مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و پنجم شماره 4 (پیاپی 196، تیر 1396)

An increase in the average age of the population and physical activities where the musculoskeletal system is involved as well as large number of people suffering from skeletal injuries which impose high costs on the society. Bone grafting is currently a standard clinical approach to treat or replace lost tissues. Autografts are the most common grafts, but they can lead to complications such as pain, infection, scarring and donor site morbidity. The alternative is allografts, but they also carry the risk of carrying infectious agents or immune rejection. Therefore, surgeons and researchers are looking for new therapeutic methods to improve bone tissue repair. The field of tissue engineering and the use of stem cells as an ideal cell source have emerged as a promising approach in recent years. Three main components in the field of tissue engineering include proper scaffolds, cells and growth factors that their combination leads to formation of tissue-engineered constructs, resulting in tissue repair and regeneration. The use of scaffolds with suitable properties could effectively improve the tissue function or even regenerate the damaged tissue. The main idea of tissue engineering is to design and fabricate an appropriate scaffold which can support cell attachment, proliferation, migration and differentiation to relevant tissue. Scaffold gives the tissue its structural and mechanical properties, for instance flexibility and stiffness that is related with the tissue functions. Biomaterials used to fabricate scaffolds can be categorized into natural or synthetic biodegradable or non-biodegradable materials. Polymers are the most widely used materials in tissue engineering. Growth factors are a group of proteins that cause cell proliferation and differentiation. Two main cell sources are specialized cells of desired tissue and stem cells. However, according to the low proliferation and limited accessibility to the cells of desired tissue, stem cells are better suggestion. Combination of mesenchymal stem cells harvested from bone marrow, adipose tissue and cord blood with proper scaffolds and growth factors could be a useful method in treatment of skeletal injuries. In this review paper, we focus on the application of mesenchymal stem cells in the repair of damaged bone, cartilage, meniscus, ligaments, tendons and spine tissue.

One of the main sources of a wide range of biological products as starting material is the human blood. These biological human plasma derived medicines play essential role in prevention and treatment of a variety of life threatening diseases. Mention to the starting material of these medicines which is blood or in another word human plasma, possibility of contamination by blood borne viruses cannot be omitted.
In recent years possibility of contamination by blood borne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) is an important concern. Nowadays most of developed countries the risk is minimum, although in developing countries it is still a challenge. Despite measures for human plasma biological derived medicines safety, such as donor selection, testing of donations, and polymerase chain reaction (PCR) testing on pooled plasma, still more actions are needed to inactivate or remove viruses such as HBV, HCV and HIV. During the process of manufacturing of biological human plasma medicines, there is several production steps which may contribute to viral reduction. These steps consist of precipitation by centrifugation, ethanol, polyethylene glycol, octanoic acid, or ammonium sulphate, chromatographic methods such as immunoaffinity chromatography or ion exchange chromatography, adsorption by aluminum hydroxide, and separation by filtration. All these steps are considered to be weakly effective as viral reduction treatment, and more effective viral inactivation methods are needed to be implemented in line of production of human plasma derived biological medicinal products. These safety measures included virus inactivation by different techniques such as acidic pH, solvent/detergent method, pasteurization and heat treatment, beta-propiolactone plus U/V and also virus removal by nanofiltration, which all these virus inactivation or virus removal methods before implementation in line of production of plasma derived biological medicines, should undergo for validation study.
Nowadays by screening and testing of donations and implementation of different measures of virus inactivation or virus removal, a good level of safety of plasma derived biological medicines has been achieved. Due to the possibility of emerging new pathogens investigation in this subject should be continued.

Familial adenomatous polyposis (FAP) is the most common components polyposis syndromes. It incidence is for less than 1 percent of colorectal cancer cases. FAP is characterized by germline mutations in the adenomatous polyposis coli (APC) gene. Generally, there are hundreds to thousands of adenomatous polyps in colon and rectum of patients. The aim of the current study was to evaluate the germline mutation at codon 1309 of the APC gene and its association with extracolonic manifestations in Iranian patients with FAP.
This Cross-sectional study was conducted at the Gastroenterology and Liver Diseases Research Center, Taleghani Hospital, Tehran, Iran from July 2012 to February 2015. In this study, thirty-three patient with FAP was examined. Demographic and clinical data were gathered from patients. In addition, peripheral blood samples were collected to study the most common mutations of the APC gene and bidirectional sequencing was carried out after genomic DNA extraction by salting out method. Primers were designed by GeneRunner version 5.0.4 (http://www.generunner.com). The samples were run on an applied biosystems 3130XL genetic analyzer. The results were analyzed by SPSS software, version 23 (IBM, Armonk, NY, USA).
After analyzing the mutation cluster region (MCR), we have identified five germline mutations with 5bp deletion at codon 1309 of the APC gene (c.3927_3931delAAAGA), that it is equivalent to 15.2% (5.33). This mutation has been known as a small deletion, that it is a variant of frameshift mutation. Mutation at codon 1309 has significant association with clinical and pathological features including the number of polyps (P=0.001), duodenum demonstration (P=0.008), fundic gland polyp (P=0.002) and congenital hypertrophy of the retinal pigment epithelium (P=0.021).
The analysis of the findings has shown that mutation in Codon 1309 of adenomatous polyposis coli gene may be associated with severe polyposis and extracolonic manifestations. In conclusion, there may be a correlation between a specific germline mutation and the extracolonic manifestations.

Candida species are opportunistic yeasts that are capable of causing different infections and diseases among immunocompromised patients. Since Candida infections are major causes and frequent of septicemia in Neonatal Intensive Care Units (NICU), and they are associated with high morbidity and mortality rates, so obtaining adequate treatment seems necessary. Low birth weight preterm infants are especially vulnerable to these devastating infections. The aim of this study was to evaluate the drug susceptibility of Candida species colonized on the skin and mucous membrane of neonates to fluconazole, amphotericin B and caspofungin.

This study was carried out in the laboratory of medical mycology and serology, School of Public Health, Tehran University of Medical Sciences for the period of 7 months from June 2016 to December 2016. In this descriptive cross-sectional study, 23 isolates of Candida species including Candida parapsilosis, Candida albicans, Candida tropicalis, Candida guilliermondii and Candida krusei were studied. These under study isolates were previously isolated from skin and mucous membranes of neonates in NICU of Imam Khomeini Hospital and Children's Medical Center were identified by PCR-RFLP (Polymerase chain reaction-restriction fragment length polymorphism). Evaluation of antifungal drug susceptibility including fluconazole, amphotericin B and caspofungin was carried out. Antifungal susceptibility test was done according to the standard protocol Clinical and Laboratory Standards Institute (CLSI M27-A3) that is specific to the yeast fungi. Statistical analysis was done by using T-test in SPSS version 22 (IBM, Armonk, NY, USA) and P

In this study, C. parapsilosis, C. albicans and C. tropicalis had the most sensitivity to fluconazole. Clinical Isolates of C. guilliermondii were also sensitive to fluconazole, but in C. krusei sensitivity was dose-dependent. All isolated species were sensitive to amphotericin B and caspofungin.

According to the results, all isolated Candida species were more sensitive to amphotericin B and caspofungin than other antifungal drugs. In final conclusion, Finally, it is emphasized that antifungal susceptibility testing is necessary to prevent treatment failure or recurrence of disease.

The histological terminology of persistent gestational trophoblastic disease (GTD) is an excessive abnormal trophoblast. GTN will mostly occur after the molar pregnancy; while, it might occur after each kind of pregnancy such as abortion, ectopic pregnancy (EP), etc. too. The follow-up process is to interest to scholars as a mandatory procedure in patients with GTN for detecting the recurrence. This disease is frequently seen in reproductive ages. It should be noticed that an approach for assessing the success in this procedure carried out by monitoring outcomes of pregnancy after chemotherapy.
A retrospective cohort study was conducted on patients with GTN who were referred to Firoozgar and Mirza Koochak Khan teaching hospitals during 10 years, starting from 2004. The inclusion criterion was patients with low-risk persistent GTN after molar pregnancy, EP, and abortion, that treated with single agent chemotherapy actinomycin-D. After following the patients for 12 months, patients with serum βHCG lower than 5 mIU/ml, who intended to have child were allowed to become pregnant. The following items were observed in the study: age, body mass index (BMI), parity, chemotherapy duration, and pregnancy outcomes such as spontaneous abortion or preterm labor, pre-eclampsia, stillbirth, fetal malformation, and repeated molar pregnancy.
74 patients were monitored, 83.78% of them had uncomplicated pregnancy and labor, 4.05% had the abortion, 4.05% had second molar pregnancy, 2.7% had pre-eclampsia, 5.40% had preterm labor. Moreover, stillbirth and malformation did not occur in this study even after chemotherapy treatment. There was not any significant correlation between age, BMI, parity, and chemotherapy duration with pregnancy outcomes.
The outcomes of pregnancy after chemotherapy with actinomycin-D is similar to the general population who did not have chemotherapy. The abortion rate and repeated molar pregnancy were similar between population and sample too. Thus, the study shows that the cured patients with low-risk GTN have as much chance of having a normal pregnancy as normal women. In other words, treatment with actinomycin-D does not have any adverse effect in future pregnancies.

Looking at the increased incidence of recurrent vulvovaginal candidiasis and refractory resulting from such non-albicans Candida species in recent decades, this study was performed aiming the use of rapid biochemical and molecular detection of drug-resistant Candida species in response to fluconazole in patients with vulvovaginal candidiasis and recurrent vulvovaginal candidiasis.
The cross-sectional study was performed at Kowsar Gynecology Center, Motahhari educational hospital and Medical Mycology Center, Faculty of Medicine, Urmia, Iran, from October 2013 to July 2015. Those patients referred to the clinic with symptoms of vaginal discharge, itching or burning that swab samples from endo-exocervix and distal fornix discharge were taken. The vaginal discharge samples submitted to Medical Mycology Center, Urmia School of Medicine for the direct microscopic examination and cultures. Identification at the level of species was performed using CHROMagar Candida and Corn meal agar media. The molecular test polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) used for confirming culture results. For the susceptibility assay, disc diffusion method was performed with fluconazole and clotrimazole.
In these study 198 samples collected from patients with symptoms of vulvovaginal candidiasis, 77 vulvovaginal candidiasis cases were identified. Candida species are common in primary and recurrent cases in terms of frequency, Candida albicans (85.7%), Candida krusei (10.2%) and Candida glabrata (4.1%) were identified respectively. Total of 27 cases of recurrent vulvovaginal candidiasis, 10 cases were resistant to both clotrimazole and fluconazole (37%) was observed that the most common species are resistant to treatment were Candida albicans by (82.1%), Candida krusei (14.3%) and Candida glabrata (3.6%) respectively. Drug resistance in Candida albicans, Candida krusei and Candida glabrata causing recurrent vulvovaginal candidiasis included 69.1%, 75% and 100% respectively.
Our findings have shown frequency of resistant non-albicans Candida species to fluconazole and clotrimazole is increasing. There is a considerable difference between Candida albicans and non-albicans species, Candida glabrata for the resistance to fluconazole and clotrimazole.

Hospital accreditation is a systematic external evaluation of a hospital’s structures, processes and results (outputs/ outcome) by an independent professional accreditation body using pre-established optimum standards. Hospital accreditation has an important role in improving the quality, safety, effectiveness and efficacy of health care services. The effectiveness of an accreditation system depends on the quality and conformity of its methods, standards and surveyors. This study aimed to evaluate the hospital accreditation method from the perspective of Iranian hospital managers.
This descriptive, applied and cross-sectional study was carried out in 2015 using a valid and reliable questionnaire. The study population consisted of 914 hospital managers. Overall 547 hospital managers were surveyed through stratified random sampling. SPSS software was used for data analysis.
Almost 71.7 percent of hospitals achieved grade one and above in the first round of national accreditation survey. The mean score of managers’ satisfaction of hospital accreditation method was 3.21±0.63 out of 5 (Average). About 38 percent of hospital managers were satisfied with the hospital accreditation method. Most complaints were related to lack of reliability among surveyors and their low knowledge, skills and experience. Hospital managers were satisfied with surveyors’ attitude and adequacy of the number of survey days. Hospital managers mostly believed that accreditation is better to be done by Ministry of Health, compulsory, and every two years. About 95 percent of hospital managers agreed that self-assessment is necessary and beneficial prior to the accreditation survey.
Hospital managers were moderately satisfied with the national accreditation system. Developing job description and person specification for accreditation surveyors and recruiting them accordingly, and providing professional education and training for them help improve the effectiveness of Iranian hospital accreditation method. The method of hospital accreditation in Iran has to be changed. Self-assessment, unannounced surveys, review of hospital key performance indicators and patient satisfaction surveys should be added to the current scheduled on-site surveys to enhance the credibility of the accreditation result.

Fungi have a worldwide distribution which can cause a broad spectrum of disease ranging from allergic to systemic infections, particularly in immuno-compromised individuals. Fungal spores are an important group of bioaerosols in hospital environment which are an emerging cause of hospital-acquired infection. Nosocomial infections cause significant morbidity and mortality as well as large financial burden on the healthcare system. This study aimed to evaluate the frequency and species distribution of airborne fungi in selected wards of two tertiary hospitals in Tehran, Iran.
In this cross-sectional study, samples were collected during six months from July 2016 to December 2016 by using of settle plate method. Samples were collected from selected wards of Imam Khomeini Hospital and Children's Medical Center and then incubated at 28 °C for 8-10 days. Fungal isolates were identified using the macroscopic features of colony and microscopic characteristics in slide cultures. Yeast isolates were identified by CHROMagar candida medium. PCR-sequencing of ITS1-5.8 S-ITS2 region of ribosomal DNA was used for identification of unknown isolates.
A total of 202 colonies including 133 colonies from the Imam Khomeini Hospital and 69 colonies from the Children's Medical Center were isolated. Cladosporium spp. were the most common obtained fungi accounted for 30.1% and 47.8% of all isolates in the Imam Khomeini Hospital and the Children's Medical Center, respectively. Penicillium spp. and Aspergillus spp. were other frequent species in two hospitals. Infectious diseases ward in Imam Khomeini hospital and emergency and urology wards in Children's Medical Center had the highest rate of contamination.
According to the results of this study, the frequency and diversity of fungal spores in hospital wards were different. In addition, since the fungal contamination in the hospital environment are affected by various environmental factors and the efficiency of ventilation systems, some of these wards require better ventilation system as well as regular monitoring to remove these fungal bioaerosols in order to maintain the health of patients and health care workers.

Paraoxonase-1 (PON1) is one of the most important enzymes for removal of the free radicals, and the main protective factor for lipoproteins against oxidative agents. The purpose of this study was to investigate the effects of eight weeks’ rope training on paraoxonase-1 enzyme, insulin resistance and lipid profiles in inactive overweight and obese girls.
This quasi-experimental study was conducted in Iranian Azarbaijan Shahid Madani University of Tabriz, from November 2016 to January 2017. In this study, 20 healthy overweight and obese in-active girls (20-25 Yr) volunteered and randomly assigned into exercise (n=10) and control (n=10) groups. Exercise protocol was rope training was 8 week for 4 day per week in 45 minute per day. Some anthropometric indexes of subjects were measured before and after exercise. A fasting blood sample was collected as pre-test and post-test, followed by 48 hours of physical inactivity to measure serum levels of PON1 enzyme, Insulin, lipid profiles and other blood variables. Analysis of the data was performed by paired and independent samples t-tests by using the SPSS software, version 20 (IBM, Armonk, NY, USA). The criterion of statistical significance was set as P The paired samples t-test results showed that after exercise intervention, in exercise group, the values of all variables (except low-density lipoprotein) were significantly changed. Also, to compare with control group, the values of PON1 enzyme (P=0.024) and maximum oxygen consumption (P=0.006) significantly increased and insulin resistance index (P=0.028), triglyceride (P=0.046) and body fat percent (P=0.001) were significantly decreased (P The results of this study showed that performing rope training for 8 weeks induced positive changes in paraoxonase-1 enzyme, insulin resistance index, maximum oxygen consumption and some lipid and anthropometric indices in overweight and obese young girls. Therefore, according to these results, rope training, as an aerobic activity it can be useful for all people especially in overweight and obese to control blood fats, body composition and prevent diseases due to obesity such as cardiovascular disease.

Jaundice is the common cause of hospitalization of infants in the first month after birth. Therefore, detection of risk factors associated with jaundice can effect on its process and complications. This study aimed to determine the prevalence and characteristics of diabetic mother's infants and comparing with infants with unknown jaundice.
In this cross-sectional study, among 2,800 infants with jaundice in Ghaem hospital in Mashhad during the 2007 to 2014, features of 59 infants of diabetic mother's (case group) and 78 infants with unknown jaundice (control group) were analyzed. After confirming of jaundice (Bilirubin ≥ 17 mg/dl) in newborns based on examination of pediatrician and laboratory results, a researcher made questionnaire containing maternal demographic data, (maternal age, parity, maternal problems during pregnancy, route of delivery). Also neonatal characteristics including age, sex, birth weight, current weight, duration of hospitalization, current age, age of recovery and laboratory data (Bilirubin, direct bilirubin, hematocrit, platelet, sodium, potassium, blood urea nitrogen, Cr, TSH, T4) were assessed. After data collection and recording information in SPSS software, version 19.5 (IBM SPSS, Armonk, NY, USA), by using tables, charts and statistical indices, the study was evaluated. Data were analyzed using statistical tests such as Mann-Whitney, Chi-square tests after normality control. Comparison of the two groups in normal distribution with t-test and for non-standard data with Mann-Whitney test. Also for definitive variables Chi-square test was used. P-value less than 0.50 was the significant level minimum.
In this study, the prevalence of jaundice due to maternal diabetes was 2.10 percent. Birth weight (P=0.02), current age (P=0.003), parity (P=0.000), maternal age (P=0.000), age of recovery (P=0.04), cesarean section (P=0.001), prematurity (P=0.000), maternal problems during pregnancy (P=0.000), abnormal physical examinations (P=0.001) in diabetic mother's infants and Bilirubin (P=0.000), length of hospitalization (P=0.003), in infants with unknown jaundice were higher.
The infant of diabetic mother are at increased risk of maternal and neonatal complications. Neonatal complications consist of high birth weight, preterm labor, more jaundice and late recovery, abnormal physical examinations. Also, maternal complications during pregnancy and cesarean section were high.