Journal of Iranian Medical Council
Volume:7 Issue: 2, Spring 2024

Pancreatic cancer commonly refers to Pancreatic Ductal Adenocarcinoma (PDAC) which accounts for more than 90% of pancreatic cancers (1). The substantial burden of disease is characterized by the approximate deaths of as many as cases annually. PDAC as the seventh leading cause of cancer-induced mortalities globally, has been a focal point of research in the field of oncology (2).Despite the vast research and significant effort devoted to the treatment of PDAC, the 5-year survival rate for this cancer remained less than 5%. This scant survival rate is a consequence of late-onset diagnosis, accelerated tumor growth, and limited extant treatments. Hence, innovative strategies, such as immunotherapy, seek to enhance antitumor immune reactions, offering a more precise and targeted therapeutic alternative (1).Immunotherapy is categorically segmented into four primary subtypes: vaccines, cellular therapies, cytokines, and antibodies, with Immune Checkpoint Inhibitors (ICIs) falling under the latter classification (3).Cancer vaccines stimulate immune responses by leveraging tumor-associated antigens to activate cytotoxic T-lymphocytes. These antigens can be sourced from whole-cell tumor lysates, recombinant tumor peptides, or recombinant viruses (1). Regarding vaccines, messenger RNA (mRNA) vaccines have been more promising than conventional vaccines, which present various challenges, for a personalized therapeutic approach in pancreatic cancer. These vaccines utilize the genetic profile of an individual’s tumors, particularly those with mutant Kras, and custom proteins can be encoded (3). KRAS as a proto-oncogene has been recognized as mutated among 90% of patients diagnosed with PDAC, making it a valid target. They enhance antitumor immunity against oncogenic KRAS by presenting oncogenic KRAS neoantigens to major histocompatibility complex molecules, leading to the generation of cancer-specific memory T cells with long-term efficacy. In terms of other vaccines that are under investigation regarding their efficacy in PDAC, telomerase vaccines, gastrin vaccines, survivin-targeting vaccines, heat-shock protein peptide complex-based vaccines, MUC-1 targeting vaccines, listeria-based vaccines, dendritic cell-based vaccines, Granulocyte-Macrophage Colony-Stimulating Factor (GMCSF)-allogeneic pancreatic tumor cells (GVAX) vaccines, and Hyper-Acute-Pancreas algenpantucel-L (HAPa), Mucin-1 (MUC-1) vaccines can be mentioned (4–6).Adoptive cell therapy is a rapidly growing technology consisting of NK cells or T cells that are either allogeneic or autologous. and have been genetically modified to target specific proteins using chimeric antigen receptors and T-cell receptors. These engineered cells are designed to recognize a peptide/MHC complex to effectively eliminate cancer cells. Numerous Chimeric Antigen Receptor (CAR) T-cell therapies have been approved for the treatment of different hematological malignancies. In PDAC, mesothelin CAR-T therapy has shown promise in preclinical mouse models by extending survival. However, the translation of this strategy to clinical settings for solid tumors faces various obstacles. To address these challenges, the development of next-generation CAR-T cells is underway to enhance the effectiveness of this therapy (3,7).Cytokine therapies, including the use of Interleukin-2 (IL-2) and Interferon alpha (IFN-α), have been utilized as an early form of immunotherapy in the management of malignant conditions, establishing them as foundational components of this treatment approach. Cytokines with immune stimulatory properties, including IL-2, IL-15, GM-CSF, and IFN-α, have been incorporated as adjunctive elements in comprehensive immunotherapy strategies for PDAC. While monotherapy with cytokines showed promise during the peri-operative period, no recent studies have been published on this subject in the last ten years (3,8).ICIs are monoclonal antibodies that target specific extracellular proteins expressed by tumor cells or tumor-associated lymphocytes, leading to the suppression of the body’s immune response against the cancer (1). To address some of the main ICIs, Anti-PD-1/Anti-PD-L1, Anti-CTLA-4, Anti-TIM-3, Anti-TIGIT, and Anti-LAG-3 can be mentioned. Anti-PD-1/Anti-PD-L1 blocks the PD-1 pathway in which PD-1 ligation induces self-tolerance by preventing the activation of T cells as well as their proliferation. In PDAC, despite other solid tumors, the efficacy of Anti-PD-1/Anti-PD-L1 as monotherapy was not as promising as its effectiveness in combination with chemotherapy. The inhibitory CTLA-4 receptor on T cells competes with the co-stimulatory receptor CD28 for binding to the CD80 and CD86 ligands on antigen-presenting cells (APCs). CTLA-4 has a higher affinity for these ligands. Lower levels of CTLA-4 and higher expression of CD80 in PDAC are associated with increased survival rates. Binding of CTLA-4 primarily inhibits the activation of naïve T cells in lymphoid organs, but may also hinder the direct anti-tumor activity of T cells in the effector phase, potentially by reducing the presence of suppressive regulatory T cells. Based on a previous study, the co-administration of GVAX with anti-CTLA-4 appears to stimulate a T cell-mediated immune reaction and could potentially enhance the survival rate of patients with advanced PDAC. Numerous clinical trials are currently underway to assess the efficacy of the combination of anti-CTLA-4 therapy with other immunotherapeutic agents and/or radiotherapy in the treatment of PDAC (8). Both PD-L1 and CTLA-4 are often overexpressed in a subgroup of PDAC and are associated with poorer survival outcomes, making them potential targets for therapeutic intervention (1).In conclusion, despite the aforementioned substantial investigations regarding therapeutic approaches for PDAC, treatment of this highly impacting disease is hampered by so many obstacles. Further research is necessary to overcome the remission-disrupting factors such as immunity evasions, altered tumor microenvironment, immunosuppressive activities, etc.Conflict of InterestThe authors had no competing interests.

 In the absence of an effective treatment for COVID-19, we need other methods to control the pandemic of this virus. To achieve this goal, we need non-pharmacological interventions and self-protection. Experience in controlling other viral diseases demonstrated that vaccines are the best way to make social immunity. In this study, we have aimed to review precautions and self-protection methods for fighting the COVID-19 pandemic. This study identified that non-pharmacological and pharmacological interventions, mask-wearing, hand washing, home quarantine, appropriate ventilation, social distancing, chemical disinfectants, and vaccination would be the efficient preventive modalities to mitigate and control the COVID-19 pandemic.

 Ischemia is one of the most common injuries that is usually caused by reduced blood flow to the tissues. Following this incident, the tissue becomes deficient in oxygen and nutrients, and energy production in the affected cells stops, eventually leading to cell damage, but there is also evidence that restoring blood flow to ischemic tissues can lead to extra tissue damage known as Ischemia Reperfusion Injury (IRI). In this study, we reviewed the relationship between vitamin C intake and ischemia/reperfusion injury to investigate the relationship between vitamin C intake and ischemia/reperfusion injury. The keywords “Vitamin C” or “Ascorbic Acid” and “Ischemic” or “Ischemia” and “Reperfusion” were used in this search. The results show that vitamin C has a positive effect on ischemia treatment in the renal tissue, brain, liver, intestine, lung, ovary, pancreas, and skin.

Good nutrition is essential to prevent Non-Communicable Diseases (NCDs) like diabetes and heart disease. NCDs account for a large Global Burden of Disease (GBD). There are different guidelines for a healthy diet to avoid obesity and NCDs and reduce GBD. World Health Organization has published recommendations named Nutrient Profile Model (NPM) to categorize foods as healthy and unhealthy. 

First, the keywords Nutrient Profile Model and Child were searched in Web of Science, Scopus, Google Scholar, and PubMed databases, then articles in the English language until October 6, 2023 were selected and entered into the Endnote X8 resource management software. Duplicated and unrelated articles with the main purpose of this project were excluded from the study. Finally, 23 studies out of 542 entered the full evaluation stage according inclusion criteria.

Various studies investigated NP models’ application to food advertisements. The results revealed that most foods and beverages advertised on TV are not healthy, according to NPM. Also, the unhealthiness of foods like sweet beverages was illustrated, and studies recommended not be marketed to children. NPM is recommended as a tool to help governments to regulate marketing rules for food and legislate food advertisement. 

NPM can be a guideline for labeling health claims and warning labels on food packages and adverting. More strict regulations are recommended for labeling health claims. Articles recommended using the Nutrient Profile Model as a tool for checking the criteria of foods before allowing producers to label them with health claims and advertise on TV.

One of the legal and ethical issues related to the medical profession and health centers is patients’ uncertainty regarding the type and quality of clinical care provided and the extent to which the health care providers comply with the necessary criteria in delivering health care. This study investigated the civil, criminal, and ethical aspects of using cameras in the operating room by describing a case that a legal complaint had filed regarding this issue and a review of the literature.

The study was a case report and narrative review. First, we introduce a case that found out that the patient admitted for brain tumor surgery did not operate on him and requested to review the videos of the operating room. Then, we investigated this issue in the literature.

The purpose and outcome of using Closed-Circuit Television (CCTV) in the Operating Room (OR), may vary depending on the goals, needs, and expectations of different stakeholders. Some countries may use CCTV in the OR primarily for educational, research, or quality improvement purposes. In contrast, others may use CCTV in the OR mainly for security, surveillance, or legal purposes. 

The suggestion of recording the events done in the operating room environment using a CCTV can be an acceptable solution and as a legal document and evidence.

Due to the increasing number of online educations, traditional methods for evaluation of different on-line education methods are not suitable and there is a need for a valid and reliable tool in this field. This study aimed to examine the validity and reliability of the Student Evaluation of Online Teaching Effectiveness (SEOTE) questionnaire among Medical Sciences’ students in Tabriz, Iran. 

Using convenience sampling method, the present study included 230 students of Medical Sciences (e.g., mean age of 21.96 ±3.47 years) in Tabriz, Iran. The SEOTE questionnaire was used to collect the data. Forward–backward translation, construct validity and content validity were utilized to check the validity of the questionnaire. In addition, temporal stability was calculated using the test-retest method and Internal Consistency Coefficient (ICC). 

It was confirmed that the SEOTE has appropriate content validity using the content validity index (CVI) of 0.80 and content validity ratio CVR of 0.70. Exploratory factor analysis (EFA) identified the following two factors for domain identification of “communication” and “learning”. A Cronbach’s alpha of 0.97 was obtained for the questionnaire’s reliability, and ICC was used to confirm the temporal stability of the questionnaire (95% Confidence Interval [CI]: 0.966-0.977). 

This study confirms that the Persian version of SEOTE questionnaire is a valid and reliable tool for evaluation of on-line teaching among Medical Sciences’ students.

Carbapenemase-resistant Enterobacteriaceae is a major threat to public health. These microorganisms are resistant to all types of beta-lactam antibiotics.

This cross-sectional study was conducted on 51 Enterobacteriaceae isolates from clinical samples in Sina Hospital and Tehran Heart Center in Iran from 2016 to 2018. Antibiotic susceptibility test was performed by disk diffusion method. Carbapenem-resistant isolates were identified by the Modified Hodge Test (MHT) and Polymerase Chain Reaction (PCR) for surveying the presence of VIM, NDM, IMMP, and OXA-48 genes.

Out of 51 clinical samples, 38 isolates were positive for both MHT and PCR tests, and 5 isolates were negative in both tests. The results of both tests are similar in 84.3% of the isolates.

The MHT is an appropriate and easy method for approving carbapenemase production. Also, a laboratory can detect the carbapenemase production by identification of the KPC genes.

Postoperative Nausea and Vomiting (PONV) is one of the most common complications of general anesthesia, moreover opioid addiction increases the risk of PONV. Hence, this study evaluates the effect of administering dexmedetomidine infusion as an intraoperative analgesic on PONV in opium-addicted patients who underwent elective laparoscopic cholecystectomy. 

In a randomized clinical trial, 100 opium-addicted patients who were candidates for elective laparoscopic cholecystectomy surgery under general anesthesia were studied in two groups of 50 participants. The intervention group received dexmedetomidine infusion 10 min after induction of anesthesia until the end of surgery. The placebo group received normal saline at the same time. The rate of PONV was compared between the two groups. 

Both groups had no significant difference in terms of hemodynamic parameters during surgery, including pulse rate, systolic and diastolic blood pressure, and duration of anesthesia. In the dexmedetomidine group, patients had less PONV than the control group, and this difference was significant (p=0.0164). 

Dexmedetomidine administration during laparoscopic surgery can reduce PONV, especially in patients addicted to opium.

The aim of the current research was to assess the clinical manifestations and diagnostic methods used in juvenile cases of Autoimmune Hepatitis (AIH).

This study employed a retrospective cross-sectional design to investigate pediatric patients diagnosed with AIH at Children’s Medical Center Hospital, which is affiliated to Tehran University of Medical Sciences (TUMS), Tehran, Iran. The study included patients who received routine examinations, treatments, and follow-ups during the period from 2018 to 2021. 

The present investigation encompassed the evaluation of 52 pediatric patients, mostly female, with a mean age of 7.76 years. The vast majority of patients have encountered the occurrence of acute AIH. Positive findings for the Anti-Smooth Muscle Antibodies (ASMA) test were seen in 50% of the patients. The mean score for fibrosis in the observed individuals was 2.56, whereas the mean value for the Hepatitis Activity Index (HAI) in a subset of 29 patients was found to be 7.34. One patient succumbed to the condition, one case underwent transplantation, and another individual was identified as a candidate for liver transplantation.

Patients with AIH saw a decrease in long-term survival. There was no observed disparity in prognosis based on gender; nevertheless, it was noted that males had a shorter lifespan, perhaps attributable to an earlier beginning of the illness. The presence of cirrhosis at the time of diagnosis constituted a significant risk factor for unfavorable prognosis, as it was associated with an elevated overall risk of mortality owing to liver dysfunction.

We aimed to identify the factors affecting the in-hospital Cardiopulmonary Resuscitation (CPR) to investigate the effect of the time of in-hospital CPR on its immediate outcome in pediatric patients.

This retrospective study investigated CPR events performed at a teaching hospital in Tehran, Iran, from March 2018 to March 2019. After obtaining the necessary academic and ethical approvals, the pertinent data were transcribed from patient records and analyzed. No identifying data about patients or their families were extracted.  

Chi-square test showed a significant difference in the occurrence of CPR on two-hour time blocks (p=0.041), with dips at 0-2 a.m. and 12-2 p.m. and heights at 2-4 p.m. and 6-8 p.m. (representing 5, 6, 17 and 17 CPR events, respectively). The occurrence of CPR during the night shift was significantly less than in the morning and evening shifts (p=0.000 and 0.005 respectively). Of 161 subjects with a known immediate outcome of CPR, 86 (53.4%) survived, and 75 (46.6%) died. The outcome was significantly less favorable in the evening shift compared to the morning shift (p=0.028), but no significant differences in the outcome were found between morning and night shifts (p=0.163), evening and night shifts (p=0.256), day and night (p=0.637) or workdays and weekends (p=0.925).

We found a significantly higher occurrence of CPR at 2-4 p.m. and 6-8 p.m., at the beginning and end of the evening shift and a higher rate of post-CPR death in this shift.

Academic staff have different roles which may impose a high mental workolad on them and affect their cognitive function. This study was designed to assess different subscales of mental worklaod and cognitive function in university academic staff. 

This was a cross-sectional study on 86 faculty members of Shahid Sadoughi University of Medical Sciences. Stratified sampling was used to select participants from different schools. The participants were divided into basic sciences and clinical faculty members. Mental workload was assessed by National Aeronautics and Space Administration-Task Load Index (NASA-TLX). Cognitive function was assessed by Stroop test. Data were analyzed by SPSS 26 using Shapiro-Wilks test, Student’s T-test, Mann Whitney U test, univariate ANOVA, and Kruskal-Wallis test. The level of significance was 0.05. 

Mean age and work history of the participants was 43.6±8.6 yr. and 11.7±9.1 yr., respectively. Mental workload, especially two aspects of mental demand and performance, was high and it was significantly higher in the participants from school of medicine and among those with executive/administrative responsibilities. From subscales of mental workload, physical demand was significantly higher among clinical than basic sciences faculty members (p<0.05). Among different aspects of cognitive function, only numbers of congruent errors were significantly higher among clinical faculties. Mental workload and cognitive function were not significantly correlated.

This study showed a high level of mental workload in university academic staff, especially in clinical faculty members, but this high mental workload did not affect their cognitive function.

COVID-19 had a destructive effect on human’s life. People with COVID-19 experienced high levels of depression, anxiety, and low Quality of Life (QOL). The aim of this study was to investigate the effect of the cognitive-behavioral intervention package on reducing stress, depression, and anxiety, as well as improving the QOL of patients with COVID-19.

In this randomized controlled trial, 60 patients with COVID-19 who entered the isolation ward were included and randomly divided into control and experimental groups. The experimental group entered the intervention sessions once a week for 45 minutes for eight consecutive weeks. The intervention consisted of 8 sessions of CBT which was implemented for the experimental group. Patients in the control group received routine care during this period. DASS21, the Symptom Checklist (SCL-90), Fear of COVID-19 Scale (FCV-19S), and WHO-QOL were used to measure patients’ mental health and QOL. Data analysis was performed with ANCOVA using SPSS24 software.

There was no significant difference between groups in terms of DASS21, SCL-90 and QOL before intervention (p<0.05). After intervention, depression symptom and QOL were significantly improved in the experimental group compared to control group (p< 0.05). Accordingly, the findings stated the session of intervention was effective in improving the QOL (p<0.05) and mental illnesses (p<0.05) in patients with COVID-19.

Our designed cognitive-behavioral intervention package can enhance the awareness and mental health of patients with COVID-19. This package as an auxiliary treatment can reduce anxiety/depression and improve QOL in patients with COVID-19. Therefore, our intervention package can serve as a useful solution for clinical settings to reduce mental health problems during crisis.

Vertebral fracture, one of the most incidents in human life, is associated with many complications. Due to the importance of this complication, this study was conducted to epidemiologically investigate vertebral fractures and their consequences in the emergency department of Kowsar Hospital in Sanandaj in 2017. In this retrospective cross-sectional study, 350 patients who visited the emergency department of Kowsar Sanandaj Hospital in 2017 due to vertebral fractures were included. The data was extracted from information collected through phone contact and patients’ medical documents. V Kramer and ETA tests were performed to analyze the hypotheses using SPSS 25 software. Men constituted 61% of the patients. The average age of the patients was 42.18 (6.86) years, and almost 41% of the patients lived in Sanandaj. The most common trauma mechanism was fall injury with 44.8%, 59.55% of which were in the lumbar region. Compression and burst fractures had the highest fracture rates with 47.85 and 21.9 percent, respectively. According to the findings, the fractures were more prevalent in men, young people, and in labor and agricultural occupations, and there is a significant relationship between the consequences of fractures with age, sex, and occupation, which indicates the need for more safety considerations in these people. Therefore, it is necessary to identify and subsequently modulate the risk factors associated with falling injuries to reduce this type of injury.

The aim of this study was to assess the psychometric aspects of Persian version of Yale Food Addiction Scale 2.0 (YFAS 2.0) and the prevalence of Food Addiction (FA) among Iranian obese population seeking bariatric surgery.  In this cross-sectional study, psychometric aspects of the YFAS 2.0 including validity and reliability were assessed. Convergent and discriminant validity of the YFAS 2.0 was evaluated using Eating Disorder Inventory-3, Referral form (EDI-3 RF), Dutch Eating Behavior Questionnaire (DEBQ), Difficulties in Emotion Regulation Scale (DERS), and Barratt Impulsiveness Scale (BIS-15) and reliability of the scale was examined by test-retest analysis and internal consistency. Among 124 patients (48.6%) who met FA criteria, 2 patients (1.6%) received a mild, 12 (9.6%) a moderate, and 110 (88.7%) a severe FA diagnosis. FA was more prevalent and severe in females, unmarried individuals, unemployed patients, and those with higher Body Mass Index (BMI) or binge eating disorder/bulimia nervosa diagnoses. Reliability analysis showed high internal consistency (Cronbach’s α = 0.89) and test-retest reliability (ICC = 0.88). Content validity was 0.8 or higher in terms of convergent validity. Except for one criterion, a one-factor structure was confirmed for the P-YFAS 2.0 (above 0.42). FA prevalence was higher in participants with BED or bulimia nervosa, and FA severity was correlated with scores on measures of impulsivity, emotion regulation difficulties, eating behaviors and psychopathology. These findings support the reliability and validity of the P-YFAS 2.0 in assessing FA as defined by Diagnostic and Statistical Manual of Mental Disorders-fifth (DSM-5). The high rate of FA identified highlights the need for targeted interventions in this clinical population.

Spheno-occipital synchondrosis is a growth center that is involved in craniofacial development. Since osteogenesis of this synchondrosis occurs relatively later than other synchondroses, it has been taken into account for age estimation in forensics. This study aimed to evaluate spheno-occipital synchondrosis using Cone-Beam Computed Tomography (CBCT) in an Iranian population.  In this cross-sectional study, 148 CBCT images (76 women and 72 men) of patients aged 7-25 years, with a mean age of 19.92±6.3 years, were assessed by two radiologists to analyze the spheno-occipital synchondrosis fusion degree using a four-stage system. In addition, the third molar development degree (Demirjian index) was assessed in panoramic and cross-sectional views of CBCT images. The correlation between spheno-occipital synchondrosis fusion degree and age was obtained. Multiple regression analysis was used for age estimation using spheno-occipital synchondrosis fusion degree and third molar development degree (Demirjian index). Intra-observer and inter-observer coefficients of agreements were also measured. IBM SPSS Statistics 20.0 was used.  There was a positive correlation between spheno-occipital synchondrosis fusion degree and age (r=0.75, p<0.001). The multiple regression model provides a more robust model than when each age marker is utilized individually. The kappa coefficient was 0.53 for inter-observer agreement and 0.77-0.92 for intra-observer agreement.  Assessing the four-stage spheno-occipital synchondrosis fusion degree was not a robust method; however, combined with the third molar development (Demirjian index), it could be considered as an appropriate marker for age estimation in 7-25-year-old Iranian population.

Beta thalassemia major (β-TM) is an inherited blood disorder. Affected patients require frequent blood transfusions, leading to iron deposition and end organ damage, particularly myocardial dysfunction. A 12-lead ECG is a readily available tool that could be used to screen for conduction abnormalities and arrhythmias as a marker of worsening myocardial function.  A total of 108 β-TM patients were evaluated for correlation between abnormal findings on the surface ECG and severity of myocardial iron deposition in magnetic resonance imaging as measured by T2* levels.  Patients with T2* below 20 msec had significantly longer PR intervals, P wave durations, and QTc intervals. Patients with T2* below 10 msec had the longest QRS duration and QRS activation times. Atrial fibrillation was more prevalent in patients with lower T2* levels. With a decrease in T2*, the probability of notching of QRS in the limb and precordial leads increased.  Abnormal ECG is prevalent in β-TM patients, and the frequency of changes increases with the severity of iron overload. A 12-lead ECG is a valuable and readily available tool for the early assessment of myocardial damage and the implementation of a timely and appropriate management strategy.

Intraoperative fluoroscopy systems are widely used nowadays, where their use allows a shorter duration of procedure time and better anatomical localization. The current study aims to investigate the most common challenges of C-arm fluoroscopy systems application.

This mixed-method study was carried out in February and March 2022. After the literature review, a qualitative study was designed using semi-structured interviews to find important themes and subthemes required to design a web survey. The web survey was completed by the Persian Orthopedic Trauma Association (POTA) event’s international presenters.  

Nine orthopedic surgeons participated in interviews and 27 participants filled out the questionnaires. Five main themes including Physical Aspect, Mechanical Aspect, Software Options, Image Quality, and Radiation Exposure were extracted. Generally, over 80% of the web survey participants agreed that the size and shape of the base of C-arm fluoroscopy systems, C-arm diameter (space between tube and detector), and maneuvering and positioning of the C-arm fluoroscopy systems can interfere with surgical procedures. 100% of the participants agreed that providing two different views (e.g., AP and lateral) from the surgical site with one shot can be beneficial. The effectiveness of real-time visualization of radiation exposure on exposure rate was acknowledged by more than 92% of the participants.  

Although the C-arm fluoroscopy systems are widely used in surgical procedures, there are considerable issues regarding the application of this imaging modality in the operation room, and medical equipment companies should pay more attention to these issues to facilitate the use of these systems.

The aim of this study was to investigate if listening to music can help reduce stress for women who work in an electric car parts factory in Mashhad.  Out of 200 people in this study, 32 were chosen at random and split into two groups: one for the experiment and one for comparison. To gather information, we used a job stress questionnaire and a music therapy plan that consisted of 30 sessions, which lasted for one month. In this study, we played the music that the participants liked 4 times during each session. Each time, we played the music for 15 minutes, while they were taking a break or before they started working. There were 16 participants in the group we tested. The people in the control group followed their normal way of doing things and did not use this procedure. The research found that music intervention helps decrease the occupational stress in women more than the traditional work schedule method. The effect size of the music intervention was 0.809, which means it had approximately an 81% impact on reducing stress.  The results of the pre-tests and post-tests indicated that the stress levels of women in the experiment group decreased significantly after listening to music. Based on these findings, it can be concluded that listening to music while taking breaks at work helps to lower job stress.

The death and fear of the COVID-19 pandemic has been a major concern in all countries. Estimating the burden of the disease is one of the indicators that estimates the severity of the damage caused by the disease. This study was performed to estimate the burden of years of life lost due to COVID-19 infection and premature death in North Khorasan.

In this study, all cases of definitive infection (PCR test positive) with COVID-19 from the beginning of the epidemic to April 2021 were included in the study. Disability-Adjusted Life -Years index (DALYs) was used to estimate the burden of the disease.

Since the beginning of the epidemic, 63697 definite cases of the disease have been identified (prevalence equal to 7%) and the total number of years of life lost due to disability and premature death was estimated at 24769 years. This number represents 28.7 years per 100,000 populations, which in women and men, this number was equal to 26.6 and 30.8, respectively.

According to the results of the study, COVID-19 has caused significant loss of years of life, which due to age and concomitant diseases, deaths are more common in the elderly.

In this study, the clinical and radiographic manifestations of a patient with linear morphea as well as her clinical features are reported with more emphasis on the oral effects of this connective tissue disease. This patient was referred to the orthodontic department due to the misalignment of her teeth and a diagnosis of linear scleroderma made three years earlier by her dermatologist. The most important intervention in such patients is to not start treatment without knowledge, since it will cause more harm to the patient. Therefore, it is necessary to find the best treatment plan with the fewest complications as soon as possible.

Tough COVID-19 predominantly affects the respiratory tract, and extra-pulmonary manifestations, including neuromuscular complaints have been associated with this disorder. It is vital to monitor COVID-19 cases for the occurrence of Neuromuscular Disorders (NMDs), which could be overshadowed by severe respiratory and cardiovascular symptoms. In this study, we reported electrophysiological findings of a series of COVID-19 patients with complaints of paresthesia and weakness.

In this case series, the Electrodiagnostic studies (EDX) of 36 patients with recent complaints of weakness or paresthesia and a history of COVID-19 before symptoms were reported.

12 cases (33.3%) had abnormal EDX, five males and seven females, with a mean age of 51.42±11.49 years, history of hospitalization in five cases (41.7%), and ICU admission in four (33.3%). Seven cases were concluded as having a predominantly axonal type polyneuropathy (five sensory-motor and two sensory polyneuropathies). Of these seven, one was suggestive of Critical Illness Neuropathy (CIN). Three cases demonstrated a myopathic pattern with a history of ICU admission, hence the impression of Critical Illness Myopathy (CIM). In addition, one of these three, developed both myopathy and neuropathy and thus, is considered as having CIM/N. One case was diagnosed with Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). The last case demonstrated an inflammatory involvement of lumbosacral roots (COVID-19-related radiculitis).

COVID-19 could be associated with a wide range of NMDs. In this study, the presence of axonal polyneuropathy, CIDP, and myopathy was demonstrated following SAR-COV-2 infection. Also, CIN/M was observed in COVID-19 patients with a history of ICU admission.

We read the following paper entitled “Telehealth Systems for Midwifery Care Management during the COVID-19 Pandemic: A Systematic Review” by Shamsabadi et al, in Journal of Iranian Medical Council, Volume 6, Issue 2, Spring 2023 with interest (1). We feel that while the manuscript addresses a number of important points regarding the provision of perinatal care during the COVID-19 era, there are several concerns considering methodology warranting the discussion. This manuscript focused on collecting data about midwifery care management during Covid-19, particularly related to telehealth applications for care delivery. Our research team has conducted several systematic reviews, and are they aware of the importance of proper assessment of quality of each of the manuscripts included in the review. Quality assessment can be somewhat complicated: each type of article has a different method for determination of quality, reliability, and generalizability of the manuscript (2,3). Thus, the present systematic review collects data from various types of articles including randomized clinical trials, qualitative studies, observational studies (including time series, cross-sectional study, retrospective cohort study, case report, and a pilot study, cross sectional and review). While inclusion of each of these manuscript subtypes can be acceptable, the substantial heterogeneity in article type further necessitates proper quality assessment of each of the included manuscripts. Proper quality assessment in systematic review warrants further discussion, and it is the subject of ongoing investigation. For example, Vo et al conducted an analysis of systematic reviews associated with mediation studies. These authors demonstrated that 23% of the reviews did not assess risk of bias at all, and 47% of the included studies used bias assessment tools that were not specifically designed for mediation studies. Perhaps, even more concerningly, 30.1% of the studies assessed the risk of bias using purely narrative means or with non-validated tools (4). Tran et al corroborate these results in the dental literature, demonstrating a high prevalence of utilization of author-developed tools to assess the quality of included manuscripts. They conclude by stating the need for the development of comprehensive guidelines for systematic reviews specifically within each field of research to more precisely assess the quality of the evidence included in the review (5). While currently there is no widely accepted form of guidelines used to curate quality assessment for systematic reviews, several quality assessment tools have been broadly validated and used across the literature. The Cochrane Risk of Bias 2 (RoB 2) tool is utilized to evaluate Randomized Controlled Trials (RCTs) included in systematic reviews (6). The tool consists of six domains, including selection bias, performance bias, detection bias, attrition bias, reporting bias, and other biases. The authors of the systematic review evaluate each study and list the potential for bias as being either high, low, or unclear. Another frequently used quality assessment tool for systematic review is assessing the methodological quality of systematic reviews (AMSTAR) instrument. In lieu of evaluation of each individual article, the original AMSTAR appraises the overall quality of a certain systematic review of RCTs. It has been further updated to remain applicable for non-randomized studies of various healthcare interventions in addition to RCTS. The updated version of the instrument, the AMSTAR 2, consists of 16 items and provides the addition of a comprehensive user guide which instructs the investigator in the proper use of the tool. The AMSTAR provides an overall score based on limitations of a certain systematic review in critical domains relevant to the interpretation of the study (7). While neither of the above assessment of bias tools may have been ideal for the study conducted by Shamsabadi et al, the authors should explain their evaluation protocols, ideally using a well-validated tool tailored appropriately to the specific article type in question. In addition to careful description of the methods used for quality assessment, the authors should more completely define cutoff points and exclusion and inclusion criteria used for article selection. Moreover, the type of technology used to provide telehealth services should be described in as detailed a manner as possible. The related applications for telehealth care provision warrant further discussion regarding their respective capabilities and requirements. The authors of this study have not clarified the methods used for quality assessment and have poorly defined the reasoning behind selection of various article types.As an additional erratum in the text, the references in table 1 include up to the number 40, while the reference list at the end of the paper only includes 32 references. Overall, we commend the authors on an interesting contribution. However, we feel that a formal published addendum including more complete descriptions of quality assessment and revisions to the reference numbering would greatly enhance the scientific value of the manuscript.