, attitude, practice and needs assessment. Analytical statistical tests including t-test, Kruskal–Wallis and Mann-Whitney tests were used to analyze the data.
The level of the participants’ knowledge was moderate (mean score: 16.6±3.17) and their attitude towards child abuse and neglect was at a good level (mean score: 45.72 ±4.25). The results of this study revealed that the overall performance of the participants in dealing with a suspicious case of child abuse and neglect was moderate. Almost all participants (95.5%) indicated the need for educational programs on child abuse both for nurses and physicians.
Results of our study revealed that the overall knowledge, attitude, and practice of the health care professionals in the field of pediatrics regarding child abuse and neglect are not satisfactory and training programs on this issue are mandatory for pediatricians, pediatric residents, and nurses due to their serious role in caring for children.

Child abuse is a significant global concern, with short-term and long-term consequences for the lives of children who are victims of violence. For effective action by decision-makers, the information and analysis obtained from surveillance systems must be used to determine the problem, the magnitude of maltreatment, its relationship with other issues, and the likelihood of preventing maltreatment. Due to the importance of child abuse and the management and control of this event, this study was conducted to design and evaluate a child abuse surveillance system. The system was designed in Visual Studio version 2017 using the C# programming language and ASP.NET framework. SQL Server was used to store the data. The design of the child abuse surveillance system was evaluated according to the usability evaluation. The minimum data set was indexed to collect and store data on abused children by the standard format. Web-based child abuse surveillance system (CASS) has 3 types of users. The system evaluation results showed that the highest number of problems were related to the principle of "help and documentation". Designing a CASS is a practical step in managing and controlling the data of abused children. This system and registration of information will help professionals, managers, and decision-makers make the right decisions to take care of injured children with up-to-date information

The present study aimed to compile and develop a professional guideline for health-care providers in Iran regarding cyberspace usage. This was a mixed-methods study, conducted in three phases. In the first phase, the principles of ethics in cyberspace were collected through a review of the literature and available documents, and were then subjected to content analysis. In the second phase, the views of experts on medical ethics, virtual education, information technology and medical education, as well as clinical sciences experts and representatives of medical students and graduates were evaluated using the focus group method. In the third phase, the draft was evaluated by various stakeholders. Finally, after receiving the comments, the necessary modifications were applied to the guideline.The professional guideline for the use of cyberspace by health-care professionals comprised 30 codes in 5 domains, including the general regulations domain, care and treatment, research, education, and personal development.This guideline presents the various ways professionalism can be maintained in cyberspace interactions. Adherence to the principles of professionalism in cyberspace is required to protect and preserve the public trust in health-care professionals.

This is a new case, affecting a twin that both with Hirschsprung’s disease, one was suffering from long-segment Hirschsprung’s disease with skip segmented. Our surgeon suspected the absence of abnormal vessel tortuosity in the transitional zone; thus, the appendix was sent for permanent pathology. There were ganglion cells in the colostomy site but no ganglion was found in the appendix. Complete biopsies from different parts of the intestine demonstrated positive ganglion cells in the transverse colon, ascending colon, and the distal ileum, jejunum, and duodenum, and negative ganglion cells in the rectum, sigmoid, descending colon, appendix, and 5 cm far from the ileocecal valve were observed. Therefore, the Kimura procedure was done. The most important key in such cases is the surgeons’ observation during operation.

Providing care for terminally ill neonates is an important issue in NICUs. This research aimed to determine nurses’ attitudes toward providing care for terminally ill neonates and their families. A total of 138 nurses working in neonatal intensive care units (NICUs) affiliated to Tehran University of Medical Sciences participated in this cross-sectional study via convenience sampling in 2019. The Data collection tool was the Frommelt attitudes toward caring for terminally ill persons and their families scale. The nurses in this study had the most positive attitudes toward the items “nursing care should include the family of the terminally ill patient, too” (4.2 ± 0.6) and “the care provider can prepare the patient or his/her family for death” (4.1 ± 0.7). The nurses had the least positive attitude toward the item “the time spent on caring for terminally ill patients creates a sense of frustration in me” (1.06 ± 1). The mean score of the attitudes of NICU nurses toward caring for terminally ill neonates and their families indicates the necessity of improving this attitude.