فهرست مطالب mostafa alavi moghaddam

According to the increasing trend of antibiotic consumption all over the world, a rising concern is the emergence of resistant pathogens due to the inappropriate use of antibiotics, which increases the risk of treatment failure and mortality. Antibiotic Order Form (AOF) is an antimicrobial stewardship program protocol recommended to improve rational antibiotic use. We aimed to compare the antibiotic consumption rate, i.e., vancomycin and carbapenems, before and after preprinted AOFs were implemented. This study also evaluated physicians' compliance with AOFs as a secondary outcome. This prospective descriptive study was conducted from July to December 2015 in a 570-bed teaching hospital in Tehran, Iran. AOF includes demographics, microbiological, and clinical data on infection designed for vancomycin and carbapenems, including imipenem and meropenem. Prescribers were asked to fill out predesigned forms after prescribing the selected antibiotics and deliver them to the pharmacy on July 1, 2015. Collected data during this 6-month study period were compared with the same period times years 2011 to 2016 (4 years before and one year after implementation of AOF) to determine the effect of AOFs on the selected antibiotics consumption that had been calculated based on Daily Doses per 100-patients day (DDD/100-bed days). This study showed that although vancomycin had an increasing trend from 2011 to 2014, implementing the AOF program could stop this trend in 2015. vancomycin consumption significantly decreased compared to the previous year (P = 0.039). This effect of the program was not the same on the use rate of carbapenems, and their use was increased nonsignificantly in 2015 (P = 0.606). The acceptance of prescribers in filling out the forms for vancomycin increased from 5.12% in the first month to 57.75% in December. This increase was from 4.20% to 37.26% for carbapenems. According to the increasing trend of antibiotic consumption in hospitals, we recommend improving utilization surveillance of antibiotics by choosing an appropriate antibiotic, optimal dosing, and desired duration of treatment that are important in decreasing the risk of developing resistant microorganisms due to misuse. The forms are much more effective when accompanied by the acceptance of prescribers.

Various treatment protocols have been recommended since the beginning of the COVID-19 pandemic and have gradually evolved. This study aimed to assess the effectiveness and safety of incentive spirometer exercise (ISE) in outcomes of hospitalized patients with moderate-to-severe COVID-19 pneumonia.

A 3-month single-blind, two parallel-armed randomized controlled trial was conducted at Imam Hossein Hospital, Tehran, Iran. Participants aged >18 years with documented COVID-19 pneumonia were randomly allocated to 2 groups of IS (ISE in addition to the usual treatment) and control (usual care alone). The IS group was also asked to perform ISE after discharge for three months. The primary outcomes were peripheral O2 saturation (SpO2), VBG parameters (pCO2, PH, HCO3), dyspnea level measured by Modified Borg Scale (MBS), length of hospital stay (LOS), and respiratory rate (RR). Secondary outcomes included mortality rate, intubation rate (IR), and ICU admission rate.

A total of 160 eligible patients were randomly assigned to either the IS (n = 80) or control (n=80) groups. Although there were no significant differences in primary and secondary outcomes between the groups post-intervention, adjusted analysis showed that participants allocated to the IS group had significantly higher SpO2 levels and lower RR, MBS levels, and LOS. Also, the adjusted model analysis showed a marginal statistically significant difference between groups in secondary outcomes, such as IR, the 1-month mortality rate, and the 3-month mortality rate.

It seems that adding the ISE to usual care in the early treatment setting of COVID-19 patients resulted in a relatively significant increase in SpO2 levels, improved respiratory status, and marginally decreased LOS. Additionally, ISE minimally reduced ICU admissions and intubation rates, with no significant impact on in-hospital or long-term mortality in patients with COVID-19 pneumonia.

The disposition decision is a great challenge for clinicians in managing patients with chronic obstructivepulmonary disease (COPD) exacerbation. This study aimed to evaluate the accuracy of Ottawa COPD Risk Scale (OCRS)in predicting the short-term adverse events in the mentioned patients.

This prospective diagnostic accuracystudy was conducted on COPD exacerbation cases who were referred to the emergency department (ED). Patients werefollowed up for 30 consecutive days for adverse events including the need for intubation, non-invasive ventilation, my-ocardial infarction, readmission, and death from any cause, and finally the accuracy of OCRS in predicting the outcomewas evaluated.

362 patients with the mean age of 65.55 ± 10.65 (6- 95) years were evaluated (58.0% male).Among the patients, 164 (45.3%) cases were discharged from ED, and 198 (54.7%) were admitted to the hospital. 136(37.6%) cases experienced at least one of the studied short-term adverse events. The mean OCSD score of this series was1.96 ± 2.39 (0 – 10). The area under the curve of OCRS in predicting the outcome of COPD patients was 0.814 (95%CI:0.766 – 0.862). The best cut-off point of the scale in predicting the outcome was 1.5. The sensitivity and specificity ofthe scale were 75.75% (95%CI: 69.6% – 81.42%) and 89.63% (95%CI: 83.67% – 93.66%), respectively. By employing thisthreshold, 48 (13.25%) cases would have unnecessary hospitalization, and 17 (0.04%) would be discharged incorrectly.

The OCRS has acceptable level of prediction accuracy in predicting the short-term adverse event of COPDpatients. The use of this scoring in the routine practice of ED clinicians can lead to a reduction in unnecessary admis-sions and unsafe discharge for these patients.

 Despite the worldwide spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an effective specific antiviral treatment for coronavirus disease of 2019 (COVID-19) is yet to be identified .We did this study to investigate the safety and efficacy of sofosbuvir as antiviral therapy among hospitalized adult patients with SARS-CoV-2. 

 Patients were randomized into intervention arm receiving sofosbuvir or comparison arm receiving usual antiviral agents in addition to standard of care. The primary end point of the study was clinical recovery as defined by normal body temperature and normal oxygen saturation. The main secondary outcome was all-cause mortality during the admission in hospital or within 14 days after discharge if applicable. Reports of severe adverse events were observed in the intervention arm. 

 Fifty-seven patients enrolled into either the clinical trial arm (n=27) or the comparison arm (n=30). Primary outcome was achieved by 24 (88.9%) and 10 (33.3%) in the intervention and comparison arms, respectively. Median hospital length of stay was significantly shorter in the intervention arm (10 days [IQR: 5-12] vs. 11.5 days [IQR: 8.5-17.75], P = 0.016). All-cause mortality was two and thirteen in intervention and comparison groups, respectively. No serious adverse events were reported by the patients receiving sofosbuvir during the study. 

 Among patients hospitalized with SARS-CoV-2, those who received sofosbuvir had more clinical recovery rate and had a shorter hospital length of stay than those who received usual antiviral agents in the study and these differences were statistically significant.

SARS-CoV-2, the pathogen responsible for COVID-19, has infected hundreds of millions since its emergence in late December 2019. Recently, concern has been raised due to the increased prevalence of co-infections with opportunistic pathogens among these patients. Though not common, co-infections may be associated with adverse outcomes and increased risk of morbidity and mortality among patients suffering from COVID-19. Cytomegalovirus (CMV) infection is a serious problem among immunocompromised and critically ill patients. So far, few cases of co-infection with COVID-19 and CMV have been reported. Here, we report the co-infection with COVID-19 and CMV in a young woman presenting with sudden, progressive fever, delusion, agitation, bizarre behavior, seizure, and loss of consciousness leading to death despite receiving appropriate anti-viral treatment. To the best of our knowledge, this is the first case of coexisting SARS-CoV-2 and CMV infection presenting with severe, progressive meningoencephalitis in the era of COVID-19.

On 31 December 2019, Chinese authorities reported the increase in incidence of severe pneumonia in Wuhan city, Hubei province of China. One week later, on January 7th, they confirmed that they had identified a new coronavirus, which is a family of microRNA respiratory viruses including the common cold, and viruses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). This new virus was temporarily named “2019-nCoVâ€. Wuhan city is a major international transport hub. This report to World Health Organization (WHO), raised global public health concern because this is the third coronavirus –associated acute respiratory illness outbreak.

Multiple trauma may cause major bleeding will result in adverse clinical outcomes in the absence of proper and on time initial management in emergency department. In the present study, we aimed to synthesis the critical appraised evidences for initial management of patients with multiple trauma and major bleeding in emergency department.

This was a systematic review study. Following formulating of PICOs for clinical questions in the study, Search strategy selected to gather related evidences in Google scholar, Pubmed, Cochrane, and Trip database in English language from original articles, between 2008 to 2018.The key words were “Multiple trauma, hemorrhage, emergency treatment, therapy”. The Prisma flowchart was used to check the quality of evidences. The strength of evidences reported according to Oxford classification.

Out of 502 articles, 44 original articles were selected for final evaluation based on the search strategy criteria. Results indicated the favorable effects and safety of permissive hypotension resuscitation, using tourniquet, applying early blood transfusion, prescription of transamine, fibrinogen and factor VII on clinical outcomes of patients with multiple trauma and major bleeding in the emergency room.

Based on the study, applying permissive hypotension resuscitation, tourniquet, early blood transfusion, prescription of transamines fibrinogen and factor VII in special patients with multiple trauma and major bleeding in emergency department are recommended.

Drug interactions, as one of the most important subsets of medication errors, can lead to adverse reactions in patients. Considering the increase in drug interactions and their consequences, this study aimed to evaluate the frequency and pattern of drug interactions in patients admitted to the emergency department of a university affiliatedhospital.

This was a cross-sectional study. The study population consisted of patients referring to the Emergency Department of Imam Hossein Hospital from Aprilto the end of September 2018. 552 patients hospitalized in the emergency department of Imam Hossein Hospital were selected via random sampling and the rate of drug interactions reported in their medical profile was evaluated.

The mean age of these patients was 58.51 ± 20.05 years. Sex distribution evaluation showed that 54.4% were male. Based on the number of patients-days recorded, 34.2% had no drug interactions. The total number of interactions recorded was 1139, the highest number of which belonged to group C and the lowest number belonged to group X and A. 50% of people experienced two or less drug interactions and 75% of people experienced 4 or less drug interactions. Mean hospitalization days were 7.63 ± 6.15 days. Finally, 90.8% of patients recovered and 9.2% died.

Based on the findings of the present study, only 34.2% of the patients had no drug interactions. The total number of interactions recorded was 1139, the highest number of which belonged to group C and the lowest number belonged to group X and A. There was a significant correlation between the number of administered drugswith duration of hospitalization, final outcome and the probability of drug interactions. In addition, there was a significant correlation between type D and X drug interactions with mortality rate in patients.

Despite the considerable advances in medical diagnosis and treatment, treatment staff errors show an increasing trend, which can lead to decline in people’s trust and rise in stress and anxiety among patients. The present study was performed with the aim of assessing the causes of diagnostic errors leading to complaints from emergency medicine specialists from 2012 to 2017.

In the present cross-sectional study,100 files that were referred to the forensic medicine unit were evaluated. The data gathering tool was a researcher-made checklist, using which the demographic data of the patients and the type of error were extracted from the patients’ profiles. Data were coded and entered to SPSS software, version 20, after gathering and then reported using descriptive statistics.

In this study, the medical profiles of 100 patients who had filed complaints due to medical errors, in which a medical error was confirmed, were evaluated. In terms of sex distribution, 67% of the patients were male and 50% of the individuals were in the 30 –59 years age range. 32% of the errors were due to the physician not ordering laboratory tests, 37% were due to errors in examination, and 31 were due to errors in interpretation of the test results. In the level ofdiagnostic error and ordering diagnostic tests, the most important cause of error was that the physician did not believe testing was necessary for diagnosis. In the stage of examination and history taking also incomplete physical examination by the physician was the most important cause of error.Among the most important factors affecting medicalerror incidence in the studied files, judgment with 58%, changing shifts without providing information about the patients with 45%, workload with 38%, and the patient not cooperating with 29% were the most important cognitive, communicative, systemic, and patient-related factors, respectively.

Error in judgment regarding need for ordering diagnostic tests or further imaging, error in shift handover and not providing information regarding the patients for the next shift, overcrowding and heavy workload in the emergency department, and patients not cooperating were among the most important underlying factors in incidence of errors in the emergency department

Appropriate management of abnormal admission blood glucose level (ABGL) in acute coronary syndrome (ACS) patients still remains a common issue. This study aims to assess the influence of ABGL on development of 30-day major adverse cardiac events (MACEs) in patients with suspected ACS. This is a prospective cohort study based on analysis of data collected from patients suspected to acute coronary syndrome admitted to emergency department. ABGL of patients was measured and its association with development of MACEs (MI, CVA, mortality) within 30 days of follow-up was studied. 814 participants with the mean age of 61.8 ± 13.4 years were studied (58.1% male). MACE endpoints were developed in 166 (39.0%) hyperglycemic, 30 (46.9%) hypoglycemic, and 53 (16.4%) normoglycemic patients (p<0.001). Mean admission blood glucose level of patients who developed MACE within 30 days was significantly higher than others (210.6 ± 123.4 vs 157.4 ± 86.6mg/dL; p<0.001; OR: 1.006 (1.005 to 1.008)). There was a significant correlation between male gender (p=0.027), abnormal admission blood glucose level (p<0.001), diabetes (p = 0.001), hyoerlipidemia (p=0.059), prior CABG (p=0.008), first and second blood troponin levels (p<0.001), first and second abnormal ECGs (p<0.001), and also ECG changes (p<0.001) with developing MACE. Abnormal ABGL, first and second blood troponin levels, and the history of diabetes were among independent risk factors of developing MACE within 30 days. It seems that abnormal admission blood glucose level in suspected ACS patients was an independent predictor of major adverse cardiac events within 30 days.

Based on the protocol of American Heart Association (AHA), target temperature of 32°C to 36°C for at least 24 hours should be provided, continuously, for all cases of spontaneous return of blood flow following successful cardiopulmonary resuscitation (CPR) in adult patients with evident altered level of consciousness. Therefore, the present study was done to evaluate the obstacles and assess the possibility of performing this protocol for patients in emergency department. This study was a qualitative research that consisted of 2 phases. In the first phase, by meeting the specialists involved with these patients, a standard questionnaire was filled regarding the obstacles to performing this protocol from their viewpoint. In the second phase, hypothermia protocol was done on a sample of eligible patients in emergency department. The aim of this phase was to find the problems of doing this protocol in real practice. The findings were reported using descriptive statistics. A total of 100 questionnaires were filled. Lack of experience or needing more information with 58%, limited facilities and equipment with 46% and lack of a national protocol with 24%, respectively, were the most important obstacles from the specialists’ point of view. In addition, losing golden time (57.14%), the in charge attend not giving permission (28.57%), and the relatives not giving consent (14.28%) were among the most important obstacles in the executive phase. Based on the findings of the present study, it seems that training the physicians involved with these patients regarding induction of hypothermia with the primary equipment present in emergency departments, writing inter-department protocols and preparing national protocols in this regard can help in spreading this treatment method.

Evidence-based practice the clinical decision-making process which integrates the best evidence of research with patients’ values and opinions of clinical professionals. The faculty members are the most important decision-makers in clinical, medical, and therapeutic centers, and play a significant role in the use of evidence-based medical concepts in daily activities, decision making and information transfer to residents. The purpose of this study was to evaluate the knowledge, attitudes,behaviour and decisions/outcomes of faculty members in the Surgical and Non Surgical wards of Imam Hossein Hospital, based on the evidence based practice adjusted tool (KABQ) in 2016.
This is a cross-sectional descriptive study using the convenient sampling method among 66 faculty members in the Surgical and Non Surgical departments of Imam Hossein Hospital in Tehran. Anadjusted evidence based practice questionnaire(KABQ) was used after the approval of its original designer (Dr. Johnston) and checking its reliability by calculating the Cronbach’s alpha coefficient to be 0.85. SPSS software version 23 was used for data analysis. The variables were analyzed using descriptive statistics and T-test. The statistical significance of all tests was considered at P It was found that 93.9% of the subjects believed in their ability to use evidence-based practice. A total of 97% of them made 62.22% of their decisions based on clinical research evidence. The Surgical and Non Surgical groups believed in the effectiveness of evidence-based practice in the proposed treatments with a mean of 5.48 and 6.16, respectively. However, unlike the Non Surgical group, the Surgical group believed that there was similar validity for clinical trialsand observational methods to prove the effictiveness of the treatment. It was necessary for the Surgical and Non Surgical groups to search for clinical evidences 5.76 and 10.16 times a week, respectively. Over 90% of them found clinical evidences through textbook once a week, through the original research papers every 12 days, every 24 days through the Cochrane database, and almost every 28 days through secondary research resources. The Surgical and Non Surgical groups were referred to the evidence 1.95 and 3.27 hours per week, before, or during treatment. They spent 3.47 and 4.97 hours per week searching for evidence, and 4.23 and 7.16 hours per week reading new research evidences, respectively. Over 92% of them considered the use of evidence-based practice because they believed it improved the outcomes for patients.
The results of this study showed that both the Surgical and Non Surgical faculty members of Imam Hossein Medical Center (Shahid Beheshti University of Medical Sciences) had good knowledge about evidence-based practice and had a positive attitude toward its medical effect, but they are less likely to use this approach. Thus, to enhance the skills of faculty professionals and adapt their decisions to the best available evidence, a collaborative action plan is required.

Evaluation of students’ learning in clinical education system is one of the most important and challenging issues that facilities in this field have been facing. The present study aimed to evaluate the role of feedback during evaluation in increasing emergency medicine residents’ clinical skills.

The present experimental study was performed on all second year emergency medicine residents of two educational hospitals, Tehran, Iran, with switching replications design and before-after method. They were randomly divided to two groups (with or without feedback) and evaluated three times regarding chest ultrasonography for trauma patients, using direct observation of procedural skills (DOPS) and valid and reliable checklist. Data were analyzed using SPSS 20.

30 emergency medicine residents with the mean age of 36.63 § 30.30 years were devided to two equal groups (56.7% male). Studied groups were similar regarding the baseline characteristics. In both groups, obtained scores showed a significant increase from the first to the third evaluation (p < 0.001). Mean scores of first and second evaluations were 10.24 § 0.77, 17.73 § 0.46 in feedback receivers and 9.73 § 0.77 and 12.13 § 0.47 in others (p < 0.001). Mean third evaluation scores after switching replication were 18.53 § 0.22 in feedback receivers and 18.99 § 0.22 in others (p = 0.213).

Based on the findings of the present study, giving feedback after evaluating the second year emergency medicine residents regarding chest ultrasonography for trauma patients, led to a significant improvement in their scores in future evaluations and consequently their skill.

Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans’ lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines.

This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21.

30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 § 1.78 (IQR = 2) in pre education and 8.17 § 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressuremeasurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically.

The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flowO2 deliverywere disappointingly low. It seems trainingworkshops and implementation of Clinical audit can improve residents’ adherence to current standard guidelines regarding severe sepsis and septic shock.

In cases with potential diagnosis of ischemic chest pain, screening high risk patients for adverse outcomes would be very helpful. The present studywas designed aiming to determine the diagnostic accuracy of thrombolysis in myocardial infarction (TIMI) score in Patients with potential diagnosis of ischemic chest pain.

This diagnostic accuracy study was designed to evaluate the screening performance characteristics of TIMI score in predicting 30-day outcomes of mortality, myocardial infarction (MI), and need for revascularization in patients presenting to ED with complaint of typical chest pain and diagnosis of unstable angina or Non-ST elevationMI.

901 patients with the mean age of 58.17 § 15.00 years (19-90) were studied (52.9% male). Mean TIMI score of the studied patients was 0.97 § 0.93 (0-5) and the highest frequency of the score belonged to 0 to 2 with 37.2%, 35.3%, and 21.4%, respectively. In total, 170 (18.8%) patients experienced the outcomes evaluated in this study. Total sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of TIMI score were 20 (95% CI: 17 - 24), 99 (95% CI: 97 - 100), 98 (95% CI: 93 - 100), 42 (95% CI: 39 - 46), 58 (95% CI: 14 - 229), and 1.3 (95% CI: 1.2 - 1.4), respectively. Area under the ROC curve of this system for prediction of 30-day mortality, MI, and need for revascularization were 0.51 (95% CI: 0.47 - 0.55), 0.58 (95% CI: 0.54 - 0.62) and 0.56 (95% CI: 0.52 - 0.60), respectively.

Based on the findings of the present study, it seems that TIMI score has a high specificity in predicting 30-day adverse outcomes of mortality, MI, and need for revascularization following acute coronary syndrome. However, since its sensitivity, negative predictive value, and negative likelihood ratio are low, it cannot be used as a proper screening tool for ruling out low risk patients in ED.

The significant role of vitamin D in bacterial infections through induction of cathelicidin, as an antimicrobial protein, has been clearly addressed in the literature. Previous studies have demonstrated that women taking vitamin D supplements are more likely to produce cathelicidin, compared to the controls. Vitamin D could play a protective role against asymptomatic bacteriuria and urinary tract infections.
The aim of this study was to evaluate the association between serum vitamin D level and asymptomatic bacteriuria in pre- and postmenopausal women.
This case-control study was performed during 6 years (2011 - 2016) in Tehran, Iran. A total of 65 pre- and postmenopausal women with asymptomatic bacteriuria were enrolled in the study. The serum level of vitamin D was measured in cases with asymptomatic bacteriuria and compared with 65 age-matched women with no asymptomatic bacteriuria (control group).
The serum level of 25-hydroxyvitamin D was significantly lower in patients with asymptomatic bacteriuria, compared to women without asymptomatic bacteriuria.
Our results demonstrated that serum vitamin D level was significantly associated with asymptomatic bacteriuria in both pre- and postmenopausal women. These results underscore the importance of understanding the nonskeletal function of vitamin D, particularly its immunomodulatory effects on the prevention of infectious diseases. However, further prospective studies with a larger sample size are required to substantiate the available evidence.

Fall is one of the common reasons of older people referring to emergency rooms. Besides suffering, it exposes huge financial burden on the patient and the community health system, as well. It is important to know about risk factors, predictors, consequences and trauma scoring in elderly following the fall. This study aimed to evaluate the efficacy of TRISS (Trauma-Injury Severity) for predicting prognosis of fall among elderly people. This cross sectional study conducted among 118 elderly patients attended to Imam-Hossein Hospital in Tehran because of the fall. A check list was used to collect the data.Then, trauma scores were assessed by TRISS, ISS (Injury Severity Score) and RTS (Revised Trauma Score). The clinical value of the TRISS was also evaluated. The findings showed that sliding (67%) and syncope (33%) were the reasons of fall. Mortality rate was 22%, more than half of participants had morbidity (bone fracture) followed by 41% impaired functional ability. Means for ISS, RTS and TRISS were 12.06 ± 8.9, 6.54 ± 4.52 and. 45 ±. 33 respectively. There was a significant relationship between the mean scores and mortality and morbidity rates, which means all scores were higher among those with higher mortality and morbidity rate (P < 0.05). As a conclusion, due to the higher risk of unintentional injury in old age, applying some strategies to prevent and treat it seems essential.It is also vital to have an appropriate management plan for the condition to prevent other side effects to be happened.

Lumbar hernias (LH) accounts for less than 1.5% of total hernia incidence. It can occur in two separate triangular areas of the flank. About 300 cases have been reported in the literature. Here, we report a 55-year old man with acute painful left side flank mass and final diagnosis of LH. The mass was appeared about three hours before admission and his pain was slight at first but became more severe gradually. He had stable vital sign and the only positive finding on his physical examination was the sphere shape, firm, mobile, and mild tender mass at his left flank.

A 16-year-old girl with an intellectual disability (known case of Down syndrome) arrived in the emergency eepartment with complaints of severe breathlessness, bloody salivation (bright red blood or clots), and difficulty in speaking and swallowing of liquids and solids. The patient gradually developed progressive bloody salivation and hoarseness, never had any history of trauma to the head and neck and respiratory problems, and was symptomatic from the previous 48 h. Furthermore, the patient had a positive history of peptic ulcer, chronic consumption of non-steroidal anti-inflammatory drugs, and traveled out of town and drank water from a well in the mentioned period. On admission, the patient had a respiratory rate of 17 per min, pulse rate of 89 per min, blood pressure of 120/80 mmHg, 90% O2 saturation in room air, and 38°C axillary temperature. The only positive finding on physical examination was inspiratory stridor. The auscultation of lung and heart sounds was normal. Digital rectal examination revealed brown feces. Throat examination was not possible owing to lack of patient cooperation. After initial assessment and essential consideration, electrocardiography (ECG) and imaging was performed. The ECG showed normal sinus rhythm, and analysis of arterial blood gas revealed the following: pH = 7. 35, Pa-CO2 = 39 mmHg, HCO3 = 24 mEq/L, PaO2 = 89 mmHg, and O2 saturation = 92%. All other laboratory data, including complete blood counts (CBC), urine analysis, hepatic and renal function tests, and coagulation profile were in the normal range.

Chronic granulomatous disease is an inherited defect in intracellular killing of ingested microorganisms characterized by recurrent life threatening bacterial and fungal infections including invasive aspergillosis in early childhood.We report a disseminated aspergillosis as the representative of adult onset chronic granulomatous disease without previous infection, with dramatic response to combination of antifungal and interferon therapy.

Celiac disease (CD) is an immune mediated condition that leads to small bowel atrophy that resolves with a gluten free diet (GFD). Extra-intestinal manifestations of CD include hypertransaminasemia. In this study, the effects of a GFD on hypertransaminasemia in patients with newly diagnosed CD were studied. Ninety eight new diagnosed consecutive patients with CD 40 males and 58 females) with mean age of 32 ± 17.1 were studied. All patients with CD were treated with a GFD. Patients with hypertransaminasemia, at diagnosis, had a cirrhosis screen performed. Patients with a negative cirrhosis screen were reviewed, 6 months after the introduction of a GFD, and serum levels of liver transaminases were measured again. Nine patients had hypertransaminasemia. One patient was Hepatitis B surface antigen positive and was excluded from this study. The 8 remaining patients had no obvious cause for the hypertransaminasemia. Mean (± SD) of baseline aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were 42.6 ± 16.5 IU/L (range: 16-66 IU/L) and 69.3 ± 9.3 IU/L (range: 52-81 IU/L). Six months after treatment with a GFD, mean AST and ALT levels decreased to 24.5 ± 5.1 IU/L (range: 18-31 IU/L) (P: 0.04) and 24.6 ± 6 IU/L (range: 17-32 IU/L) (P: 0.01), respectively. In 7 patients the hypertransaminasemia, at diagnosis had resolved. This study provides further evidence that some patients with CD have a reversible hypertransaminasemia that resolves with a GFD.

Hepatitis C is a major reason of morbidity and mortality among hemophilia patients. Although combination therapy with peginterferon (peg-INF) and ribavirin is considered as standard treatment for chronic hepatitis C (CHC), but more evidence of the efficacy and safety is needed.. In this study, efficacy and tolerability of combination therapy with peginterferon α-2a–ribavirin was investigated among hemophilia HCV infected patients.. Patients and Materials: In a quasi-experimental, 45 naive hemophilia patients with chronic HCV received 180 mg of pegylated interferon (Pegasys) by subcutaneous injection weekly plus an oral dose of 800-1200 µg ribavirin daily according to body weight. The treatment continued 48 weeks in patients with genotype one and 24 weeks in those with genotype 3. Sustained virological response (SVR) was considered as efficacy of treatment.. Forty three patients (95.6%) reached to end of treatment response (ETR); only two (4.4%) patients did not respond and were discontinued from treatment. None of 43 patients relapsed. SVR obtained in 43 of 45 patients (95.6%), in multivariate logistic regression model, third month’s treatment WBC (WBC > 2000) remained the only significant predictor of SVR. Regimen dose reduced in three patients; two of those because of ALT increasing and other one for his retinal bleeding. In repeated measurement analysis, alanine aminotransferase (ALT) and hemoglobin (Hb) decreased significantly during treatment, but reduction of platelet (PLT) was not significant.. Results show high efficacy and safety of combination therapy of Peg-IFN-α 2a plus ribavirin among hemophiliacs with chronic hepatitis C.

We investigated whether the level of IL8 was different in patients with chronic and acute Toxoplasma gondii infection during the pregnancy compared with control group. It is well established that T.gondii infection induces a strong cell-mediated immune response.Patients and ELISA was used to determine the level of IL8 in sera of 568 pregnant women. Patients were divided into three groups according to a T.gondii serology. The first group included 202 women with positive IgG titres, the second group was 66 women with IgM and negative IgG T.gondii serology; and the third group comprised the sera of 300 healthy pregnant women with negative T.gondii serology and served as controls. The level of IL8 in group I was within normal range similar to control group. However, the level of IL8 was increased in those pregnant patients with positive IgM T.gondii serology. The serum levels of pro-inflammatory cytokines such as IL8 seem to be increased in patients with serological evidence of acute T.gondii infection.

Background According to the available evidence, problem-based learning (PBL) is one of the most successful methods in achieving higher educational objectives. In this method, the discussion about the subjects that should be taught to the students is based on a real clinical case.Various advantages and disadvantages of this method have been addressed in difJerent studies, but the students' attitude toward this method is vita/for its success.Objective To evaluate the students• altitude toward problem- based learning and to compare it with lecture-based learning.Method In this experimental study, two topics of basic immunology were chosen after holding coordination meetings. The students were divided randomly into two groups.Group A received PBLfor the first and LBLfor the secondtopic, and group B had LBLfor thefu-st and PBLfor the second topic. After the last session, a questionnaire was given to the students.Results The students considered PBL as superior in view of the student's active role in education. According to the students' opinion, group working was more evident in PBL. Although they preferred LBL to be used in a complete immunology course, they suggested that PBL is good to be used in some of the sessions.They suggested that although the learner's role is more evident in PBL, the instructor's role is still significant. They believed that self-assessment is better and easier in PBL.Discussion According to the results it is clear that, at least in some aspects, the students' attitude toward PBL is positive.This shows that by considering these aspects in educational reform programs, and by further study on the items not definitely determined in this research, we could modify PBL so that it could be used in a broader level.