مجله دانشکده پزشکی دانشگاه علوم پزشکی تهران
سال هفتاد و هفتم شماره 6 (پیاپی 222، شهریور 1398)

Animals have an internal biological clock with melatonin hormone that helps them to adapt to light/dark circles. Since melatonin is associated with an alteration in the expression and production of opioid receptors, this study aimed to evaluate the effect of changes in the light/dark circles on pain sensation in rats.

This research study in order to investigate the thermal and chemical pain sensation using tail flick and formalin tests, 35 Wistar rats were randomly divided into five groups of seven animals, including 24 hours of light (24L), 16 hours of light / 8 hours of darkness (16L/8D), 12 hours of light / 12 hours of darkness (control), 8 hours of light / 16 hours of darkness (8L/16D) and 24 hours of darkness (24D) were tested. The study was conducted at the Department of Biology of Ferdowsi University of Mashhad, Iran, from April to September 2015. Also besides the Rotarod test was performed to determine the general motor activity of animals.

In the tail flick test, an increase in the time of darkness elevated the threshold of thermal pain and subsequently resulted in analgesic effect in the 24 hours of darkness (24D) group (P=0.03), while reducing the dark period in the group of 16 hours of brightness / 8 hours of darkness caused a reduction in the threshold of thermal pain, resulting in hyperalgesia (P=0.002). In the formalin test, the chemical pain score at the end of the chronic phase was significantly increased in the experimental group of 16 hours of brightness / 8 hours of darkness compared to control, indicating hyperalgesia (P=0.03).

Perhaps, alterations in light duration may change the production of melatonin and opioids and their receptors. Therefore, it is expected that reduction of the duration of darkness and thus shortening the period of increased production of melatonin and the subsequent lower expression of opioid receptors, in this group, resulting in a lower thermal pain threshold and analgesic response.

Metalloproteinase enzymes can lead to the digestion of the extracellular matrix and its compounds and ultimately facilitate the metastasis of cancer cells to other tissues. This study aimed to evaluate the activity of matrix metalloproteinases (MMPs) 1 and 13 in the tissue and plasma samples of the patients with breast cancer and their relationship with clinical features of the disease.

In this experimental study, twenty-five patients with the diagnosis of non-metastatic luminal A breast cancer in the stage 2 or 3 from the patients referred to the Cancer Institute of Iran, as well as eight healthy subjects which was performed in the Cancer Research Center of Tehran University of Medical Sciences from March 2017 to September 2017, were entered into the study. After obtaining written consent, a few biopsies of breast tumor tissues and 10 cc of the whole blood were collected from all the subjects. Then, the collagen zymography assay was used to evaluate the activity of MMPs 1 and 13.

The results of the present study showed that the activity of MMPs 1 and 13 in the plasma samples was significantly increased in comparison with the healthy group (respectively P=0.0055 and P=0.0263). Unlike the MMP-13, the activity level of the MMP-1 in the tumor and plasma samples was significantly different (P=0.0227). Plasma activity levels of MMP-1 (P=0.0037) and MMP-13 (P=0.0311) were also significantly different in stages 2 and 3 of the disease. Unlike the MMP-13, the activity level of MMP-1 was significantly different in lymph nodes between the tissue and plasma samples (respectively P=0.03 and P=0.015). Moreover, there was no significant difference in the activity level of MMPs 1 and 13 with menopausal and non-menopausal status between the tissue and plasma samples.

The results of the present study showed that plasma concentrations of the MMPs 1 and 13 in comparison with their tissue concentrations could be an appropriate diagnostic tool for breast cancer patients.

 Rapid repair of skin donor sites in partial-thickness skin grafts in burn is critical to the patient. Severe pain during dressing change and scarring also reduce the quality of life and treatment. Recently, nano-silver particles are available which have a high surface to volume ratio and remain effective even at a very low concentration and minimize the chance for tissue toxicity due to silver. Our aim in this study was to evaluate the effect of nano-silver dressings on increasing the rate of repair and reduction of complications in non-infectious wounds of skin graft donor sites.

 This was comparison study that involved patients admitted to a single-center burn unit who required a skin graft donor site. 10 burn patients with thermal injury and 10-30% of total body surface area (TBSA) who referred to Shahid Motahari Hospital, Tehran, in 2016 were studied. Each patient was compared to herself. After anesthesia, the site of the skin graft was randomly divided into three sections in each patient and was covered with Agicoat®, Mepitel and vaseline gauze. On the 4th and 8th of the day, the pain was recorded during the dressing change on the basis of the visual analogue scale (VAS). After 6 months, the patients were evaluated for the remainder of the scars based on VSS (Vancouver scar scale).

 The mean time to repair in both groups were similar and significantly shorter than that of vaseline (P=0.005). The pain comparison between groups showed that on the fourth day, the mean pain in the Agicoat group and Mepitel was significantly less than the Vaseline group (P=0.004). Also, the mean pain of the epileptic group was significantly lower than that of the Vaseline group (0.002). However, there was no significant difference between the duration of regeneration and pain between the two groups of Agicoat and Mepitel, but there was no significant difference between the mean pain on the 8th day and the mean VAS 6 months after the graft.

 Agicoat dressing has been effective in reducing pain and increasing the repair speed, but this effect was similar to that of the silver-free Mepitel dressing. Expensive silver nano-crystal dressings limit their use. The silver nanocrystal did not have much effect on improving the remaining scar. However, more studies are needed in this regard.

Gestational diabetes mellitus (GDM) is one of the most common metabolic disorders in pregnancy, which is associated with serious complications. In the event of early diagnosis of this disease, some of the maternal and fetal complications can be prevented. The aim of this study was to early predict gestational diabetes mellitus by two statistical models including artificial neural network (ANN) and decision tree and also comparing these models in the diagnosis of GDM.

In this modeling study, among the cases of pregnant women who were monitored by health care centers of Kermanshah City, Iran, from 2010 to 2012, four hundred cases were selected, therefore the information in these cases was analyzed in this study. Demographic information, mother's maternal pregnancy rating, having diabetes at the beginning of pregnancy, fertility parameters and biochemical test results of mothers was collected from their records. Perceptron ANN and decision tree with CART algorithm models were fitted to the data and those performances were compared. According to the accuracy, sensitivity, specificity criteria and surface under the receiver operating characteristic (ROC) curve (AUC), the superior model was introduced.

Following the fitting of an artificial neural network and decision tree models to data set, the following results were obtained. The accuracy, sensitivity, specificity and area under the ROC curve were calculated for both models. All of these values were more in the neural network model than the decision tree model. The accuracy criterion for these models was 0.83, 0.77, the sensitivity 0.62, 0.56 and specificity 0.95, 0.87, respectively. The surface under the ROC curve in ANN model was significantly higher than decision tree (0.79, 0.74, P=0.03).

In predicting and categorizing the presence and absence of gestational diabetes mellitus, the artificial neural network model had a higher accuracy, sensitivity, specificity, and surface under the receiver operating characteristic curve than the decision tree model. It can be concluded that the perceptron artificial neural network model has better predictions and closer to reality than the decision tree model.

Sjögren’s syndrome is the second most common systemic autoimmune disease after rheumatoid arthritis, RA, with a prevalence of about 0.5% in the general population. It occurs primarily in perimenopausal women (at a ratio of women to men of 9: 1) Sjögren’s syndrome is characterized by lymphocytic infiltration to exocrine glands. The specific autoantibodies of this syndrome are against Ro (SSA) and La (SSB). B cell dysfunction occurs in patients with Sjögren's syndrome. B lymphocyte cells produce monoclonal immunoglobulin heavy and light chains addition to producing Ro (SSA) and La (SSB). Up to 25% of patients in this situation are associated with antibody production. This study aimed to evaluate the prevalence of monoclonal immunoglobulin in patients with primary Sjögren's syndrome.

31 patients with primary Sjogren's syndrome diagnosed according to the American College of Rheumatology (ACR) criteria referred to Rheumatology Clinics of Firoozgar Hospital, Tehran, during first six months of 2016, were studied. Clinical examinations and tests carried out. We analyzed serum monoclonal immunoglobulins by immunofixation electrophoresis (IFE) on agarose gels with specific antisera to IgG, IgM, IgA, and κ and λ chains. The IFE was performed with a Helena immunofixation agarose kit (Helena Laboratories, Beaumont, TX, USA) following the manufacturer's recommended procedure. The measures of Anti-Ro, anti-La, rheumatoid factor (RF), antinuclear antibodies (ANA) with immunofluorescent method, complete blood count (CBC) with differential by peripheral blood smear, an erythrocyte sedimentation rate with western green tube, dip stick urine analysis, urine specific gravity (SG) with Refractometer (Mesu Lab Instruments Co., Guangzhou, China), turbidimetry serum complement, and the complement CH50 with ELISA were done.

Most of (87%) patients were female. The mean age of patients was 45.32±12.02 years. The majority of the patients (94%, 29 cases), ocular sign was observed. Xerostomia were common in 84% cases (n=26). Arthralgia/arthritis and submandibular enlargement were common 48% and 19% of patients, respectively. Lymphadenopathy, lung involvement and parathyroid, each was prevalent in 16% of patients. Vasculitis in 13% and Raynaud's phenomenon in 6% of the patients were common. Liver and kidney involvements with the lowest prevalence, each was prevalent in 3% (1 person) patients. RF and the erythrocyte sedimentation rate (ESR) were abnormal in 22.58% and 12.90% of patients, respectively. The immunofluorescent antinuclear antibody (ANA or FANA) pattern, C3 and C4 complements levels were abnormal in 16.12%, 12.90% and 6.4% of patients, respectively. In 29% (n=9), monoclonal antibodies were higher than normal. IgG, IgM and IgG, were abnormal in 19.3% (n=6), 6.4% (n=2) and 3.3% (n=1), respectively.

Monoclonal immunoglobulin levels in patients with primary Sjogren's syndrome increases. To achieve more definitive and reliable results, this study should be repeated with larger sample size and at different times.

Osteoarthritis (OA) is a degenerative disease that can cause pain and limited function. One of the non-surgical treatments is intra-articular ozone injection. This study aimed to compare the effect of ultrasound-guided corticosteroid injection with ozone injection in patients with grade 3 osteoarthritis of the knee.

This randomized, double-blind, clinical trial was carried out in 32 participants with diagnosis of grade 3 knee osteoarthritis were divided into 2 groups randomly. In one group 40 mg triamcinolone (1 cc) injected into the knee joint (under ultrasound-guided in suprapatellar pouch). In another group under sterile conditions, 10cc oxygen-ozone (O2O3), (Ozone generator, Hyper Medozon Comfort, Herrmann Apparatebau GmbH, Kleinwallstadt, Germany) (15 μg/ml) under ultrasound-guided (in suprapatellar pouch), injected into the joint. This study was carried out in Physical Medicine and Rehabilitation, Clinic of Hazrat Rasul Akram and Firoozgar University Hospitals, Tehran, Iran, from September 2017 to August 2018. Outcome instruments were WOMAC, clinical parameters of the knee (knee flexion), ultrasound index (suprapatellar pouch) and pain, visual analog scale, VAS). Measurements were done before, 1 week and 1, 3 months after treatment. All injections were done under ultrasound guide. All patients were trained to perform knee strengthening exercises.

From 32 patients, 7 men and 25 women were enrolled in our study. The mean age of patients, in the steroid group was 58.50 and in the ozone group was 60.06 years. Recovery was significant after treatment in both groups (P<0.05). Our results showed that there was the improvement in VAS criteria in both groups before and after treatment but there was no significant difference between the two groups (P=0.261). There was no significant difference in the WOMAC score between the two groups (P=0.265). The recovery in one month after treatment, was in favor of the ozone group (P=0.008). There was no significant difference in ROM criteria and joint effusion between the two groups (ROM P=0.270, Effusion P=0.630), but in the ozone group, joint effusion was decreased (P=0.009).

Steroid and ozone injections has no superiority to each other in the improvement of pain, function, ROM, and effusion in patients with grade 3 knee osteoarthritis.

Vitamin D deficiency can cause frequent infection of tonsil and adenoid. Recurrent upper airway infections are associated with hypertrophy of lymphoid tissues (adenoid and palatine tonsils) in children. Obstructive sleep disorders, failure to thrive, facial deformity, and cognitive disorders are among the most important complications of adenotonsillar hypertrophy. Surgery is indicated in cases with symptomatic adenotonsillar hypertrophy, who did not respond to conservative management. This study aimed to evaluate the relation between serum vitamin D level and size of palatine tonsils and adenoid. If there was a significant relationship between them, vitamin D replacement therapy could replace surgery in many cases. It seems to be a logical way to prevent possible complications of adenotonsillar hypertrophy and avoid many adenotonsillectomies. 

A prospective cross-sectional study was conducted among 3 to 15-year-old children, who were referred to the Otorhinolaryngology Clinic of Taleghani Hospital, Tehran, from 2015 to 2017. The patients should not have any history of chronic diseases and not be treated with vitamin D supplements. Adenoid hypertrophy was evaluated in patients with suspected symptoms. Lateral nasopharyngeal x-ray was used to determine adenoid hypertrophy. The tonsillar size was assessed in all patients by careful oral physical examination. They were divided into 4 groups, according to the grade of tonsillar hypertrophy. Then, each group was subdivided as with or without adenoid hypertrophy.

The total number of cases was 140. Sixty-nine girls (49.3%) and seventy-one boys (50.7%) were enrolled. The average of their age was 7.69 years (SD=3.28). There was no significant difference in the vitamin D levels among all groups (P=0.211), but children with grade 3 and 4 of tonsillar hypertrophy had lower serum vitamin D levels compared with others. Also, the difference between serum vitamin D levels in patients with or without adenoid hypertrophy was not significant (P=0.254).

Although vitamin D deficiency may predispose patients to recurrent infections, it has no effect on creating adenotonsillar hypertrophy. The serum level of vitamin D does not seem to correlate with the adenoid size, but lack of vitamin D may predispose patients to more sever tonsillar hypertrophy. More extended studies should be conducted in this regard.

Celiac disease is a chronic inflammation of small intestine which is caused by an increased permanent sensitivity to a protein named gluten. This protein is present in some cereals such as wheat, barley, and rye. The immunologic response to this protein can cause clinical symptoms in people with specific human leukocyte antigens (HLAs) (including HLADQ2 or HLADQ8). Most studies have reported an increased incidence of celiac disease in patients with diabetes mellitus type I. This study aimed to determine the prevalence of the celiac disease in patients with diabetes mellitus type I under the age of 18 years old.

This cross-sectional, analytic descriptive study was performed on forty children with diabetes mellitus type I in Sanandaj Diabetes Association (Kurdistan University of Medical Sciences), Iran, from September 2012 to September 2013. After obtaining consent from their parents, demographic data, including gender, age, family history of diabetes, duration of illness, symptoms of celiac disease, were recorded in the questionnaire. The measurement of the tissue transglutaminase (tTG) antibody and total immunoglobulin type A in the serum was necessary for the screening of celiac disease. Therefore in the laboratory, 5 ml of the venous blood sample was taken and then the serum levels of tTG antibody (from immunoglobulin type A) and total serum levels of this immunoglobulin were measured by the enzyme-linked immunosorbent assay (ELISA) method. Upper endoscopy with multiple biopsies from small intestine was performed in patients with positive serological screening. Finally, the disease was evaluated by histological finding.

Forty children with diabetes mellitus type I included 19 boys (47.5%) and 21 girls (52.5%) were enrolled in the study. The mean age of these patients was 10.53±4.05. The prevalence of celiac disease was 7.5% in these individuals. In the subjects, there was no significant relationship between gastrointestinal symptoms and celiac disease.

In the present study, the prevalence of the celiac disease in type 1 diabetic patients was 7.5% which is higher than the normal population.

Unnecessary patient admission to a hospital refers to the hospitalization of a patient without clinical indications and criteria. Various factors related to the patient (e.g., age, disease severity, payment method, and admission route and time), the physician and the hospital and its facilities and diagnostic technologies affect a patient unnecessary admission in a hospital. Unnecessary patient hospitalization increases nosocomial infections, morbidity and mortality, and decreases patient satisfaction and hospital productivity. This study aimed to measure unnecessary patient admissions in hospitals in Iran.

This study was conducted using a systematic review and meta-analysis at Tehran University of Medical Science in August 2019. Seven electronic databases were searched and evaluated for original research papers published between March 2006 and 2018 on patients’ unnecessary admission to a hospital. Finally, 12 articles were selected and analyzed using comprehensive meta-analysis software.

All studies used the appropriateness evaluation protocol (AEP) for assessing patients’ unnecessary hospitalization in the hospitals. Overall, 2.7% of hospital admissions were rated as inappropriate and unnecessary (CI 95%: 1.5-4.9%). The highest unnecessary patients’ admissions were 11.8% in a teaching hospital in Meshginshahr city in 2016, (CI 95%: 8.8%-15.8%) and the lowest unnecessary patients’ admissions was 0.3% in a teaching hospital in Yasuj city in 2016 (CI 95%: 0%-3.6%). Unnecessary patient admission in public hospitals was higher than private hospitals. A significant statistical correlation was observed between unnecessary patient admission, and sample size (P<0.05).

The rate of unnecessary hospital admission in Iran is low. However, hospital resources are wasted due to unnecessary admissions. Expanding the primary health care network, reducing hospital beds, introducing an effective and efficient patient referral system, using a fixed provider payment method, and promoting residential and social services care at macro level, and establishing utilization management committee, using the appropriateness evaluation protocol, establishing short-stay units, and implementing quality management strategies at the hospital level are useful strategies for reducing avoidable hospital admissions.

Hypoglycemia is a condition when blood glucose level is lower than 70 mg/dl in people without diabetes. The symptoms of hypoglycemia include tachycardia, sweating, pallor, pupillary dilatation. Hypoglycemia is a non-lethal and often preventable clinical problem in non-diabetic patients that can occur during fasting or after dining.

A 52 years old man referred to Shohada-e-Tajrish Hospital, Tehran, with diagnosis of kidney stones candidate for percutaneous nephrolithotomy (PCNL). The patient underwent general anesthesia and after 40 minutes, the surgeon requested injection of tranexamic acid because of bleeding, but unintentionally the patient received 100 unites of crystalline insulin by nurse anesthesia. Vital signs were stable, the patient's blood glucose was 85 mg/dl and he had no sweat. Then the therapeutic intervention consisted of administering a bolus dose of 50 cc 50% dextrose water (DW) and then infusion of 50% dextrose water over that time. The patient was monitored for 10 hours in recovery and also received 1 mg of glucagon. The blood glucose was checked frequently. Fortunately, there were not any detectable hypoglycemic attacks (blood glucose less than 70 mg/dl) during that time. Throughout the first three hours in ICU, he suffered from severe hypoglycemic episodes and treated by DW 50% (bolus stat and infusion) and after stabilization of vital signs he transferred to ward.

The mortality of iatrogenic hypoglycemia is lower than other causes of hypoglycemia. However, on time diagnosis and aggressive treatment can prevent serious complications. In addition, proper communication between health care providers and precise checking of drugs labels before injection can dramatically decrease these events.