مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و هشتم شماره 6 (پیاپی 234، شهریور 1399)

Infertility as a vital process in human reproduction involves many couples worldwide. Although many genetic causes of infertility are known, the genetic basis of infertility in men is largely unknown. Therefore, the identification of genetic biomarkers in this field is important and genetic polymorphisms in key genes of the spermatogenesis pathway can be valuable biomarkers in this field. Genechr('39')s polymorphisms with specific genetic background and/or environmental factors can lead to the dysfunction in testicular function or the process of sperm production. Matrix metalloproteinases (MMPs) are a family of zinc-dependent enzymes that play an important role in extracellular matrix remodeling by activating gelatinases, collagenases, and proteolytic enzymes. These enzymes are essential for the regulation of cellular connections in the testis. Extracellular matrix degradation and connective tissue remodeling are important structural changes in germ cell migration that are controlled through important genes, including MMPs and their biological inhibitors. Given the important role of MMPs in the structural and functional characteristics of reproductive organs, genetic polymorphisms in MMP genes are significant because they can influence gene transcription and the biological function of proteins. Studies have shown that matrix metalloproteinases are involved in the degradation of extracellular matrix and play an important role in the process of spermatogenesis and sperm quality. This review article aims to evaluate the role of two common, functional MMP2 G1575A and MMP9 C-1562T polymorphisms in male infertility. The findings indicate that polymorphisms of MMP2 G1575A and MMP9 C-1562T can affect gene transcription, protein level, and enzymatic activity, and also, these variants can be as one of the genetic causes in male infertility among different ethnic populations. Therefore, identifying these molecular changes can help to adopt appropriates therapeutic and diagnostic measures as well as guide therapeutic approaches to intelligent therapies. To achieve a definitive conclusion and confirm the association of these polymorphisms with male infertility, evaluations of gene-gene and gene-environment interactions can be important for larger sample sizes of different ethnicities.

Breast cancer is the most common cancer among women and the earlier it is diagnosed, the easier it is to treat. The most common way to diagnose breast cancer is mammography. Mammography is a simple chest x-ray and a tool for early detection of non-palpable breast cancers and tumors. However, due to some limitations of this method such as low sensitivity especially in dense breasts, other methods such as 3d mammography, ultrasound and magnetic resonance imaging are often suggested to obtain additional useful information. Recently, computer-aided diagnostic or intelligent diagnostic have been developed to assist radiologists to improve diagnostic accuracy. In general, a computer system consists of four steps: pre-processing, dividing areas of interest, extracting and selecting features, and finally classification. Nowadays, the use of imaging techniques in the identification of patterns for diagnosis and automatic determination of breast cancer by mammography and even digital pathology (which is one of the emerging trends in modern medicine) reduces human errors and speeds up the diagnosis. In this article, We reviewed recent findings and their disadvantages and benefits in the diagnosis of breast cancer by neural networks, especially the artificial neural network, which is widely used in the diagnosis of cancers and intelligent breast cancers. This literature review shows that hybrid algorithms have been better at improving classification and detection accuracy. Providing a convenient way to diagnose tumors in the breast by computer-assisted diagnosis systems will be of great help to the physicians. Much work has been done in recent years to diagnose breast cancer, and many advances have been made in improving and diagnosing breast cancer by computer. All methods have a significant error percentage and are different depending on the type of breast, but compared to other types of neural networks, convolution and combining methods with convo have better results. Another advantage of the convoluted network is the automatic extraction of desirable features. Today, the best percentages of accuracy in detecting benign or malignant cancerous mass are achieved by convolution.

Identifying risk factors for conversion to open surgery laparoscopic cholecystectomy and factors are difficult to predict cholecystectomy surgery is required. The aim of this study was to evaluate the findings of preoperative ultrasound in predicting the length of laparoscopic cholecystectomy surgery.

The present study was performed cross-sectional on 122 patients who underwent laparoscopic cholecystectomy in Shahid Beheshti, Forghani and Nekoei’s Hospital in Qom from September 2016 to September 2017.Inclusion criteria: All cases of acute cholecystitis, chronic cholecystitis, symptomatic gallstones and biliary pancreatitis underwent laparoscopic cholecystectomy. The exclusion criteria included patients undergoing laparoscopic cholecystectomy at the same time were other procedures. Before surgery patientschr('39') information such as age, sex, ultrasound findings including gallbladder wall thickness, compressed stone and the presence of fluid around the gallbladder were recorded in the checklist. Finally, the duration of cholecystectomy was divided into two degrees of easy operation (less than 60 minutes and without complications) and difficult operation (above 60 minutes with complications) according to the mentioned variables. Data were analyzed by SPSS software, version 22 (IBM SPSS, Armonk, NY, USA). In this study, a significance level of less than 0.05 was considered.

28 (22.4 percent) males and 97 (77.6 percent) females with a mean age of 44.66 13 13.85 years were studied. There were 35 difficult cases (28 percent) and 90 easy cases (72 percent). Conversion to open surgery occurred in three cases. Among the sonographic findings, there was a significant relationship between the increase in gallbladder wall thickness and Impacted stone with the duration of operation (P≤0.05). But no significant relationship was found between the findings of Presence of pericholecystic fluid and the duration of operation (P>0.05).

Overall, the findings of this study showed that preoperative ultrasound is able to provide valuable data in predicting the duration of laparoscopic cholecystectomy.

One of the main causes of maternal death in developing countries is postpartum hemorrhage. Cesarean section is one of the most common surgeries all around the world. In comparison with normal vaginal delivery, cesarean section is a greater risk factor for postpartum hemorrhage and need for blood transfusion. The risk of postpartum hemorrhage will increase when other risk factors such as multiple pregnancies, polyhydramnios, severe preeclampsia, peripartum hemorrhage, protracted labor, labor induction, and obesity are present. Oxytocin is conventionally used for the prevention of uterine atony during the cesarean section. The aim of this study was the evaluation of the effect of sublingual misoprostol in combination with oxytocin in reducing blood loss during and after cesarean delivery.

This randomized clinical trial was performed in Ommolbanin hospital; an academic hospital that is affiliated to Mashhad University of medical sciences from September 2016 to January 2018. The subjects were 90 pregnant women with a term pregnancies who were candidates for emergent cesarean delivery under spinal anesthesia and were at high risk for postpartum hemorrhage. All participants received 40 IU oxytocin in 1 liter of normal saline after delivery, and then they were randomly assigned to the intervention group who received 400 μg sublingual misoprostol in combination with oxytocin infusion, and the control group who received only oxytocin infusion without adding misoprostol.

Sublingual misoprostol in combination with oxytocin infusion during cesarean section led to a significant decrease in postoperative blood loss for six hours after the surgery (P<0.001). The decline in the hemoglobin and hematocrit levels and the amount of intraoperative hemorrhage were the same in both groups. Less additional uterotonic agents were needed in the misoprostol group. The frequency of fever and other side effects were similar in the two groups.

It seems that adding sublingual misoprostol to oxytocin infusion among high-risk women for postpartum hemorrhage is more effective for reducing blood loss during and after cesarean section.

Central venous catheterization is a procedure that is being performed frequently especially in critical clinical settings. In such conditions, good knowledge of the surface anatomy of venous structures is vital to avoid possible complications which could result in life-threatening situations such as bleeding and pneumothorax. Considering the difference between venous anatomy of children and adults and even among different age groups of children, and the fact that our recent knowledge of anatomy is based on studies performed on non-Iranian population, we decided to evaluate the anatomy of the intrathoracic systemic venous system in adults and children and assess the rate of catheter malposition in children.

This was a retrospective cross-sectional study performed in Dr. Shariati Hospital and Children Medical Center of Excellence, Tehran, Iran, from April 2016 to August 2019. In our study, the surface location of brachiocephalic vein (BCV) formation, the junction of superior vena cava (SVC) to right atrium and, formation of SVC were examined in 150 contrast-enhanced chest computed tomography (CT) scans in children. They were classified into three groups based on their age (neonates to three years, three to seven years, and seven to ten years). Also, 100 similar CT scans in adults were being studied. The other category which has been evaluated through 130 pediatric X-rays, was the location of the tip of the central venous catheter.

The formation of BCV was mostly depicted posterior to the sternoclavicular joint in adults while in children it’s located posterior to the medial aspect of the head of clavicle. In adults, the SVC formation was at first intercostal space (ICS) in 52% and second ICS in 29%. In first group of children, SVC was commonly at the level of 2nd costal cartilage (CC), but changed to the first ICS or first CC by increasing age. In adults, junction of right atrium to SVC was at the 3rd CC then 4th CC but in the first group of children was located at the 4th CC that changed to 3rd ICS /3rd CC by increasing age. Also, the tip of central venous catheters was located in the proper position in 74.7% of cases.

This study indicated the different anatomy of central veins in children and adults which could be a cause for malposed central catheter, so knowing this difference and controlling the tip of the catheter by ultrasound during catheterization could help in avoiding this malpositioning.

Cataract surgery is one of the most common surgeries in the world, especially in elderly patients, and often performed topically with sedative agents. Ketamine is one of the most commonly used agents and the effect of different doses on intraocular pressure is in dispute. The present study investigates the effect of a low dose of ketamine on intraocular pressure in patients undergoing cataract surgery.

This case-control study was performed in Farabi Hospital, Tehran University of Medical Sciences from January 2020 to February 2020. In this study 92 patients undergoing cataract surgery were randomly divided into two groups of 46 patients. Patientschr('39') intraocular pressure and blood pressure were measured at baseline, and then all patients received 1 mg midazolam and 1 μg/kg fentanyl before initiation of the study. In the case group, 0.15 mg/kg ketamine was injected intravenously. Intraocular pressure and blood pressure of all subjects were measured three minutes after injection of sedation. Also, postoperative pain, need for opioids and, postoperative nausea and vomiting were compared between the two groups.

There was no significant difference in age, sex and weight between the two groups. Mean intraocular pressure in both groups was not significantly different at baseline. The trend of changes in intraocular pressure was lower in both groups after sedation and there was no statistically significant difference between the two groups. After sedation injection, the mean arterial blood pressure changes in the control group were decreasing while in the case group showed an increasing trend and this difference was statistically significant. Five patients in the control group and one in the case group complained of moderate to severe pain postoperatively. There was no significant difference between the two groups regarding nausea and vomiting and the need for postoperative opioids.

Low-dose ketamine administration had no significant effect on intraocular pressure and did not cause side effects of ketamine such as nausea, vomiting and hallucinations and it may improve the hemodynamic stability of patients if they are injected with sedative medications.

Ensuring adequate depth of anesthesia during surgery is essential for anesthesiologists to prevent the occurrence of unwanted alertness during surgery or failure to return to consciousness. Since the purpose of using anesthetics is to affect the central nervous system, brain signal processing such as electroencephalography (EEG) can be used to predict different levels of anesthesia. Anesthesia disrupts the interaction between different regions of the brain, so brain connectivity between different areas can be a key factor in the anesthesia process. This study aims to determine the depth of anesthesia based on the EEG signal using the effective brain connectivity between frontal and temporal regions.

This study, which is done from April to December 2018 in Tehran, used EEG signals recorded from eight patients undergoing Propofol anesthesia at Waikato Hospital of New Zealand. In this study, effective brain connectivity in the frontal and temporal regions have been extracted by using various Granger causality methods, including directional transfer function, normalized directional transfer function, partial coherence, partial oriented coherence, and imaginary coherence. The extraction of effective connectivity indices in three modes (awake, anesthesia and recovery) was calculated using MATLAB software. The perceptron neural network is then used to automatically classify the anesthetic phases (Awake, Anesthesia, and recovery).

The results show that the directional transfer function method has a high correlation coefficient with BIS in all cases. Also, the directional transfer function index due to faster response on the drug, low variability, and better ability to track the effect of Propofol works better than the BIS index as a commercial anesthetic depth monitor in clinical application. Also, when using an artificial neural network, our index has a better ability to automatically detect three anesthesia than the BIS index.

The directional transfer function between the pair of EEG signals in the frontal and temporal regions can effectively track the effect of Propofol and estimate the patientchr('39')s anesthesia well compared to other effective connectivity indexes. It also works better than the BIS index in clinical centers.

Currently, cutaneous leishmaniasis (CL) as a parasitic disease is treated with Glucantime and Pentostam in most of the endemic countries. This study aimed to identify factors affecting the glucantime therapy duration rate in patients with CL using a survival analysis model.

This retrospective descriptive-analytic study was conducted on 1017 CL patients that were referred to the urban and rural comprehensive health centers of Qom Province under the supervision of Qom University of Medical Sciences, Qom, Iran, from April 2014 to March 2019 through the census. The recovery time was measured by the Kaplan-Meier method, and then the survival function was plotted based on each variable. The Log-Rank test was applied to analyze the differences among variables, and after the evaluation of the PH assumption by Shoenfeld residuals, a stepwise forward Cox progressive regression was used to determine factors affecting intralesional or systematic treatment duration in the patients involved with cutaneous leishmaniasis. 

The recovery rate of lesions in cutaneous leishmaniasis cases was found to be 96.7% by the intralesional treatment and 93% by the systematic one. The mean recovery time for cutaneous leishmaniasis patients was 8.00 weeks for the intralesional treatment and 18.00 days for the systematic treatment. The only significant variable in the intralesional treatment was observed on cases with thigh lesions, meaning that those patients who had CL lesions on their thighs experienced a significant reduction in their recovery time. Furthermore, the lesion variable was also significant (P=0.039) as the recovery chance of those patients who had four or more CL lesions was 30% less.

The existence of lesions on CL patients’ thighs and a low number of lesions in CL patients can decrease the recovery time. The use of the Cox regression model in medical studies is more appropriate because not only does it consider the occurrence of the event but also it can reveal the occurrence time of the disease.

Oxford Shoulder Score (OSS) is a specific questionnaire for the assessment of pain and function in subjects with shoulder pain. The reliability and validity of the Persian version of this questionnaire have been shown previously. But its responsiveness has not been investigated yet. This study aimed to determine the Persian OSS responsiveness in subjects with shoulder pain.

This was a prospective cohort study design conducted in the Physiotherapy Clinic, School of Rehabilitation, Tehran University of Medical Sciences in 2018.  Thirty-one subjects with shoulder pain (20 females and 11 males) with a mean age of 50±15.3 participated in this study. They completed the Persian OSS, Disability of Arm, Shoulder & Hand (DASH) questionnaire, and Visual Analog Scale (VAS) before and after 10 physiotherapy sessions. After the 10th session, the Global Rating of Change (GRC) was also completed. The statistical analysis included the Effect Size (ES), Standardized Response Mean (SRM), and the Spearman or Pearson correlation coefficients.

The results showed that the ES and SRM of the Persian OSS were 1.73 and 1.79, respectively. The correlation between the Persian OSS and the VAS scores was 0.69 and between the Persian OSS and the DASH scores was 0.89. The correlation between the Persian OSS changes and GRC was not statistically significant (r=0.25, P=0.18). However, a significant moderate correlation was identified between the VAS and DASH with the GRC scores (r=0.43, r=0.42, respectively). 

The Persian OSS has internal and external responsiveness for the assessment of subjects with shoulder pain. The Persian OSS, as a responsive instrument, can be used to investigate the effectiveness of interventions in the clinical settings and research to detect the changes in patients with shoulder pain. Further study with larger sample of patients with shoulder pain is warranted to confirm the findings and to estimate the minimally clinically important change.

Chronic kidney disease is considered as one of the most common health problems in the world. High mortality and morbidity in these patients, are due to cardiovascular disease and infections. Neutrophil to lymphocyte ratio is recently known as an inflammatory marker. This study aimed to determine the ratio of neutrophil to lymphocyte count in hemodialysis patients in Birjand Special Disease Center, and its role in mortality and morbidity during one-year follow-up.

This is an analytical descriptive study that was performed on 59 End-Stage Renal disease patients referred to the dialysis department of Special Disease Center, Birjand University of Medical Sciences Birjand, Iran. The levels of neutrophil to lymphocyte ratio, erythrocyte sedimentation rate, and C reactive protein were measured and cases divided into 4 groups according to the NLR: less than 1, 1-1.5, 1.5-2.5, 2.5-3.5, and>3.5. All patients were followed up for one year to determine rate of mortality, cardiovascular and infectious events.

The mean NLR was 2.89±1.38. There was no significant difference in mortality rate between groups according to NLR with P=0.052, also no remarkable difference in infectious and cardiovascular morbidity events in groups with P=0.09 and P=0.21, respectively. The mean NLR in patients with cardiovascular or infectious events was 4.2 and 3.75 respectively, which were notably higher than patients without cardiovascular (NLR:2.49) and infectious (NLR:2.68) events, P=0.02 and P=0.03 respectively. In the bivariate correlation analysis, NLR was positively correlated with CRP in hemodialysis patients.

ESRD patients with NLR>2.5 have higher cardiovascular and infectious events than patients with NLR<2.5 but there was no difference in mortality rate between them.