مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و هشتم شماره 9 (پیاپی 237، آذر 1399)

High incidence and mortality rate of pulmonary thromboembolism urge physicians to be aware of its occurrence and treatment. Pulmonary thromboembolism (PE) typically manifests itself with acute dyspnea and tachycardia and may occur along with deep vein thrombosis. However, syncope, chest pain and heart failure decompensation in previously stable patients might be another presenting signs and symptoms.  Although there are several guidelines about PE prophylaxis both in medical and surgical patients, guideline adherence is not good enough. The most important reasons are; inappropriate PE risk scoring, insufficient prophylaxis dosage and the fear of probable bleeding. Both unfractionated and low-molecular-weight heparin has been suggested as prophylactic agents. The role of echocardiography in the diagnosis of PE has been challenged; however, it is mandatory to do an echocardiogram to define the prognosis and also the proper treatment approach. Based on the severity of right ventricular dysfunction, biomarker levels and hemodynamic status of the patients, they will be categorized as low, moderate and high-risk. Moderate to high risk patients should be planned for more invasive treatments such as thrombolytic therapy. In conclusion, PE is the third common cardio-vascular acute condition after myocardial infarction and cerebrovascular accident. The most important reason for death in PE is right-side heart failure. Besides, PE is the most preventable fatal disease in hospitalized patients. Long hospital stay, inappropriate thromboembolic prophylaxis and baseline comorbidities predispose patients to this fatal event. Sometimes, the fear of probable bleeding precludes guideline-based thromboprophylaxis, especially in post-operative patients. If PE occurs; it will be hard to manage and treat. New oral anticoagulants are advised as fixed-dose which does not need to be closely monitored. Drug and food interaction is significantly lower in New oral anticoagulants (NOACs). Thrombo-prophylaxis is better than mechanical thrombo-prophylaxis. Post-discharge thromboprophylaxis is also advised in orthopedic patients. It is mandatory to advise patients to walk after discharge and avoid long-term bedrest if possible. A too early discharge may also be an important risk factor and prone patients to PE at home.

The endocannabinoid system interacts with the vanilloid and opioid systems. The current study aims to investigate the effects of the extract obtained from the heated Cannabis Sativa female flower base either with capsaicin at the spinal cord level or naloxone at the systemic level on the intensity of chemical and thermal pain sensation.

This experimental study was performed in the Department of Biology at Ferdowsi University of Mashhad from April 2014 to March 2015 using adult male Wistar rats (200-250 g) categorized into groups of 7 animals. In addition to the control and sham (solvent of chemicals) groups, groups with intraperitoneal administration of 50 mg/kg of the hydroalcoholic extract, 2 mg/kg of naloxone alone and naloxone together with extract were investigated. Moreover, intrathecal administration groups including the concentration of 0.01 mg/ 10 μl of extract, the concentration of  0.002 mg/10 μl of capsaicin alone and the extract together with capsaicin were evaluated. To measure the thermal pain threshold, a tail-flick test was used and to measure the chemical pain intensity, the formalin test was utilized. The obtained data were analyzed statically.

Intrathecal administration of the extract together with capsaicin led to a significant reduction of thermal hyperalgesia (P<0.001) and chemical hyperalgesia (P<0.001) induced by intrathecal administration of capsaicin. On the other hand, intraperitoneal administration of naloxone together with the extract did not effect on the thermal pain threshold. While the administration of naloxone increased the severity of chemical pain during the acute phase compared to the group treated with the extract alone (P<0.01).

The phytocannabinoids of the flower extract may have inhibited capsaicin-induced hyperalgesia via cannabinoid receptors activation and the TRPV1 receptor desensitization. Naloxone administration has also been able to attenuate the analgesic effect of hydroalcoholic flower extract during the acute phase of chemical pain. Probably the extract is thought to exert part of its effect on pain through opioid receptors.

Celiac disease (CD) is a common disease caused by autoimmunity to the gluten protein. Although some studies have shown an association between infertility and abortion with CD, there are many risk factors that may influence this relationship that should be addressed in the researches. Therefore, we designed this study to evaluate this association with respect to these confounding factors.

This study was designed to investigate the association between infertility and abortion with CD in women who were referred to the celiac clinic in Fars province, from October 2017 to April 2020. CD was defined as an increase in serum levels of tissue transglutaminase antibodies and histological confirmation of a small bowel specimen, infertility with no pregnancy after 12 months of unprotected sex, and abortion with spontaneous termination of pregnancy before the 20th week.

Out of 711 patients, 98 women with CD were eligible for inclusion. The mean age (SD) was 31.73 (7.52) ranging from 19 to 45 years. 27 (27.6%) and 39 (39.8%) patients had a history of infertility and abortion, respectively. According to Robust Poisson regression models, weight loss with a body mass index of less than 18.5 kg/m2 was significantly associated with infertility (PR=0.779, CI95%=0.640-0.950, P=0.013) and abortion (PR=0.794, CI95%=0.649-0.971, P=0.025), but other variables such as age, ethnicity, education level, gastrointestinal manifestations, tissue transglutaminase antibody level, histological severity, family history of CD, and history of cousin marriage were not significantly associated with infertility or abortion.

In this study, weight loss due to long-term malnutrition was suggested as an important risk factor for fertility problems in CD. There was no significant association between infertility and abortion with other variables such as the level of anti-transglutaminase antibody and histological findings. Therefore, routine use of antibody levels and evaluation of the severity of histological findings as criteria for predicting the risk of abortion or infertility in these patients is not recommended until further research is performed.

To date, different kinds of treatment methods have been proposed for radiotherapy of cancer patients. Choosing the kind of treatment method affects the quality of the patientchr('39')s treatment. This study aims to investigate the effect of the number of radiation treatment sessions on the dose received by the patient and the distribution of tumor dose and dose received by organs at risk in breast cancer radiation therapy. These results help us to select the appropriate treatment schedules for the treatment of left breast patients.

This prospective cross-sectional study was performed on the treatment plans of 35 patients with left breast cancer who referred to Isfahan Milad Hospital between July 2019 and April 2020. They were candidates for left breast radiation therapy. Also, these patients had no history of surgery or chemotherapy, and no supraclavicular or axillary lymph nodes were involved. Patients were treated with a conventional fraction regimen (CF) or hypofractionated (HF) treatment schedule. Different dosimetry parameters for the target and organ at risks such as conformity index, homogeneity index and mean dose were obtained from the dose-volume histogram plot. Finally, the results of both plans were compared with each other.

The data obtained from this study indicate a decrease in the average dose of all organs in the hypo fractionated regimens compared to conventional plans. The differences between two plans were statistically significant for tumor, lung, and skin (P=0.0). Moreover, the maximum dose for the skin was also reduced when hypofractionated regimens were used. However, the values of the homogeneity index and conformity index of tumor in the two methods did not show a significant difference (P were 0.99 and 0.86, respectively).

In general, the results of the current study indicate that the hypofractionated regimen leads to a reduction in dosimetric factors compared to conventional fraction plans. It seems that this method can be used as an alternative treatment plan for breast cancer radiation therapy due to the reduced duration of the treatment period.

Infectious diseases in the pandemic stage have significant life-threatening, psychological and social effects. Identifying the characteristics associated with peoplechr('39')s cooperation in self-care leads to greater immunity for themselves and others. Therefore, this study was conducted to predict the self-care of the Iranian people according to their individual and social characteristics in face of the Covid-19 pandemic.

A survey study was conducted on 1056 adults aged 18 and over in different provinces of Iran through a form of answering online researcher-made questions (n=40, α=0.9) in social networks in four days. This paper studies the level of self-care of people against Covid 19 pandemic which was conducted with the support of Isfahan University of Medical Sciences in April 2016. Data were analyzed using Student t-test and variance. Moreover, "decision tree technique" was used to identify communication patterns.

The findings showed that the average self-care score in women, the most educated, married women, women aged 41 to 55, housewives and some other occupations was very high. However, the average self-care score of single men with a diploma was average. In general, the mean score of womenchr('39')s self-care was higher than men (P<0.0001) and the educated were more than the less educated literate (P=0.007). There was no significant difference between the self-care scores of the respondents in terms of their marital status and employment.

The results showed that the average scores of self-care in women, more educated people, married women, women in the age group of 41 to 55 years, housewives and some other occupations were reported to be very high; While the average self-care score reported in single men with a diploma was average. Overall, the mean score of self-care reported in women was higher than men (P<0.0001) and people with doctoral education reported more self-care than illiterate people (P=0.007). Besides, there was no significant difference between the self-care scores of the respondents in terms of their marital status (single and married) and their employment status (employed and non-employed).

Obesity is associated with chronic inflammation in obese subjects, which leads to an increase of inflammatory cytokines. This study aimed to evaluate the effect of different intensity circuit resistance training on levels of interleukin 1 beta and interleukin-10 in obese men.

In a semi-experimental trial during May to August 2020, 44 obese men from Tehran city were selected and randomly divided into 4 groups including 1) control (n=11), 2) low-intensity circuit resistance training (n=11), 3) Moderate intensity circuit resistance training (n=11) and 4) High-intensity circuit resistance training (n=11). Resistance training was performed in different intensities including1) High-intensity circuit resistance training: three sets of 10 repetitions with 80% 1RM 2) Moderate intensity circuit resistance: three sets of 13 repetitions with 60% 1RM and 3) low-intensity circuit resistance training: three sets of 20 repetitions with 40% 1RM, three sessions per week for 12 weeks. Also, the control group had their daily life during the 12-week research period and were prohibited from participating in regular exercise. Serum interleukin-1 beta (IL-1β) and interleukin-10 (IL-10) levels were measured using an ELISA kit. Data were analyzed with covariance analysis at P<0.05.

Twelve weeks of low, Moderate and high intensity circuit resistance training significantly decreased IL-1β levels (P=0.001) and increased IL-10 levels in obese men (P=0.001). The decrease of IL-1β was significant in the high-intensity training group compared to low intensity (P=0.009) and moderate-intensity training groups (P=0.046). Also, the increase in IL-10 levels was significant in the high-intensity training group compared to the low-intensity (P=0.002) and the moderate intensity training group compared to the low intensity training group (P=0.004).

According to our findings, resistance training has a positive effect on inflammatory and anti-inflammatory factors in obese men, and high-intensity circular resistance training had more benefits.

The health of pregnant mothers is one of the most important health indicators of each country. The midwifery clinic is one of the first places in which pregnant mothers become familiar with at the time they arrive. Providing health services at a desirable level and improving the quality of services in the midwifery clinic require an accurate understanding of the situation and its complications. This study aimed to assess how well pregnant mothers were satisfied with the midwifery services that they have received at midwifery to improve their quality.

This cross-sectional study was performed on 364 pregnant women who were referred to the midwifery clinic of Shariati Hospital in Tehran in August and September in 2018. Data were collected using a validated, pre-designed questionnaire and were analyzed using chi-square and multivariate logistic regression.

Among the pregnant women referred to the clinic, 70.2% were satisfied with the care services received and 29.8% of them were not satisfied. This satisfaction level had a significant relationship with pregnancy (P=0.009) and motherschr('39') age (P<0.001) while decreased by the increment in the number of pregnancies and age. Also, in this study, the least satisfaction was related to the crowds and waste of time and lack of access to the parking spot (P<0.001). In this research, the least satisfaction was due to crowding and waste of time, which can be addressed by improvement in the health services in the residential areas, appropriate referrals, informing about the expected time of arrival, and providing information on the alternative of the new hospitals in areas around the city with less traffic congestion and better parking sites.

 The results of our study showed the detailed patient satisfaction factors of an educational medical hospital. In overall the satisfaction.

 Health insurance literacy is a nascent concept that has emerged mainly after the implementation of the law known as Obamacare in the United States. This study seeks to identify the themes of health insurance literacy in Iranian society.

 The study approach is qualitative. Data were collected using nine semi-structured interviews, ten focal group meetings with the presence of 86 experts of an insurance organization and a specialized meeting with fifteen academic experts, from September to December 2018 at the organizationchr('39')s location. MAX QDA10 software was used to organize the data. Qualitative data analysis was performed using continuous comparison analysis and in the form of directional qualitative content analysis based on the conceptual model (Paez et al 2014). Coding was performed independently by two researchers and then collected. Results were reviewed by an external observer. Finally, in a specialized meeting with the participation of representatives of specialized (groups secretaries) and academic experts(participants in the initial interviews), the findings of the study were re-examined and confirmed

 By reviewing the collected texts, 264 initial codes, 21 components, 10 sub-themes, and five themes were extracted. Based on the conceptual model of the study, the data were organized in three axes. In the knowledge axis, the themes of health insurance knowledge (including health insurance knowledge and attitude toward health insurance) and awareness of insured rights and assignments (including insured assignments and insured rights), in the axis of skill, themes of information search and services (including information acquisition and service search) and utilization of insurance coverage (including receiving insurance coverage and benefiting from benefits), and in the axis of self-confidence, the theme of self-efficacy (including Timely decision making and environmental awareness) have been identified.

 Health insurance literacy for Iranian society, instead of being able to choose the type of insurance, focuses on its application in improving decision-making behavior and seeking insured treatment in the health market.

Nephrotic syndrome is a kidney disorder that is identified by signs of nephrosis, severe proteinuria, hypoalbuminemia, and edema. It is a component of glomerulonephrosis, in which different degrees of proteinuria may occur. The complications of this syndrome may include blood clots, infections, and high blood pressure. Essentially, decreased protein through the kidneys (proteinuria) leads to low protein levels in the blood (hypoproteinemia including hypoalbuminemia), which causes water to be drawn into soft tissues (edema). Severe hypoalbuminemia may also lead to different secondary problems, including water in the abdominal cavity (ascites), around the heart or lung (pericardial effusion, pleural effusion), high cholesterol (hyperlipidemia) and, loss of molecules regulating coagulation (increased risk of thrombosis). Other symptoms may be weight gain, feeling tiredness, and also foamy urine. This study aimed to introduce a case of successful treatment of nephrotic syndrome in twin pregnancy.

The patient was a 30-years old woman who presented with twin pregnancy in 31 weeks of gestation with a history of IVF (In-Vitro Fertilization) in the current pregnancy. She referred to Ghaem hospital of Mashhad University of Medical Sciences in March 2017 because of severe lower extremities edema and 3+ proteinuria. Considering severe proteinuria (more than 6 gr/24 hr), edema, hypoalbuminemia and hyperlipidemia, the nephrotic syndrome was diagnosed and she was treated with methylprednisolone, Hydrochlorothiazide and Fenofibrate. At last, premature rupture of membrane occurred at 36 weeks of gestation. Cesarean was done because of the breech presentation of both fetuses and two healthy neonates were born with an optimal Apgar score.

Early diagnosis of nephrotic syndrome and accurate prenatal care in these patients could have optimal pregnancy outcomes, especially if it was not complicated by hypertension and renal dysfunction.

Laryngeal tuberculosis (TB) is one of the most common complications of pulmonary tuberculosis, which increased for various reasons such as more prevalence of immune system suppression diseases, increasing the survival of the elderly, immigrants from high-risk areas and the appearance of atypical or resistant organisms over the past two decades, and its clinical pattern changed compared to the past. In contrast to the past that patients complained about dyspnea, coughing and other symptoms, today, the main complaints of these patients are hoarseness and Odynophagia. In reality, the prevalence of laryngeal TB without pulmonary manifestation was increased these days. The purpose of this study was to evaluate these symptoms in laryngeal TB.

In this case report study, we examined a 77-year-old man who was admitted to the otorhinolaryngology department of Shafa hospital of Kerman (an academic hospital of Kerman University of Medical Sciences), Iran in April 2019 due to hoarseness since 6 months before admission and the results of evaluation confirmed the presence of laryngeal tuberculosis in this patient. The patient treated with Anti-TB drugs (Isoniazid, Rifampicin, Pyrizinamide, and Ethambutol) according to standard protocol and responded appropriately to this medication regimen.

Although laryngeal tuberculosis is a rare disease, it still occurs. Therefore, by increasing the incidence of tuberculosis, changes in the clinical pattern and its spreading mechanism, physicians should always be aware of the unusual clinical features of laryngeal tuberculosis and the possibility of developing it for early diagnosis and treatment. It should be considered as a differential diagnosis in all laryngeal diseases to prevent the complications of the disease and decrease the risk of transferring it to other people.