احمدرضا سروش

Considering the increasing and alarming trend of overweight and obesity as well as its related complications, in this study, a comprehensive clinical guide for the medical care of patients with obesity was written based on the clinical recommendations of the American Endocrinology Association and the American College of Endocrinology, and it has been adjusted as much as possible based on the conditions in Iran.

A complete search was performed in the available databases without any restrictions with a specific strategy. Using the opinions of experts in this field, the best clinical guidelines were selected and obesity clinical guidelines were written for Iranian adults. Recommendations were given based on a detailed review of available clinical evidence and considering objective factors.

A total of 1788 references were used and in response to 9 clinical questions, 123 recommendations, including 160 special statements, were provided to determine a comprehensive medical care program for obesity. In this article, we discuss the prevention, screening, diagnosis, benefits and goals of obesity treatment. Questions 6 to 9 regarding obesity treatment steps and its individualization will be published in the next part of the article.

The detailed evidence-based questions and recommendations outlined in this study identify clinical considerations that facilitate decision-making in obese patients from screening and diagnosis to goals of treatment.

Nowadays, metabolomics studies are performed with different approaches to identify biomarkers, clarify the underlying mechanisms of diseases and achieve novel treatment strategies. In this context, gut microbiota-derived metabolites are known as one of the most important mediators of gut microbiota effects on human health and various diseases. Due to the inefficiency of conventional therapies in some cases, personalized medicine is of great clinical importance. Recent studies have shown that alterations in gut microbiota metabolites like short-chain fatty acids (SCFAs), amino acids, bile acid metabolites, and choline metabolites can link gut microbiota to numerous chronic non-communicable diseases including obesity, diabetes, inflammatory bowel diseases, psychological disorders, cardiovascular diseases and cancers. Understanding the composition of gut microbiota and the relationship between its derived-metabolites and the occurrence of various diseases is necessary to achieve new clinical applications. Furthermore, potential therapeutic agents such as prebiotic supplements and next-generation probiotics, dietary interventions, antibiotics, and fecal microbiota transplantation (FMT) could be among the leading strategies for personalized medicine in prognosis, diagnosis and treatment of various diseases, via modulating the diversity and composition of gut microbiota and its metabolites.

Personalized nutrition is a new approach in medical sciences that is based on genetic profile, individual needs, and environmental conditions considering health status and chronic diseases of every person. Studies have shown that genetic differences cannot solely justify various responses to medications and diets, and other important factors including gut microbiota are also involved. Human body hosts an active and dynamic ecosystem composed of a large number of microorganisms consisting of genes about ten times more than the human genome. Gut microbiota interacts with the human body through releasing metabolites such as short-chain fatty acids and secondary bile acids and fermentation products such as kynurenine, indoles and indole derivatives, tryptophan, serotonin, histamine, and dopamine. Body weight, metabolic rate, and health and diseases are formed as a result of these interactions.

Diabetes and obesity are among the most important metabolic disorders which are of worldwide concern. Today, it has been proven that the diversity and composition of the intestinal microbiota play a key role in the incidence and control of metabolic diseases via regulating the metabolism and immune responses of the host. Previous studies reported links between Akkermansia muciniphila, a commensal bacterium in the gut microbiota, and obesity and diabetes. Human and animal studies have shown that this mucin-degrading bacterium is effective in preventing obesity and diabetes by reducing intestinal wall permeability and preventing metabolic endotoxemia and inflammation, as well as modulating energy and fat metabolism. New evidence shows that both forms of the A. muciniphila (live bacterium or its pasteurized form) can control the disease. Considering the difficulties of the survival and cultivation of this anaerobic bacterium and in order to help optimal use of A. muciniphila in clinical treatments of metabolic diseases, in this study we compared the effect of live and pasteurized A. muciniphila. Besides, we investigated the effects of this bacterium as the next generation of probiotics on obesity and management of diabetes.

Increasing prevalence of obesity over the past few decades constitutes a global health challenge. Recent evidence suggests that gut microbiota may contribute to weight control. So, the present study aimed at comparing the frequency of different bacteria in gut microbiota between obese and normal weight people in Iran.

Thirty normal weight (BMI of 18.5- 25 kg/m²) and 27 obese adults (BMI of 30 kg/m² or higher) were included in this case-control study. Dietary intake was assessed using food frequency questionnaire (FFQ). Anthropometric measurements and collection of blood and faecal samples were also done. Then, gut microbiota composition was assessed using quantitative real-time PCR.

The mean age of participants and concentrations of fasting blood glucose and insulin, insulin resistance index, triglyceride concentration and hsCRP were higher in obese group than the normal group (P<0.05). The frequency of Akkermansia was significantly higher in individuals with normal weight than obese individuals (P=0.003). On the other hand, the frequencies of Prevotella and Lactobacillus genera were higher in obese individuals (P>0.05).

In this study, the frequencies of some bacterial genera of intestinal microbiota were significantly different between obese and normal weight individuals. Therefore, population-based studies are needed to confirm current findings. Moreover, in order to achieve personalized medicine goals, information on gut microbiota composition could be helpful.

Cognitive disorders are one of the major public health issues in older population worldwide. Problems in forming and storing new memories, short-term memory impairment, and other cognitive problems are common symptoms of cognitive disorders that have no definite treatment yet. Recent studies have shown an association between gut microbiota and cognitive impairments described as microbiota-gut-brain axis. It seems that gut microbiota is able to influence behavior, brain system, and cognitive functions through this pathway in old age. In this review, the underlying mechanisms of the effect of gut microbiota on cognitive disorders and the role of dietetic intervention with probiotics in cognitive function are discussed.

The anti-personnel landmine is a type of warfare placed beneath the soil designed to explode when one walks on it causing disabling injury or death of one or more people. This dreaded weapon can damage the civilian population long after evacuating the conflict zone; taking a huge human and economic toll. Landmines and cluster munitions have been widely used in the world, since World War II. In addition to conventional and widespread use in military conflicts, a significant proportion of the world's population lives in areas infested with mines, cluster munitions, ammunition and explosive remnants of war and are prone to explosive risks. Knowledge of the mechanisms of anti-personnel mines is essential for rescuers and other personnel.

This study assessed the causes of infection in cholecystectomy and compared the infection rates between the open and laparoscopic cholecystectomy.
This was a retrospective cohort study, performed on all patients admitted to Shariati Hospital since February 2017 for cholecystectomy. Initially, the patients were evaluated for infection risk factors, and then surgical site infection rates in these individuals were measured. Infection was assessed at the time of patients discharge (in the first few days after surgery) and again a month later, either in clinic or by phone. Information from 81 patients was collected, and SPSS software version 24 was used to analyse the data using appropriate statistical tests. Statistical significance was defined as p value The mean age of the participants was 45.89 ± 13.38. The relationship between surgical site infections (SSI) and age, sex, comorbidities (diabetes, hypertension, ischemic heart disease, malignancy, chronic lung disease, and chronic kidney disease), taking corticosteroids, smoking, and the emergency or elective nature of the surgery was not significant. The mean age of the patients who underwent open cholecystectomy was higher than the laparoscopic group (p = 0.005). Similarly, the average hospitalization period for those underwent open cholecystectomy was higher (p = 0.03). Finally, the infection rates for open cholecystectomy were 6 times higher than laparoscopic surgeries (RR: 6.11).
There was no significant relationship between SSIs and the risk factors assessed in this study. However, infection rates were higher in the open cholecystectomy group. More studies on the various risk factors of infection and the differences between the laparoscopic and open surgical methods are required.

In recent years, a new manner has been common practice in emergency departments (EDs) of governmental hospitals in Iran, in which, of course illegally, patients are encouraged to self-discharge or refer to other EDs. This is done by giving incomplete or even false information and deceiving patients. The purpose of this study is to identify the underlying causes from the point of view of ED's personnel to clarify the root of this burden for authorities and pave the way for more studies.This is a cross-sectional descriptive-analytic study, gathering opinions via questionnaire and/or direct interview with open-ended questions. During November and December 2009, hospital managers, hospital heads, faculty members, residents in specialties involved with the ED, interns, ED nurses, and nurse supervisors were interviewed regarding the frequency of such instances in their hospital, the main violators, and its possible causes and determinants.In this study 114 persons from different groups took part. From participants’ point of view, the main violators in EDs are junior residents and interns; 48 (42.1%) participants pointed to junior residents and 29 (25.4%) participants found interns responsible. The estimated number of patients which were refused during a week was stated as 18.1 ± 15.6 (range between 0 to 90). Among participants remarks, the most important factors which lead staff to non-admission were high work load, overcrowding of EDs, lack of facilities, lack of any motivation or incentive for doing tough tasks, inappropriate patient transfer by city emergency system, bad policies and rules, lack of sufficient supervision from deputies, and improper work sharing between different levels.Patient non-admission and diversion through deception is a common practice among EDs of educational hospitals in Tehran. High work load and overcrowding of these centers should be considered a high priority target for interventions. Further studies are highly suggested to find appropriate solutions. In future studies, junior residents and interns should be considered as main target groups.

Introduction & Splenectomy is among the operations that are performed laparoscopically nowadays. One of the challengaes in this surgery is hilar vessels ligation. It is especially critical about the spleen which is prone to hemorrhage and its resection is based on hilar vessels ligation. Ligasure which ligates the vessels with bipolar electrical activity seems simple, effective and safe. The purpose of the current study was to evaluate the function and safety of ligasure in performing laparoscopic splenectomy and its possible complications. This was a descriptive study to assess safety and weakness of Ligasure in laparoscopic splenectomy. The study carried out on patients with idiopathic thrombocytopenic purpura (ITP) who needed splenectomy in Shariati hospital. During the study period, 35 patients with ITP underwent laparoscopic splenectomy with Ligasure vessel sealing system. We assessed surgery duration, intraoperative and postoperative bleeding, decrease in hemoglobin due to surgery, need to blood transfusion during or after surgery, and need to conversion to open surgery as well as post operative complications and hospital stay. 35 patients were included in this study, with the mean age of 31.5±9.2 years. 25 patients were male and 10 were female. Mean operative time was 132±40 minutes. Intraoperative bleeding volume was 145±103 ml. Decrease of hemoglobin level due to surgery was 1.8±1.1dL. Postoperative hospital stay was 3.8±1.4 days. None of the cases converted to open surgery. Intraoperative or postoperative blood transfusion was required for three patients. The amount of bleeding from abdominal drain was 104±90 cc. According to the result of our study, ligating hilar vessels of spleen with ligasure in patients with ITP is safe in laparoscopic surgery which results in appropriate hemostasis without major bleeding during or after operation. Thus, this method is recommended in the case of laparoscopic splenectomy of patients without splenomegaly, such as idiopathic thrombocytopenic purpura.

Introduction & Pain control is one of the main issues in laparoscopic surgeries. Although opioid and non-steroidal anti-inflammatory drugs (NSAIDS) are used for pain control but there are severe side effects, but it is thought that, new generation of NSAIDS are able to control pain without any significant side effects of narcotics. We compared postoperative pain, analgesic administration, duration of hospital stay, and side effect of surgeries such as vomiting. From September 2008 to March 2009, we enrolled 75 laparoscopic cholecystectomy patients in a randomized clinical trial study. The patients were randomly divided into two groups. In intervention group, 200 mg for celecoxib administered one hour before surgery and then 200 mg each 12 hours, for two days after surgery. Placebo was administered in the control group. Then severity of pain was measured by visual analogue score (VAS) every six hours during 48 hours. Opioid consumption, duration of hospital stay, antiemetic usage, and other complications of surgery (such as nausea and vomiting) were recorded. Statistical analysis was performed with SPSS version 16.0. Data were reported as means and SD. Data with normal distribution was tested with independent t-test. Qualitative data was analyzed with chi-square. Means of pain intensity were analyzed with repeated measures anova. P

Introduction & Pain control after surgery is one of the important issues in postoperative care. Pain alleviation leads to patient satisfaction, faster recovery, and improvement in the function of cardiovascular, respiratory, and gastrointestinal systems. Pain control with anesthetic substances administration in the wound through catheter, is one of the methods which is under study. In this study we assessed Bupivacaine administration in the wound through catheter between and over rectus fascia after midline laparotomy. In this study, after informed consent, the patients were divided into three groups. In one group, a catheter was placed between fascias of each rectus muscle. In other groups two catheters ware placed over fascia, after fascia repair. In first two groups, 5cc Bupivacaine 0.25% was administered through each catheter. In third group, normal saline was used and when patients suffered server pain, 50mg pethidine was administered. Pain score was assessed by visual analogue score and narcotic use and post-operative recovery were compared in the three groups. For statistical analysis, the proportions were compared using chi square test. The continuous variables were compared with ANOVA test followed by Dunnett post-test for significance. All 90 patients under study were similar according to age, gender, incision length, literacy level, and cooperativeness. Pain scores in three groups were different (P < 0.0001) and pain was less in patients with catheter in their wounds. Dose of pethedine administration in patients with catheters between rectus fascias, over fascias, and the control group were 250±97.3, 293.2±135.7, and 357±116.6 milligrams respectively (P=0.01). Time of return of bowel sound and gas passage, and hospital stay after surgery were longer in the central group than the other two groups significantly. No wound complication was seen in patients with catheter. There was no significant difference between the two groups with catheters. Bupivacaine administration with catheter in surgical wound after midline laparotomy can reduce pain. This method can reduce period of ileus and hospital stay without major complications. Inserting Bupivacaine catheter between rectus muscle fascias was not significantly beneficial and needs more studies.

Introduction & Colorectal carcinoma is one of the most prevalent cancers. Early diagnosis and diagnosis in primary stages are important in patient’s prognosis. In this study we evaluated factors such as age, sex, stage and tumor location in colorectal patients in five year peroid. From the cancer database of a single referral institution, Shariati Hospital 109 patients who had resection of colorectal cancer from 1999 to 2002 were identified. Cases with recurrent colon cancer or previous history of neoadjuvant chemotherapy were excluded. Survival curves were constructed using the kaplan-meier method. The factors that were used included: age, sex, TNM stage, T-status, nodal status, distant metastasis, grade, lymphatic and vascular invasion, tumor location, preoperative CEA level and liver function tests. Multivariate analysis of factors was conducted using cox-regression analysis. The mean survival time for all patients was 42.8±2.8) months. The overall 1, 3, 5 year survival rates were 72%, 54%, 47% respectively. The single variable analysis, patients age (P

Introduction & Bilateral neck exploration is the good standard for parathyroid adenoma localization in primary hyperparathyroidism. But not all of surgeon have the necessary experience for accurate surgical exploration. But there are new methods for surgery like unilateral exploration and minimally invasive surgery. Thus, preoperative localization could reduce time and stress of surgery. In a prospective study 80 patients with documented primary hyperparathyroidism through raised serum calcium and parathyroid hormone (PTH), the results of sonographic localization were compared with the findings of surgery and 99mTechnetium sestamibi scintigraphy. Also variables such as preoperative serum calcium, PTH level and adenoma weight were compared between patients whom adenoma had been localized or not localized through sonography or Sestamibi scan with student’s t-test. In a prospective diagnostic tests accuracy study, 80 patients with primary hyperparathyroidism enrolled. Sonography detected enlarged parathyroid glands in 61 of 80 patients (76.3%), with sensitivity of 83.5% and positive predictive value (PPV) of 89.7%. Sestamibi scintigraphy detected adenoma in 63 patients (78.8%) with sensitivity of 85% and PPV of 91.3%. There was no significant deference between sonography and scintigraphy in localization of adenomas. When both sonography and scintigraphy were used for localization, they located 73 adenomas (91.3%), with sensitivity of 97.3% and PPV of 93.5%. Sonography is an accurate method for localization of enlarged parathyroid glands in primary hyperparathyroidism, and overall it is comparable with sestamibi scintigraphy. This study suggests a strategy of initial testing with one or the other method, followed by the alternate imaging test if the first test gives negative result.

General surgery residents are in chronic partial sleep deprivation during their training years at hospital. Chronic sleep deprivation adversely affects their mood, behavior, social relationship, learning ability, decision making, and patient care. Adverse effects of sleep deprivation on carefulness and precision, promptitude, hand skills, and dexterity of surgeons have been shown in different studies. The aim of present study was to estimate the degree of sleepiness among general surgery residents and obtaining their views about consequences of sleep deprivation and fatigue. This cross sectional study was performed on general surgery residents in Sina, Imam Khomeini, and Shariati Hospitals in Tehran, using a 38-item quantitative structured questionnaire. Epworth Sleepiness Scale (ESS) was used for assessment of sleepiness degree. Forty eight general surgery residents were entered to the study. Average weekly work hours were 140-160 for first and second year residents and 100-120 for third and fourth year residents. Mean ESS score was 11.6 ± 0.69 (range, 3-21), which indicated moderate sleepiness. Twenty percent of residents were in the severe range of sleepiness. From the studied residents, 52.1% believed that sleep deprivation and fatigue had a major impact on their personal life, and 31.3% of them believed these factors had major impact on their work. Extended work hours, sleep deprivation, and fatigue lead to sleepiness of general surgery residents and this problem adversely affects their quality of life and performance. Based on the results of this study, revision and modification of general surgery resident's work hours are suggested.

Introduction & Laparoscopic cholecystectomy is the safe and gold standard treatment in most patients with gallbladder diseases worldwide. Routine drain placement after laparoscopic cholecystectomy is controversy and most surgeons use it to prevent collection of blood, bile or pus. But drains can cause pain, infection, more prominent scar and delay in discharge of patients. This study assessed drain efficacy in laparoscopic cholecystectomy by assessment of volume and contents of drained fluid, and its advantages and disadvantages. This study was performed on 92 patients in Dr. Shariati hospital during 2007-8 underwent urgent or elective laparoscopic cholecystectomy. Demographic characteristics of patients, indication of surgery, duration of surgery and postoperative pain and events were collected. Value and content of drained fluid, and postoperative hospital stay were recorded and analyzed. Drains were fixed in 59 (64.1%) patients and 33 (35.9%) patients did not have drain. Mean drained fluid was 40.4 ± 28.4 milliliters (range: 10-300 cc). Fluid was serous or serosanguineous in all cases, no fresh blood or bile in any case. In most cases (90%) fluid volume was less than 100 cc. None of the patients without drains suffered abdominal collection, percutaneous drainage or repeated surgery. Pain was more in patients with drains. Using visual analogue score (0-10), pain was scored 1.5±1.2 in patient without drain and 2.2±1 in patients with drain, 12 hours after surgery (P-value=0.018). Mean postoperative hospital stay was 1.3±0.5 days in patients without drain and 1.8± 0.6 days in the other group ((P-value<0.0001). It seems that drains in laparoscopic cholecystectomy evacuate little insignificant fluid. Drain placement can cause more pain, longer admission period and more cost. It is recommended not to place drains were not necessary cases. Reducing use of drains through correct clinical judgment can decreases its disadvantages such as pain, infection, patient anxiety, longer admission period and costs.

Introduction & In pervious studies it has been shown that gum chewing after elective GI tract operation may stimulate bowel motility and decrease duration of postoperative ileus. The aim of the present study was to assess the effects of sugar free gum chewing after upper GI tract on operation postoperative ileus. In a randomized clinical trial, 50 patients, who were scheduled for elective upper GI surgeries were randomly allocated to 2 groups of gum-chewing group (n=26) and control group (n=24) postoperatively. The patients in the gum-chewing group chewed postoperatively sugar free gum 3 times daily for 1 hour each time until discharge. Patient's demographic characteristics, surgery duration, time to first flatus, time to first bowel movement, and complications were compared. All gum-chewing patients tolerated the gum. The first passage of flatus (72.23±25.52 vs. 92.79±27.35 hours) and time to first bowel movement (95.58±25.88 vs. 110.83±26.18 hours) were significantly lower in the gum-chewing group compared with control group. Gum chewing speeds recovery after the upper GI tract operation. Gum chewing is an inexpensive and helpful care in the upper GI tract postoperative period.

One of the routine methods for diagnosis and treatment of cholelithiasis is endoscopic retrograde cholangiopancreatography. It is an effectivemethod but is associated with some complications (9.8%) which the most common is pancreatitis (5.4%). One of the rare complications is basketimpaction in the common bile duct which is treated with different methods. A 58 years male history of laparoscopic cholecystectomy was referred for endoscopic retrograde cholangiopancreatography. During the extraction of stones, the basket was impacted and the distal part was dissociated from the proximal part. Stent was placed in the common bileduct and with laparatomy and choleducotomy, bascket with stent and remained stone were extracted and choleducoduodenostomy was done.There are several suggested methods for basket removal; as stenting to relieve the obstruction and possibly allow for spontaneous passage of theimpacted stone and basket, endoscopic lithotripsy by percutaneous transhepatic approach, extracorporeal shockwaves to fragment an ampullary impaction, laparoscopic exploration, stone dissolution andsurgical intervention. Treatment must be tailored to the patient's clinical situation and condition, and the modalities that are accessible.