فهرست مطالب

Caspian Journal of Internal Medicine
Volume:13 Issue: 4, Autumn 2022

  • تاریخ انتشار: 1401/07/18
  • تعداد عناوین: 25
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  • Dimitrios Velissaris, Nicholas Zareifopoulos*, Vasileios Karamouzos, Charalampos Pierrakos, Menelaos Karanikolas Pages 650-665
    Background

    The biomarker soluble urokinase plasminogen activator receptor (suPAR) is an indicator of inflammation which is increased in a variety of chronic and acute disease states. Its most promising application in the emergency setting is to aid in the prognostic stratification of patients by identifying those at high risk of deterioration. This is a narrative review of studies evaluating the use of suPAR

    Methods

    We conducted a Medline search for studies on the use of suPAR in patients acutely admitted to the emergency department.

    Results

    25 original studies were included in the review. suPAR as a marker of inflammation has been used alone or combined to other inflammatory biomarkers in the assessment of patients suffering from various acute and chronic diseases in an emergency setting. As it is non-specific, it may increase in infectious disease, malignancy or acute coronary syndromes among other conditions, but quantitative suPAR levels correlate with disease severity. It may be useful for the identification of high risk patients regardless of underlying pathology.

    Conclusion

    As the ideal biomarker in the emergency setting has not been identified yet, suPAR may be a promising addition to the established biomarkers for the initial assessment of patients in this setting. Additional research is necessary to evaluate the usefulness of suPAR guided management algorithms.

    Keywords: suPAR, Biomarker, Emergency Department, Mortaliti, Infection, Sepsis
  • Alireza Heidarian Naeini, Ghahraman Mahmoudi*, Jamshid Yazdani Charati Pages 666-674
    Background

    There has been a growing international evolution of the role and purpose of quality improvement in primary health care. The present study aimed to develop a quality model of the Family Physician program in Iran.

    Methods

    In the qualitative part of these mixed-method studies, grounded theory was used according to the systematic method of Strauss and Corbin. Semi-structured interviews were conducted with recipients and providers of Family Physician cares in the pilot provinces of Iran in 2020 to 2021 and continued until the theoretical saturation based on the purposive technique. The qualitative evaluation of the model was performed and approved. Structural equation modeling and Amos software were used to quantify the model.

    Results

    The results of the structural equation analysis showed that the conceptual model of the research with chi-square test was 2.96 and RMSEA= 0.066, GFI=0.860 are well fitted. Structure, context, process, accountability, attitude, and empowerment factors directly and indirectly provide good predictors for the quality of care in the family physician program. The most important research findings in the field of quality improvement in the family physician’s cares included factors such as developing the attitude and vision of society, providers and policymakers in health subject and health needs, simultaneously corrections in all levels of the referral system, attention and adaptation to the context of society, developing the infrastructures and improving the related processes, systematic appraisal, and accountability and pay attention to the empowerment.

    Conclusion

    To achieve the quality of care in the family physician program, we need change and development in our attitudes, context, infrastructures and processes, accountability and empowerment systems, and overall modification.

    Keywords: Primary Health Care, Health Care Quality, Physicians, Family
  • Arpita Chakraborty, CH Sai Kumar, Mukhyaprana Prabhu, Weena Stanley*, Ranjan Shetty Pages 675-680
    Background

    Coronary artery disease (CAD) is a cardiovascular disease which is related to mortality and morbidity among the Indians predominantly in the older age group. But, recently CAD has been found more often in young population. Hence, our study aims to observe the outcomes based on various categories of high density lipoprotein (HDL) cholesterol levels estimated during admission at the hospital and correlate the levels of HDL cholesterol with severity of CAD as measured by Gensini score.

    Methods

    A cross-sectional study was conducted in 151 young patients (18-45 years) who were admitted at the hospital with newly diagnosed acute coronary syndrome (ACS). Tests such as electrocardiogram, cardiac enzyme assay, hematologic and biochemical tests including fasting lipid profile levels were taken into account.

    Results

    There was an inverse relation observed between the number of vessels involvedand HDL cholesterol levels. Those with lower levels of HDL cholesterol were more vulnerable to multi-vessel CAD. However, no association was observed between HDL cholesterol and severity of CAD as measured by Gensini score.

    Conclusion

    In young patients with acute coronary syndrome and diminished HDL cholesterol levels had a greater number of vessels involved when compared with elevated HDL cholesterol levels group. However, low HDL cholesterol levels had no association with severity of CAD as measured by Gensini score. No statistically significant association was noticed between levels of HDL cholesterol and in hospital mortality /morbidity.

    Keywords: Acute coronary syndrome, coronary artery disease, HDL cholesterol, myocardial infarction, Gensini score
  • Mahshid Chaichi-Raghimi, Reza Ilkhani, Elham Parsa, Mahmood Khodadoost, Rasool Choopani, Roshanak Mokaberinejad, Mojgan Tansaz, Mina Movahhed, Hasan Namdar, Elham Emaratkar, Mahdi Alizadeh-Vaghasloo, Mamak Hashemi, Malihe Tabarrai, Reihane Moeini, Narjes Gorji, Abbas Alipour, Parisa Jafari, Fatemeh Hakimi, Farideh Yaghmaei, Armin Zareiyan, Ali Montazeri, Morteza Mojahedi* Pages 681-688
    Background

    Gastric disorders are one of the most common human ailments, which impose a huge economic burden on countries. In Persian Medicine (PM), it is possible to predict the susceptibility to gastric diseases with diagnosis of gastric Mizajes (temperaments) and dystemperaments. The semiology of gastric dystemperaments has been investigated in PM textbooks, although the value of each sign and symptom is not mentioned. Consequently, this research is designed to determine the major and minor criteria for classifying gastric dystemperaments on the basis of valid manuscripts and with the help of PM specialists in the present era.

    Methods

    This was a consensus-based study consisting of four phases. In the first phase, reference PM textbooks were studied. Symptoms and signs of gastric dystemperaments were collected and listed in four groups. In the second phase, semi-structured interviews with a sample of PM experts were carried out. Phase three included a focused group discussion with experts. Eventually, findings were integrated from the three study phases in a two-day meeting in Sari City.

    Results

    Selected criteria included eight major and eight minor criteria for hot-cold dystemperament, as well as six major and eight minor criteria for wet-dry gastric dystemperament.

    Conclusion

    Modern lifestyles and the interfering factors are responsible for some changes in diagnostic signs and symptoms according to PM. This was the first step to coordinate PM diagnostic criteria for gastric dystemperaments. Further studies are recommended to reach a unique protocol in the field of PM diagnostics. The next step includes design and validation of national diagnostic tools.

    Keywords: Iranian Traditional Medicine, Persian Medicine, temperament, Mizaj, stomach, Su-e-Mizaj
  • Fares Najari*, Jalaladin Khosnevis, Zahra Javaheri, Dorsa Najari, Sahar Mirzaee Pages 689-692
    Background

    Implantation of vascular access devices is of great importance in critically ill patients or those vulnerable to clinical worsening. The aim of this study was to identify the complications of implantation of vascular access leading to complaints from patients, in the forensic medicine commissions of Tehran.

    Methods

    The present descriptive-cross sectional study was performed on all cases that died from implantation of vascular access devices and complaints about permanent local complications caused by this procedure, filed with the forensic medicine commissions of Tehran in period of 2013-2018, based on selected variables, and the results were statistically analyzed using the chi-square and Fisher exact tests in SPSS Version 18. A p-value of <0.01 was considered statistically significant.

    Results

    All alleged deaths were due to implantation of central venous port placed in a large vein in the neck, and most organ failure cases were attributed to anterior forearm deformity. The most common cause of death was acute cardiac death; internal bleeding was observed in 14% of them. Most complaints of death were filed against general surgery and anesthesia assistants, and most complaints about peripheral venipuncture were against trainee nurses. The present study findings were significantly different in terms of cannulation site, age, cause of death, type of local complication (p<0.01).

    Conclusion

    This study shows, as patients become more aware, complaints from physicians about implantation of vascular access, in the judicial authority are also on the rise. Therefore, in choosing these patients, Venice should be treated more carefully.

    Keywords: Malpractice, IV Access, Legal Medicine, Sheldon catheter
  • Seyed Mohammad Javadzadeh, Mohsen Tehrani, Mohsen Keykhosravi, Rajehe Mohamadian-Amiri, Omolbanin Amjadi, Nasim Hafezi, Ehsan Zabouli, Mobina Montazeriun, Abolghasem Ajami* Pages 693-698
    Background

    Immune checkpoint molecules have critical roles in directing immune responses into co-inhibitory and co-stimulatory signals. Herpes virus entry mediator (HVEM) is a receptor of tumor necrosis factor receptor superfamily with unique features due to its interaction with both inhibitory and stimulatory ligands. The aim of this study was to measure the serum level of the soluble form of HVEM in patients with gastric, colorectal and breast cancers and evaluating its diagnostic and prognostic value.

    Methods

    The concentration of the soluble HVEM (sHVEM) was determined in the serum of 36 patients with breast cancer, 50 patients with colorectal cancer and 59 patients with gastric cancer using ELISA method. Moreover, 50 healthy donors (HD) as well as 31 patients with non-ulcer dyspepsia (NUD) were used as control groups. The patients’ samples were obtained from the Biobank of Cancer Research Center, Mazandaran University of Medical Sciences, Sari, Iran.

    Results

    The level of sHVEM was significantly higher in patients with gastric (P=0.001) and breast cancer (P=0.01) than in control groups (HD). The higher level of sHVEM was observed in colorectal cancer patients in comparison with HD group, although it was not significant. Moreover, the elevated level of sHVEM was shown to be higher significantly in stage III and IV compared to stage I and II in breast cancer (P=0.03). Similar finding was detected in gastric and colorectal cancers, but not to be statistically significant.

    Conclusion

    The results of the present study suggest that the serum level of sHVEM may be considered as a promising indicator for diagnosis as well as evaluating the progression of cancers such as gastric, breast and colorectal cancers.

    Keywords: Herpesvirus entry mediator, gastric cancer, breast cancer, colorectal cancer
  • Hamideh Feiz Disfani, Mostafa Kamandi*, Seyyedeh Bahareh Hoseini, Narges Shirazi, Maryam Panahi Pages 699-704
    Background

    Mild head trauma often causes several complications and disabilities including nausea and vomiting in hospitalized people. The aim of the present study was to compare the effectiveness of metoclopramide and ondansetron, and compare it with placebo to control nausea in the patients with mild head trauma admitted to the emergency department.

    Methods

    This is a randomized double-blind placebo-controlled clinical trial conducted on the patients with mild head trauma and normal brain CT scans who were admitted to the emergency department within 24 hours after the injury. The subjects were randomly divided into three groups of ondansetron (n= 41), metoclopramide (n= 44), and placebo (n= 39), and the severity of nausea and vomiting was assessed using the visual analogue scale (VAS).  

    Results

    A total of 124 patients with mild head trauma were included in the study. The assessment of the VAS scores during the study showed that over time, the patients in all three groups had reduced nausea (p<0.01). On the other hand, the percentage change of the VAS score indicated that metoclopramide and ondansetron had the greatest changes (46.97% and 66.90%, respectively) within 15 and 30 minutes after the injection, respectively.

    Conclusion

    The results of the present study showed that ondansetron and metoclopramide had similar effects on nausea in the patients with mild head trauma. However, metoclopramide was most effective in 15 minutes and ondansetron in 30 minutes after the injection.

    Keywords: Mild head trauma, nausea, vomiting, Ondansetron, Metoclopramide
  • Pegah Kamkarfar, Roya Shahriyaripoor, Samaneh Rokhgireh, Seyed Reza Saadat Mostafavi, Shahla Chaichian, Abolfazl Mehdizadeh Kashi* Pages 705-712
    Background

    Endometriosis is one of the most common gynecological disorders, which causes pain and reduces fertility. An accurate diagnostic technique would be helpful in the management of these patients preoperatively. The objective of this study was to do a comparative evaluation of uterosacral involvement in deep infiltrative endometriosis by transvaginal sonography (TVS) and laparoscopic biopsy.

    Methods

    TVS and laparoscopy were done in all patients suspected to have endometriosis. TVS examination was carried out to identify endometriotic lesions, and in suspicious laparoscopic views, biopsy was done and laparoscopic findings were confirmed by pathologic report. Then, TVS and pathological findings in laparoscopy were compared and data analyzed by SPSS Version 23.

    Results

    In our study on 80 patients, the mean age was 34.47 ± 5.94 (mean ± SD) years. Comparison of ultrasound with laparoscopic examinations showed that ultrasound as the gold standard method, has sensitivity, specificity, and positive and negative predictive values of 93%, 65%, and 87%, and 78.9%, respectively, while in the diagnosis of increased uterosacral ligament thickness showed 82%, 100%, and 100% and 6.66%, respectively. While in the diagnosis of nodules in the uterosacral ligament, 100% for all four parameters in the diagnosis of endometrioma in the ovaries, and 71%, 96.4%, and 97.3% and 64.2%, respectively, in the diagnosis of rectal, bladder, and ureteral involvement.

    Conclusion

    TVS can be used in the diagnosis of endometriosis by examining the increase in the thickness of the uterosacral ligament and the presence of hypoechoic nodules in it; also, this method demonstrates acceptable sensitivity and specificity in ovarian endometrioma.

    Keywords: Endometriosis, Uterosacral ligament, Transvaginal sonography (TVS), Laparoscopy
  • Saeideh Najafi, Fattah Sotoodehnejadnematalahi, Mohammad Mehdi Amiri, Mohammad Reza Pourshafie, Mahdi Rohani* Pages 713-720
    Background

    Probiotic Lactobacillus spp. modulate immune response via interactions of their binding proteins with epithelial cells. We studied the presence of attachment protein-encoding genes (mub1, mub2, and mapA) in Lactobacillus strains with probiotic features isolated from inflammatory bowel disease (IBD) patients and their attachment strength relative to healthy individuals.

    Methods

    Bacterial strains have been isolated from stool samples of 35 healthy and 23 IBD volunteers. Lactobacillus spp. were identified using PCR. Strains with probiotic features were determined by testing resistance against acid and bile. Isolates were assigned as non-adhesive, adhesive, and strongly adhesive strains based on the number of attached bacteria to epithelial cells. Finally, PCR was used to detect the presence of mub1, mub2, and mapA genes.

    Results

    Probiotic lactobacilli were isolated from 35/35 and 9/23 of healthy and IBD individuals and yielded a total of 87 and 28 strains, respectively. The Mub1 gene was detected in 95.4% and 100% (p>0.05), mub2 in 95.4% and 89.3% (p>0.05), and mapA in 94.3% and 78.6% (p<0.05) of healthy and IBD isolates, respectively. The numbers of bacteria attached to epithelial cells in healthy and IBD isolates were respectively 33.68±6.00 and 12.23±3.87 in non-adhesive, 71.3±10.83 and 42.17±1.33 in adhesive, 124.40±8.59 and 104.67±5.50 in the strongly adhesive group (p< 0.05).

    Conclusion

    Less Lactobacillus spp. with weaker attachments to epithelial cells colonize the gut in IBD than healthy individuals. These findings suggest the beneficial role of probiotics in the management of IBD.

    Keywords: Attachment protein-encoding genes, inflammatory bowel diseases, Lactobacillus
  • Amirhassan Rabbani*, Shiva Aliabbar, Saman Nikeghbalian, Seyed Ali Malek-Hosseini, Mana Baziboroun Pages 721-727
    Background

    Cytomegalovirus (CMV) disease is one of the most common infectious complications after liver transplantation. It is the cause of numerous morbidity and mortalities. Intensity of immunosuppression defined as overall immunosuppressive drug dosage seems to affect infectious complications. The main purpose of this study is to investigate the intensity of immunosuppression on conversion of CMV infection to disease in this population.

    Methods

    In this cross-sectional study, we retrospectively evaluated and analyzed the data of all recipients who underwent orthotopic liver transplantation (OLT) between March 2014 and March 2016 and had positive serum PCR for CMV after transplantation in follow- up course. Of 134 recipients, only 66 adult liver transplant recipients were eligible to be studied.  Multiple variables such as MELD score, cold ischemic time, warm ischemic time, operative data, immunosuppressive drugs and regimen, plasma CMV viral load, donor and recipient CMV IgG serostatus were recorded and analyzed.

    Results

    of the 66 patients, 50 (76%) had CMV infection and 16 (24%) had disease. There was significant association between donor CMV IgG serostatus, extra corticosteroid pulse therapy, acute cellular rejection, serum tacrolimus level and conversion of CMV infection to CMV disease (P=0.005, 0.001, 0.031, 0.031).

    Conclusion

    It seems that the intensity of immunosuppression has influence on conversion rate of CMV infection to disease in liver recipients.

    Keywords: Cytomegalovirus, Liver Transplant, Immunosuppression
  • Hossein Ghalehnoei, Ahmad Hormati, Amir Houshang Mohammad Alizadeh, Sajjad Ahmadpour, Seyed Hassan Abedi* Pages 728-734
    Background

    Pancreatitis is one of the most crucial complications following endoscopic retrograde cholangiopancreatography (ERCP). The purpose of the current study was to investigate patient-related post-ERCP pancreatitis (PEP) risk factors in two groups of patients: prophylactic pancreatic stent and rectal indomethacin.

    Methods

    Two different prophylactic modalities were planned and complications were assessed based on the defined inclusion criteria. In this study, the patients were evaluated for the procedure and patient-related risk factors in post-ERCP pancreatitis in the recipient groups of the prophylactic pancreatic stent and rectal indomethacin.

    Results

    Pancreatitis was confirmed in 27 of all 170 selected patients after ERCP. By univariate analysis, two variables were significant with the development of PEP. Regarding the patient-related risk factors, unique subjects with common bile duct (CBD) dilated 10mm were more exposed to an increased chance of PEP (P=0. 015); meanwhile, other factors did not correlate with the increased possibility of PEP in both groups. The only procedure-related risk factor for PEP was the deep cannulation of the pancreatic duct in both groups during the procedure with an incremental significant incidence of pancreatitis (P=0.005). Comparison of prophylactic pancreatic stent and rectal indomethacin showed no effects in term of post ERCP pancreatitis reduction. Additionally, there was no significant difference between these two strategies in the rate of PEP.

    Conclusion

    Prophylactic pancreatic duct stents and administration of rectal indomethacin cannot have particular approaches for reducing the possible occurrence of PEP. The increase in time of deep cannulation and the presence of CBD dilation <10mm could be considered as important risk factors.

    Keywords: ERCP, post ERCP pancreatitis, pancreatic duct stent, rectal indomethacin
  • Nahid Reisi*, Azar Mirzaei, Alireza Moafi, Pouran Raeissi, Maryam Naghdhassani Pages 735-740
    Background

    Vitamin D (Vit-D) is a necessary ingredient for human growth and its deficiency may increase the risk of cancer and its recurrence. The main purpose of this research was to assess the levels of Vit-D in children with recurrence of malignancy and compare it with new cases of malignancy and the control group.

    Methods

    The status of 25(OH) Vit-D was determined utilizing the HPLC method in 47 patients with recurrence of malignancy (group A), 50 children with new malignancy (group B) and 49 normal healthy siblings of the two groups as a control (group C).

    Results

    Vit-D was low (<30 ng/ml) in the 92% of patients with recurrence of malignancy, which was a significant difference compared to groups B (60%) and C (45%). Vit-D insufficiency (10-30 ng/dl) in group A was also higher than the other two groups. The mean levels of Vit-D in patients with recurrence were significantly lower than the new cases and controls. Low Vit-D (<30 ng/ml) in group A in both male and female, and also in all ages (<6 and ≥ 6 years) was higher than groups B and C. Also, low Vit-D in terms of the type of malignancy in group A was higher than group B only in leukemic patients while this was not different for non-leukemic patients in these two groups.

    Conclusion

    Results of this study showed an increased prevalence of low Vit-D in children with recurrence of malignancies. Therefore, it may increase the risk of recurrence of malignancies in children.

    Keywords: Vitamin D, Recurrence, Cancer, Children
  • Adel Ebrahimpour, Mehrdad Sadighi, Amin Karimi, Amir Sabaghzadeh, Farsad Biglari, Mohammadreza Chehrassan, Mehdi Azizmohammad Looha, Meisam Jafari Kafiabadi*, Mohammad Esmaeil Akbari Pages 741-748
    Background

    Epidemiological characteristics of bone sarcomas are variant in different populations, however, there is no previous study on primary bone sarcomas among Iranian population. This study aimed to evaluate the incidence, age, sex distribution, histologic type, and location of malignant bone sarcomas, based on the Iran National Cancer Registry (INCR).

    Methods

    This was a national population-based study using INCR data from March 20, 2008, to March 20, 2015, on patients who were diagnosed with primary bone sarcomas of the appendicular (C-code:40) and axial skeleton (C-code 41), excluding skull and face bones. Primary bone sarcomas were classified according to the International Classification of Diseases for Oncology (ICD-O-3: C40–C41).

    Results

    A total of 4112 patients (59.5% males and 40.5% females) with a mean age of 36 years were included in the study. 60.38% of patients were between 10 to 44 years old. The overall age-standardized incidence rates (ASIR) was 8.23 (males=9.67 and females=6.80) per million person-years. Osteosarcoma chondrosarcoma and Ewing sarcoma were the three main histology subtypes with the ASIR of 2.36, 1.26, and 1.08 per million person-years. Long bones of the lower limb were the most affected area, with the ASIR of 3.18 (95% CI: 3.02-3.33) per million. We found an increasing trend in the incidence of bone sarcomas in Iran from 8.59 in 2007 to 11.37 per million person-year in 2015.

    Conclusion

    This study provided the epidemiological features of bone sarcomas, including the histological type of sarcoma, tumors’ location, and patients’ age and gender in the Iranian population for the first time.

    Keywords: Osteosarcoma, neoplasms, bone tissue, epidemiology, incidence
  • Mehdi Gholami Bahnemiri, Shivasadat Mirabedini, Parisa Mohammadi, Haniyeh Barmaki, Zohreh Qaffaripour, Masomeh Rezapour, Morteza Alijanpour* Pages 749-756
    Background

    The growth and development of children affect biochemical variables. This population-based study was designed to evaluate the reference interval for alkaline phosphatase (ALP) routinely measured in the clinical laboratory.

    Methods

    For this examination, 873 cases were selected among the healthy children and adolescents aged 1-18 years who referred to the endocrinology clinic of Amirkola Children's Hospital for growth evaluation. After overnight fasting, early morning blood samples were obtained to measure the ALP level and other biochemical parameters using an automatic biochemical analyzer. Subjects were categorized by age, sex, and body mass index (BMI) values. The age groups were categorized as follows: 1-4 years, 5-8 years, 9-13 years, and 14-18 years.

    Results

    There was a significant difference among the age and sex categories; on the contrary, there was no meaningful variation between the two groups categorized by BMI. The reference range for ALP was 474.14-517.71 U/L for children aged 1-4 years, 273.47-871.44 U/L for 5-8 years, 215.04-893.69 U/L for 9-13 years, and 228.9-739.22 U/L for 14-18 years. Also, significant positive correlation was found between ALP with length (P=0.000, r=0.134), weight (=0.04, r=0.073), phosphorus (P) (P=0.001, r=0.122), and alanine aminotransferase (SGPT) (P=0.000, r=0.142) respectively.

    Conclusion

    This project's data established a reference interval for ALP in healthy children and adolescents, which will prepare a basis for diagnosis and monitoring liver- or bone-related disorders.

    Keywords: Children, Alkaline phosphatase, Reference interval, Biochemistry, Liver function
  • Hassan Aghajani, Susan Hashemi, Amirali Karimi, Somayeh Yadangi, Arash Jalali, Yaser Jenab* Pages 757-764
    Background

    Some earlier studies demonstrated an increased mortality risk attributed to delayed pulmonary embolism (PE) diagnosis. Therefore, we mainly aimed to determine the predictors of diagnostic delays and the effect of delayed diagnosis on mortality.

    Methods

    We prospectively studied 756 consecutive patients admitted with PE between March 2007 and September 2017. The delayed diagnosis was defined as (1) patient presenting > 7 days after onset of symptoms, (2) diagnosis takes > 24 hours upon arriving in the ED, or (3) undergoing coronary angiography before establishing PE diagnosis.

    Results

    A total of 127 (16.7%) patients met the delayed group’s criteria. Heart failure (OR= 2.257, 95% CI: 1.130-4.508, P= 0.021), diabetes mellitus (OR= 1.568, 95% CI: 0.996-2.469, P= 0.052), and precordial T wave inversions (OR=2.559, 95% CI: 1.649-3.970, P< 0.001) were linked to higher rates of delayed diagnosis, while hemoptysis (OR=0.254, 95% CI: 0.059-1.087, P= 0.065) and hemodynamic instability (OR= 0.434, 95% CI: 0.168-1.123, P= 0.085) negatively correlated with it. Delayed PE diagnosis did not significantly impact the overall survival during the follow-up. The unadjusted and adjusted mortality hazard ratio for delayed diagnosis were 1.198 (95% CI: 0.758- 1.894, P= 0.439) and 1.215 (95% CI: 0.762- 1.939, P=0.413), respectively. Older age, heart failure, and hemodynamic instability increased the risk of death (p<0.001).

    Conclusion

    Hemoptysis, hemodynamic instability, diabetes mellitus, heart failure, and T wave inversions in precordial leads were the independent predictors of delayed diagnosis. Delayed PE diagnosis did not increase the patients' mortality rates.

    Keywords: Delayed diagnosis, Mortality, Pulmonary embolism, Pulmonary thromboembolism
  • Vahid Azizi, Farida Abesi*, Ahmad Tamaddoni, Soraya Khafri Pages 765-771
    Background

    Due to anemia in thalassemia major (TM) and thalassemia intermedia (TI) patients, bone changes occur, especially in the broad bones like jaw and skull, which are the main sites of hematopoiesis. Therefore, the dentist should be aware of the disease to prevent complications. The aim of this study was to evaluate the radiographic findings of the jaw and teeth in TM and TI patients and to compare the two groups.

    Methods

    50 TM patients and 50 TI patients in Amirkola Thalassemia Center, whose thalassemia were definitively diagnosed by a hematologist, were selected as the study group and the control group consisted of 50 healthy individuals. In patients` panoramic radiographs, dental anomalies (microdontia, root shortening etc.) and bone disorders (bone marrow hyperplasia, maxillary sinus invisibility etc.) were assessed. A p<0.05 was considered.

    Results

    Dental anomalies were (42.84%) in TI patients and (23.46%) in the control group, the difference was significant. Dental anomalies in TM patients were (38.76%) and in the control group (23.46%) and a significant difference was observed (p<0.001). Bone disorders were (47.94%) in TI patients and in the control group (32.64%). Bone disorders in TM patients were (44.88%) and in the control group was (32.64%) that showed a significant difference.

    Conclusion

    This study showed that in thalassemia patients, bone and dental disorders frequency were higher than healthy individuals. Bone disorders were also more common than dental anomalies. Dental and bone disorders were more common in TI.

    Keywords: panoramic radiography, thalassemia major, thalassemia intermedia
  • Somayyeh Noei Teymoordash, Maliheh Arab*, Massih Bahar, Abdolali Ebrahimi, Maryam Sadat Hosseini, Farah Farzaneh, Tahereh Ashrafganjoei Pages 772-779
    Background

    Lynch syndrome (LS) is one of the commonest genetic cancer syndromes, with an incidence rate of 1 per 250–1000 population. The aim of this study was to evaluate the frequency and characteristics of MMR deficiency in endometrial cancer in Iranian women.

    Methods

    One hundred endometrial carcinoma cases who referred to the gynecological oncology clinic of Imam Hossein Medical Center located in Tehran, Iran, from 2018 to 2020 were included in the study. Immunohistochemistry (IHC) evaluation was performed mainly on the hysterectomy specimens of all endometrial cancer (EC) patients to assess MMR proteins (MLH1, MSH2, MSH6, and PMS2) expression.

    Results

    A total of 23 out of 100 (23%) cases were identified through IHC screening to be MMR-deficient. The most common types were loss of MLH1/PMS2 (17.4%) and solitary MSH2 (17.4%) expressions followed by PMS2/MSH2 loss (13%). MMR deficiency (dMMR) histopathology was significantly overrepresented in patients with family history of cancer or Lynch syndrome (LS) associated cancers (p-values of 0.016 and 0.005, respectively). The rate of myometrial invasion and lower uterine segment involvement were also significantly higher in dMMR EC patients compared to MMR-intact EC (p-value of 0.021 and 0.018, respectively).

    Conclusion

    MMR deficiency, observed in 23% of endometrial cancer cases, was associated with higher rates of poor prognostic factors including myometrial invasion and lower uterine segment involvement. The presence of positive family history of cancer and family history of LS-associated cancer increased the probability of MMR-deficiency in endometrioid endometrial cancer to 47% and 70%, respectively

    Keywords: Endometrial Cancer, Microsatellite Instability, Mismatch Repair Protein Deficiency, Lynch Syndrome
  • Ramya R Nayak*, Srikanth Narayanaswamy Pages 780-785
    Background

    Stroke vastly contributes to death and disability worldwide. Acute ischemic stroke (AIS) is caused by a reduction in supply of blood to the brain. Accumulation of unnecessary intracellular serum calcium in AIS induces the cytotoxic actions that activates enzymes involved in cell death. The present investigation assessed the relationship of total serum calcium level (at admission) and initial diffusion weighted imaging (DWI) infarct volume and correlated with National Institute of Health Stroke Scale (NIHSS) scores.

    Methods

    A hospital-based observational study was conducted on 74 consecutive patients identified with AIS fulfilling the inclusion criteria. NIHSS scores and serum ionized calcium were calculated in every patient and compared with DWI infarct volume for assessing correlation between these three. Statistical software R Version 4.0.2 and Microsoft Excel were used for statistical analysis.

    Results

    Out of the 74 patients, most of them were in age group of 50-69 years, with a male preponderance (68.9%). A significant association was noticed between diabetes and dyslipidemia with age (P=0.01499). A strong negative correlation was observed between NIHSS scores (at admission & discharge) with ionized calcium, while a strong positive correlation was noticed between stroke scores with infarct volume. A statistically significant negative correlation was recorded between serum calcium (on admission) and infarct size (r=-0.851755, P=0.0001). The mean of NIHSS scores on admission (8.24±5.19) has been remarkably higher when compared with NIHSS scores at discharge (5.25±3.89).

    Conclusion

    In patients with AIS examined within 6-24 hours of symptoms onset, serum ionized calcium and volume of infarct on DWI showed inverse association. Serum calcium serves as a marker of severity and acts as prognostic factor in AIS.

    Keywords: Acute Stroke, Serum Calcium, NIHSS Score, Infarct Size, Prognosis
  • Zahra Fath Tabar, Ahmadreza Moghadamnia, Ali Bijani, Seyyed Reza Hosseini, Ali Akbar Moghadamnia* Pages 786-794
    Background

    Due to physiological changes and co-existing chronic diseases, the elderly has to take various drugs with different mechanisms that may increase the risk of drug interactions and side effects of medications. This study was performed to evaluate the profile of drug interactions of Amirkola elderly patients.

    Methods

    This cross-sectional descriptive-analytical study is part of the Amirkola Health and Ageing Project (AHAP) which was done during 2012-2013 (Amirkola, Babol, Iran). Initial data collection was done on 1616 persons of ages 60 and older by observing their prescribed drugs and those prepared by self-medications.

    Results

    Drug interactions were detected in 31.7% (95% CI; 29.41, 33.95) of the drug prescriptions. This included 28% of mild, 63.3% of moderate and 8.7% of severe drug interactions. Cardiovascular drugs (64.4%) were the most frequent drugs that induced drug-interactions. According on Beer criteria 2015, 39.97% of the elderly medications were identified as “inappropriate medication”. NSAIDs had the highest prevalence of inappropriate drugs. There was a significant relationship between female gender, having underlying disease, living alone, having insurance, and polypharmacy with obtained drug interaction results (p<0.05).

    Conclusion

    The findings of the present study indicate considerable drug interactions among the elderly in Amirkola, which highlights the need for careful prescribing and using of drugs in the elderly.

    Keywords: Elderly, Drug interaction, Inappropriate medication, Inappropriate Drug
  • Morteza Mojahedi, Roshanak Saghebi, Nargess Gorji, Reihaneh Moeini, Seyed Reza Hosseini, Ali Bijani, Reza Ghadimi, Seyyed Ali Mozaffarpur*, Hoda Shirafkan Pages 795-799
    Background

    One of the principles of Persian medicine (PM) is the individualized approach that is presented with the concept of Mizaj. In this viewpoint, Mizaj is determined for every person based on 10 criteria, which is a result of the Mizaj of the main organs, including the brain, liver, and heart. There is no standard diagnostic tool for Mizaj assessment in the elderly. The purpose of this study is to explain the method of Mizaj assessment and data analysis in the elderly in the second phase of the Amirkola health and aging project (AHAP) in Iran.

    Methods

    In this study, a novel Mizaj assessment method in two phases is presented. In the first phase, 1541 elderly were assessed by a PM expert and typical diagnoses were determined. At the second phase, an expert panel including 5 PM experts evaluated the cases. The paraclinical and metric data of the elderly whose Mizaj agreed in the expert panel was used to assess its correlation with Mizaj.

    Conclusion

    In the lack of valid and reliable questionnaires to assess the personalized viewpoint of PM, a new expert-based method has been introduced that can be used in similar studies. The result of the Mizaj assessment in this way will be used to obtain objective values for the Mizaj assessment.

    Keywords: Geriatrics, Cohort Studies, Medicine, Traditional, Complementary Therapies, Temperament, Precision Medicine
  • Shahram Ala, Majid Saeedi, Arash Ghasemi*, Melika Namdari, Neda Koulaeinejad Pages 800-804
    Background

    Oral mucositis is a troublesome symptom for people who receive radiotherapy and chemotherapy and it is a dose-dependent factor. Atorvastatin is a HMG-CoA reductase inhibitors and various studies have proven its anti-inflammatory effects. The goal of this study was to evaluate atorvastatin 1% mouthwash effects in prevention of radiotherapy-induced mucositis.

    Methods

    Atorvastatin 1% suspension was prepared for mouthwash in this randomized, double-blind clinical trial. Thirty patients randomly received atorvastatin or placebo mouthwash. They had to gargle 5cc of mouthwash, 3 times per day during radiotherapy. The severity and pain of mucositis was evaluated every week, during their treatment.

    Results

    The severity of mucositis between the two study groups was significant every four weeks (p<0.05) and the percentage of patients with more severe mucositis was less in the atorvastatin group. It is found that the pain intensity was lower after 3 and 4 weeks in atorvastatin group.

    Conclusion

    These findings indicated that atorvastatin mouthwash showed a significant activity in relieving of radiotherapy-induced oral mucositis and pain.

    Keywords: Atorvastatin, Mouthwash, Oral mucositis, Radiotherapy
  • Michael Edwar*, Usama Ragab, Ahmed Atia Kamel Pages 805-809
    Background

    Bardet-Biedl syndrome (BBS) is characterized by obesity, cognitive abnormalities, rod-cone dystrophy, skeletal abnormalities, and many other secondary features.

    Case Presentation

    We describe a 28-year-old man presented with postaxial polydactyly, retinitis pigmentosa, obesity, hypogonadism and learning difficulties. Renal insufficiency in form of acute kidney injury was the presenting feature and this explain the worse outcome. The diagnosis was delayed despite being classic. This delay in diagnosis leads to a lot of complications that worsen the patient's condition.

    Conclusion

    The characteristics of BBS should be noted by doctors because an early diagnosis will result in a better outcome. The case was prone to numerous consequences due to the delay in diagnosis, which could have been avoided if an early diagnosis had been established.

    Keywords: Bardet-Biedl Syndrome, Polydactyly, Retinitis Pigmentosa
  • I Gede Yasa Asmara*, Henry Pebruanto, I Made Arya Winatha Pages 810-814
    Background

    Diagnosis and management of rhabdomyolysis-induced acute kidney injury (AKI) are challenging in resource-limited settings. Laboratory markers for the diagnosis of rhabdomyolysis and continuous renal replacement therapy (CRRT) for the management of unstable hemodynamic AKI may be difficult to access. This report presented a case of rhabdomyolysis with compartment syndrome, which had a high prognostic factor for kidney failure and death in Lombok, Indonesia.

    Case presentation

    A 34-year-old man came to the hospital complaining of pain and swelling in his right thigh after being buried by an avalanche of buildings. Laboratory examination showed leukocytosis, hemoconcentration, increased creatinine, metabolic acidosis, hyperkalemia, and dark brown urine. Muscle damage markers showed levels of creatinine phosphokinase >20000 U/L, aspartate aminotransferase 255 U/L, alanine aminotransferase 186 U/L, and lactate dehydrogenase >3000 U/L. Diagnosis of rhabdomyolysis, compartment syndrome, and AKI was primarily on clinical grounds. Despite immediate management (fluid therapy, antibiotics, and fasciotomy), the patient continued progress to AKI. Because CRRT was not available, the patient received a single hemodialysis treatment. A day later, the patient developed hypotension, went into septic shock, and died after five days of treatment.

    Conclusion

    A patient with rhabdomyolysis, compartment syndrome, and acute kidney injury could have a better outcome if the patient arrived early and is treated immediately in a fully-equipped health care facility.

    Keywords: Acute Kidney Injury, Compartment Syndrome, Rhabdomyolysis
  • Ali Jangjoo, Mohammad Ebrahim Kalantari, Tooraj Zandbaf* Pages 815-817
    Background

    Postoperative hematoma and seroma, foreign body reaction, infection, mesh rejection, and fistula formation are the complications associated with the use of surgical mesh. Mesh migration is a rare but serious and challenging complication after hernia repair. When this happens, infection, abscess, fistula, and bowel obstruction are the most common seaquelae.

    Case presentation

    Our patient was a 62-year-old woman with a history of appendectomy 30 years ago and then underwent 3 incisional hernia repair surgeries which the last one was 5 years ago using laparoscopic IPOM. The patient was nominated for surgery with a diagnosis of recurrent incisional hernia. The patient underwent laparotomy and after enterolysis, a small bowel loop was seen that adhered to McBurney's region, which was released. There was a mass inside the small bowel. Resection and anastomosis of the involved intestine were performed. After enterotomy, it was determined that this mass was the mesh used in the previous surgery.

    Conclusion

    Mesh migration is a rare consequence of incisional hernia repair with a prosthetic mesh. It can happen years after a hernia repair and it is additionally crucial to consider as a differential diagnosis in all patients who show unusual symptoms or abdominal pain.

    Keywords: Surgical mesh, Hernia repair, Mesh migration, Hernioplasty complication, incisional hernia
  • Fatemeh Montazer, Saeedeh Farahani, Zoha Shaka, Zeinab Aryanian, Azadeh Goodarzi* Pages 818-826
    Background

    Cutaneous Rosai-Dorfman disease (CRDD) is a rare variant of benign histiocytic proliferative disorder limited to the skin. The underlying etiology is still unclear, but it had been claimed that infections, immunodeficiencies, and autoimmune disorders might have a role in the etiology of this disorder. The characteristic presentation of RDD is lymphadenopathy due to abnormal production and accumulation of histiocytes in lymph nodes; however, the extra-nodal areas could also be affected, such as cutaneous. Herein, we presented a 45-year-old Iranian woman presented with an atypical pure cutaneous Rosai Dorfman disease, in addition to a summarized list of atypical cases of RDD that are reported as pure cutaneous RDD with atypical presentation.

    Case presentation

      Herein, we presented a 45-year-old woman who referred to us with an ulcerative nodule with a size of 5×5 cm on her buttock, gradually growing over one year. After the primary evaluations, a biopsy specimen was obtained, and histologic studies revealed a dense cellular infiltrate involving the dermis and the subcutis, which was composed of abundant sheets of large histiocytes with admixtures of lymphocytes, plasma cells, neutrophils, and eosinophils within their cytoplasm -known as the emperipolesis phenomenon. The immunohistochemistry staining was positive for S100 and CD68 and negative for CD1a.

    Conclusion

    The diagnosis of CRDD was confirmed based on these histopathological findings.

    Keywords: pure cutaneous Rosai Dorfman disease, histiocytosis, atypical cutaneous presentation, non-Langerhans cell histiocytosis, review, case report, histopathology