Caspian Journal of Internal Medicine
Year:2023 | Volume:14 | Issue:1|Papers Count:25

Background: Chronic lymphocytic leukemia (CLL) can transform into fast growing lymphoma for diffuse large B-cell lymphoma (DLBCL) called Richter's syndrome (RS), which is commonly related to an existence of large B-cells with equal or larger size than macrophage nuclei or more than twice those of normal lymphocyte. We conducted a systematic review of the existing literature to assess the clinical efficacy of auto-HCT for patients with RS. Methods: We searched 4 main databases,EMBASE, Google Scholar, Scopus, PubMed and Web of Science and was done on December 26, 2021. All analyses in this study were performed by Stata software and this review was reported in accordance with PRISMA 2020. Results: Data was extracted from 4 articles,the total number of patients was reported to be 110. Based on the meta-analysis findings, pooled overall survival rate was 56. 36% (95%CI= (46. 98–, 65. 31). In figure 2, the forest plot of combined results is shown. Conclusion: Despite the use of common treatment regimens such as chemo immunotherapy and the availability of novel therapies including B-cell receptor inhibitors and rituximabcyclophosphamide-hydroxydaunorubicin-Oncovin-prednisone (CHOP-R) regimen, the status of disease progression and recovery in RS cases is still not strong enough.

Background: Hematologic malignancies in childhood and their treatments can cause dental anomalies and jaw bone abnormalities,therefore, the aim of this study was to assess the prevalence of these disorders in children. Methods: This cross-sectional study was conducted on all children diagnosed with hematologic malignancies that referred to in Amirkola Children’, s Hospital from 2011 to 2018. All of children underwent clinical evaluation in a Dental Radiology Clinic and panoramic imaging was performed. The radiographs were examined for dental anomalies and jaw bone abnormalities. The data were analyzed by descriptive analysis using chisquare, Mann-Whitney and Kruskal-Wallis with a 95% confidence interval. Results: The study population consisted of 32 children and 9. 46% of these patients showed intraoral signs in clinical evaluations. Panoramic radiographs indicated dental anomalies in 12 (63. 9%) and jaw bone abnormalities in 17 (89. 4%) patients. The most common dental anomaly and bone abnormality were taurodontism and changes in lamina dura, respectively. By measuring the mandibular cortical index (MCI), it was revealed that 13 had osteopenia, in which 4 of them had severe osteopenia (osteoporosis). The statistical analysis demonstrated that there was a significant difference between the incidence of osteoporosis and changes in lamina dura with the gender (p<0. 05). Conclusion: Due to early onset of osteopenia and osteoporosis and the presence of dental and bone abnormalities in half of study population, early assessment of their clinical and radiographic condition can be helpful in the prevention and the early treatment of their oral complications.

Background: Mycosis fungoides (MF) is a lymphoproliferative disorder characterized by skin-homing atypical lymphocytes. This study aimed to evaluate the quality of life (QoL) in MF patients in the early stages of the disease and the associated factors using the Dermatology Life Quality Index (DLQI). Methods: Thirty MF patients (21 females/9 males) with a mean age of 46. 73±, 15. 9 years and in the early stages of the disease (26 stage Ι,and 4 stage Ι, Ι, ) were enrolled and were asked to fill the DLQI questionnaire. Results: The mean DLQI score was 9. 93±, 5. 89. The QoL was largely affected by the disease in near half of the patients (46. 7% of patients had a DLQI score11-20). QoL was significantly correlated with educational level and was more impaired in patients with lower educational status (DLQI score spearman rho=-0. 382, P=0. 037). QoL was not associated with sex, age, disease stage and disease duration. The symptom and feeling dimension of DLQI was significantly more impaired in patients with both patch and plaque compared to patch only (spearman rho= 0. 397, P= 0. 03). Conclusion: This study demonstrates how largely patients’,QoL is influenced in the early stages of MF, especially in patients with lower educational levels.

Background: Optic neuritis (ON) is one of the main neuro-ophthalmic presentations of multiple sclerosis (MS), and it causes optic nerve atrophy and axonal loss. However, so far, there is no effective treatment to improve long-term outcomes. Methods: In a double-blind placebo-controlled randomized clinical trial, 50 patients with MS-related ON were allocated into two arms (24 in the control group and 26 in the intervention group) receiving either 25000IU retinyl palmitate or an identical placebo for six months. Visual evoked potential (VEP), visual acuity, and the retinal nerve fiber layer (RNFL) thickness were evaluated and compared before and after the treatment. Results: RNFL thickness reduction in the affected eyes at sixth month compared to the baseline were 14. 81 and 19. 46 μ, m, in the intervention and control groups, respectively (P=0. 017). However, VitA therapy did not affect visual acuity and VEP. Conclusion: Vitamin A supplementation in the patients with acute ON in MS could lessen optic nerve axonal loss.

Background: Hyperkyphosis is a frequent problem in older adults. Depressed mood and decreased quality of life are supposed to be related to age-related hyperkyphosis. This study aimed to explain the relation between depression, quality of life, and hyperkyphosis in old patients. Methods: 142 patients who applied to the outpatient clinic of geriatrics were enrolled in this cross-sectional study. Mean age of participants was 72. Hyperkyphosis was evaluated by the bloc method defined in the Rancho Bernardo Study (1). Depression was evaluated by the Short form of Yesavage Geriatric Depression Scale (GDS). Quality of life was assessed by the 3-level version of EQ-5D. Results: Hyperkyphosis was found to be positively related to depression (P=0. 037), negatively related to the QOL (p<0. 001). QOL, depression, and hyperkyphosis were in a ship with each other when evaluated with one-way MANOVA (F [3. 135] =5. 23, P=0. 002, Wilk's Λ, =0. 896, partial η, 2=0. 104). Chronic pain was negatively related to QOL (p<0. 001). Depression was positively related to chronic pain (p<0. 001). QOL evaluated with VAS was independently related to the presence of hyperkyphosis in logistic regression analysis (r2=0. 179, P=0. 007). Conclusion: Considering the relationship with depression and quality of life, early recognition, and treatment of hyperkyphosis in elderly individuals is important. More studies evaluating the association between postural disorders, quality of life and mood disorders in older adults will be useful.

Background: Accumulating evidence has demonstrated that RDW (red blood cell distribution width) may independently predict clinically important outcomes in many populations. However, the role of RDW has not been elucidated in brain death. We conducted this study with the aim of evaluating the predictive value of RDW in brain death. Methods: A retrospective study of seventy-seven of brain death cases during 36 months were evaluated at university hospitals, affiliated in Tehran, Iran. Demographical data include age, sex, BMI and cause of brain death, also laboratory results (red blood cell distribution, mean corpuscular volume, hemoglobin) collected by checklists from patient records. Having the three RDW measurements (days of hospital admission, day of brain death, and day of cardiac arrest) required. Results: Time interval from hospital admission until brain death was 5. 27±, 4. 07. The mean age of brain death cases was 32. 65±, 16. 53. The mean RDW values on days of hospital admission, the day of brain death, and the day of cardiac arrest were 14. 53±, 1. 98, 15. 12±, 1. 93 and 15. 18±, 2. 07, respectively. Results of the repeated-measures ANOVA test reveal that RDW level was constantly higher in the traumatic patient group compared to the nontraumatic ones (P=0. 008). Conclusion: The frequency of brain death was high in patients with high RDW values. RDW might be a prognostic biomarker for brain death. More prospective studies with large sample size and long follow-up period should be carried out to determine the prognostic significance of RDW and brain death in future.

Background: Methadone is one of the most useful opioids that can be used to achieve many therapeutic goals, and also it may be abused as an illicit drug. Methadone can cause different gastrointestinal, neurological, and cardiac complications. This study was performed to obtain a better understanding of the cardiac side effects of methadone in patients with methadone poisoning. Methods: This cross-sectional study was performed on 210 samples in Sina Hospital of Hamadan in a one-year period from March 2019 to March 2020. After assessing patients who had methadone poisoning and completing their demographic information and evaluation of changes in patients' EKGs, the data was collected and analyzed by SPSS 16 software. Results: Out of 210 participants, 178 (84. 8%) were males and the rest were females. The average age of the studied patients was 39. 56 years old. The study found that 6. 1% of methadone-poisoned patients were illiterate. It was found in this study that the most common cardiac complications of methadone intoxication were sinus tachycardia (20%), QT interval prolongation (6. 64%), and sinus bradycardia (4. 3%), respectively,nevertheless, 66. 2% of patients did not have any EKG abnormalities. Conclusion: According to the findings, it is necessary to have continuous cardiac monitoring for patients with methadone intoxication and by transferring such findings to medical centers, steps can be taken to use methadone more intelligently.

Background: Methotrexate (MTX) and actinomycin D (ActD) have been used as first-line chemotherapy agents in the treatment of low-risk gestational trophoblastic neoplasia (GTN). Although low-risk GTN is considered a curable disease, its reported primary remission rates of 49 to 93% reflect the difficulties of treatment and different factors influencing it. Hence, this study aimed to determine the remission rates and related factors of single-agent chemotherapy resistance in low-risk GTN patients. Methods: This retrospective study included patients with diagnosed low-risk GTN who received either MTX once a week (IM, 30mg/m2) or ActD once every two weeks (pulsed IV, 1. 25mg/m2). Then, the patients were followed-up until complete remission or singleagent treatment failure to assess resistance rate and related factors. Results: Eighty-four patients were included in the study (18 patients were receiving MTX and 66 patients were receiving ActD). 85. 7% of all participants achieved complete remission after first-line chemotherapy (72. 2% in MTX vs 89. 4% in ActD). There was a significant association for higher tumor size (P=0. 046), the occurrence of metastasis (P=0. 019), and pretreatment β,-HCG levels (P=0. 005) with resistance to treatment. Conclusion: This study demonstrated higher tumor size, the occurrence of metastasis, and pretreatment β,-HCG levels have been associated with increased resistance to first-line chemotherapy agents.

Background: Frailty is a common problem in elderly individuals. However, this issue is not well investigated among heart failure (HF) patients with appropriate scales. We aimed to translate and evaluate Edmonton frailty scale (EFS) validity and reliability in Iranian HF adults. Methods: We implemented this methodological study on stable HF patients referred to an outpatient heart clinic in Isfahan, Iran. The translation was done using the forwardbackward method. Ten individuals were asked to comment about all items in terms of understandability and simplicity. Fifteen experts were invited, and their ratings on each item were collected to measure the content validity index (CVI) and content validity ratio (CVR). Cronbach’, s alpha was used for the assessment of internal consistency. After completing the scale for the second time with a two-week interval, test-retest reliability with intraclass correlation coefficient (ICC) measurement was done. Results: The translation process was performed uneventfully. All items were reported to be simple and meaningful. CVI of items ranged from the minimum of 0. 80 to a maximum of 1. 00 plus an acceptable CVR of at least 0. 60. Fifty HF patients (age: 67. 2±, 14. 1 years, males: 56%) completed the questionnaire twice without missing data. Cronbach’, s alpha was first to be 0. 550. After omitting three items about social support, drug usage, and nutrition, the value was raised to 0. 711. Test-retest reliability showed a good index of consistency (ICC: 0. 693, 95% confidence interval: 0. 527-0. 810). Conclusion: Modified Persian EFS is a simple and meaningful tool with high validity and acceptable reliability for assessing frailty in HF individuals irrespective of age.

Background: Atrial fibrillation (AF) is a common complication after heart surgeries. Advances in imaging technologies and an understanding of the pathophysiology of preoperative left atrial (LA) dysfunction can lead to more definitive potential therapeutic approaches. This study aimed to determine the role of conventional echocardiography and LA two-dimensional (2D) strain echocardiography in assessing LA function and predicting POAF after CABG surgery. Methods: All patients with sinus rhythm who underwent CABG surgery were enrolled. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and perioperative features, electrocardiogram (ECG) and Holter monitoring were recorded. Results: Of the 105 patients included, 85 patients (81%) were men with a mean age of 60. 26±, 10. 61 years. POAF was seen in 22. 9% of patients during hospitalization, and AF duration was 10 hours (median,IQR: 2. 0-19. 5). AF patients had a higher LA volume index (LAVI) than patients with sinus rhythm (p=0. 018). Patients with sinus rhythm had higher rates of LA reservoir (26. 97±, 6. 87 VS. 20. 46±, 4. 27, p<0. 001), LA contractile (14. 98±, 3. 68 VS. 12. 76±, 3. 72, p =0. 012) and LA global strain (24. 28±, 6. 57 VS. 17. 71±, 4. 11, p<0. 001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p=0. 014) and LA global strain (p=0. 027) were independent predictors of AF detection. Conclusion: Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic method to predict the possibility of post-CABG AF.

Background: the assessment of P16 expression and Ki-67 proliferative index is now proposed as an adjunct test for the diagnosis of high-risk precursor lesions for cervical cancer. The aim of the present study was to elucidate the quality expression of P16 and quantification Ki-67 index in different types of cervical intraepithelial neoplasia and also to determine the cutoff for Ki67 index to predict the severity of CIN lesions. Methods: This cross-sectional study was conducted on patients with colposcopic indication. Selected samples with different CIN grades were examined for P16 and Ki-67 index by immunohistochemical (IHC) methods. Results: All LSIL (CIN I) cases were negative for P16, while in 58. 7% of HSIL cases (CIN 2/3), P16 was positive. The mean Ki67 index in the present study was 3. 13 ±,2. 65 in the upper two/third of the squamous epithelium in the LSIL group and 19. 04 ±, 36. 40 in the HSIL group, which was statistically significant. Also, the mean Ki67 index in full thickness squamous epithelium in HSIL group was significantly higher than LSIL. The sensitivity of P16 and Ki67 index in our study was 58. 73%, 66. 67% and the specificity was 100% and 100%, respectively. Conclusion: Assessment of P16 expression and Ki67 index can be used to distinguish low grade (CIN1) intraepithelial lesion from high grade (CIN2/3) intraepithelial or precancerous lesions.

Background: Previous research showed some clinical benefits regarding the nephroprotective effect of melatonin. So, this study aimed to evaluate the beneficial effect of oral melatonin on preventing acute kidney injury (AKI) in patients who received vancomycin therapy in the intensive care unit (ICU). Methods: We performed a randomized, double-blinded, placebo-controlled pilot study in an academic hospital. Adult patients admitted to the ICU who received vancomycin with normal gastrointestinal and kidney function were randomized into treatment or placebo groups. After that, enrolled patients received a tablet of melatonin (3 mg) or placebo twice daily for seven consecutive days. The occurrence of AKI was assessed by RIFLE criteria (by measurement of serum creatinine (SCr)) and plasma neutrophil gelatinase-associated lipocalin (NGAL) concentration. Moreover, other data related to renal functions and SOFA were also compared between groups. Results: A total of 90 patients were included in the study, while 21patients in the placebo group and 20 in the intervention group completed the study. There were no significant differences between groups regarding baseline SCr, BUN, urine output, NGAL, SOFA, and glomerular filtration rate (GFR). Our results showed that these differences remained insignificant after a 7-day follow-up between groups. However, the incidence of AKI was significantly lower in the melatonin group based on the NGAL cutoff (> 150 ng/mL). Conclusion: We detected a significant decrease in vancomycin-induced nephrotoxicity incidence in patients receiving melatonin compared to placebo. However, more clinical trials in a larger population were required to confirm this result.

Background: Abnormality in the cardiovascular system such as left ventricular dysfunction caused increased serum CRP and change in electrocardiography pattern. The present study aimed to understand the association between increased levels of highly sensitive CRP (hsCRP) and non-arrhythmic ECG changes and electrocardiographic abnormalities in patients with the acute coronary syndrome. Methods: This study was done on 120 patients diagnosed with acute coronary syndrome and hospitalized at CCU. The patients were classified into two groups, one group with an increased level of hs-CRP and another with a normal hs-CRP level. Results: The patients with an increased level of hs-CRP showed a significantly higher level of cardiac enzymes also ST-segment elevation myocardial infarction (STEMI) was seen in the group with an increased level of hs-CRP than those with normal serum hs-CRP level, but another diagnosis including unstable angina, non-STEMI, heart failure, and emergency hypertension was similarly observed in both groups. Two groups were assessed in terms of left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVeDD) the prevalence of valvular heart disease, and wall motion abnormality, also showed that groups with increased hs-CRP level, ST-segment elevation leads more significant differences than a normal group (P=0. 001). Conclusion: Patients with an increased level of hs-CRP can be diagnosed as STEMI but not valuable to suppose as echocardiographic abnormalities such as left ventricular dysfunction or hypertrophy.

Background: Medication satisfaction is a patient-reported outcome which could show medication adherence. The aim of this study was to determine Iranian MS patients’,satisfaction with Disease Modifying Therapies (DMTs). Methods: A standardized questionnaire was developed using Treatment Satisfaction Questionnaire for Medication (TSQM). The online link was released on IMSS (Iranian Multiple Sclerosis Society) social media channel, accessible to 4272 MS patients totally. Results: Three hundred and ninety-four patients participated in our survey with 324 females, 70 males and an F/M ratio of 4. 6: 1. The most frequent DMTs used were interferon-beta (IFNβ, ) followed by rituximab. The mean effectiveness and global satisfaction scores were significantly higher for injectable DMTs, while the convenience score was significantly higher for oral DMTs. Mean effectiveness and side-effect scores were significantly higher in the Tysabri group and convenience score was significantly higher in the fingolimod group while global satisfaction was higher in the IFNβ,group. Conclusion: The global satisfaction and effectiveness were significantly higher with injectable DMTs while the convenience score was significantly higher with oral DMTs.

Background: Vitamin D is associated with numerous disorders, including infertility. Accordingly, the goal of this research was to find out the level of vitamin D and messenger RNA (mRNA) expression of vitamin D receptor (VDR) in the sperm of male subjects with unexplained infertility. Methods: Twenty-four unexplained infertile men as the case group and 22 healthy fertile men as the control group were recruited. Vitamin D levels were evaluated in seminal fluid using enzyme-linked immunosorbent assay (ELISA). Afterwards, the swim-up test was performed to isolate motile sperm cells. From these cells, RNA was extracted, complementary DNA (cDNA) was synthesized, and mRNA expression of the VDR gene was evaluated with quantitative real-time polymerase chain reaction (PCR). Results: A decrease in VDR mRNA expression levels was detected in the case group compared to the control group, but this reduction was not statistically significant (p>0. 05). Besides, the level of vitamin D in seminal fluid was not detectable in both groups. Conclusion: The sperm of unexplained infertile men express VDR gene mRNA, although there was no vitamin D in seminal samples. Hence, vitamin D and VDR signaling might not be effective in the etiopathogenesis of unexplained infertility in men.

Background: Knowledge about the associated factors with epilepsy in the elderly in Iran is limited. Therefore, yes s ydtts siht to determine the prevalence of epilepsy and associated factors in Amirkola elderly patients. Methods: This cross-sectional study is a part of a comprehensive and cohort research of "The Amirkola Health and Ageing Project". The Mini-mental State Examination was used for cognitive impairment, Geriatric Depression Scale for psychiatric diseases and the Physical Activity Scale for Elderly questionnaire for physical activity. Results: The prevalence of epilepsy was 35 from 1482 participants (24/1000). The significant association between Parkinson’, s Disease (OR=6. 25, 95%CI=1. 35-28. 4, P=0. 001), falls (OR= 3. 81, 95%CI=1. 62-8. 97, P=0. 001), depression (P=0. 001), hyperphosphatemia (P=0. 039) and hypokalemia (P= 0. 031) concluded with epilepsy. Past history of stroke (6 % versus 2%, OR= 2. 8, 95%CI, 0. 97-8. 27, P=0. 07), increased serum level of triglyceride (OR= 1. 96, 95%CI= 0. 99-3. 88, P=0. 06) and low-density lipoprotein (LDL) (P=0. 45) were seen in epileptic patients vs. non-epileptic patients. Conclusion: Parkinson's disease, frequency of falls and depression were the associated factors in epileptic patients and a correlation between past history of stroke, increased serum level of triglyceride and LDL with epilepsy were seen. Associated factors required screening, diagnosis and treatment.

Background: Low-risk gestational trophoblastic neoplasia could be cured in the case of appropriate management with single-agent chemotherapy. This study was carried out to compare the efficacy of single-dose methotrexate versus Actinomycin-D in low-risk gestational trophoblastic neoplasia to analyze the most effective agent. Methods: This retrospective cohort study was conducted on the medical record of 170 cases with the diagnosis of low-risk gestational trophoblastic neoplasia from 2012 to 2019 to evaluate the response rate of single-dose weekly-methotrexate versus biweeklyActinomycin-D. Results: Single agent chemotherapy was required in 170 patients with final risk score of less than 7. Among the 100 cases under weekly-methotrexate therapy, 29 patients were required second-line chemotherapy with Actinomycin-D and combination therapy which means complete remission of 71% with methotrexate, in comparison with 78. 5% in the other group. Resistance was mostly seen in patients with documented choriocarcinoma in histology who had not received timely diagnosis and treatment. Conclusion: Individualized decision in the management of low-risk gestational trophoblastic neoplasia cases, based on histology, HCG, and history is the corn stone in successful treatment.

Background: The purpose of this study was to determine the distribution of intraocular pressure (IOP) and assess its association with age, sex, systemic blood pressure, diabetes mellitus, body mass index (BMI) and tobacco smoking in Iranian elderly population. Methods: This cohort-based, cross-sectional study assessed elderly individuals aged 60-90 years in Amirkola, northern Iran, in 2016-2017. Past medical history, blood pressure, diabetes mellitus, BMI and tobacco smoking were recorded through an interview and physical examination. IOP was assessed using non-contact tonometry. Results: Total of 1377 individuals participated in this study, out of which 1346 IOP measurements were included for the final analysis. The mean age of participants was 69. 4 ±,7. 1 years and mean IOP was determined to be 16. 7 ±,3. 2 mmHg. Majority of the participants were males (56. 1% vs 43. 1%), 73. 8% of participants were overweight or obese, 6. 1% smoked tobacco, 28. 9% had diabetes mellitus and 84. 9% had higher than normal blood pressure. Through multiple regression analysis, it was determined that age (β, =-0. 132, p<0. 001) was negatively associated with IOP, and the presence of diabetes mellitus (β, =0. 118, p<0. 001), systolic blood pressure (β, =0. 101, p<0. 001), and BMI (β, =0. 020, P=0. 020) were positively associated with IOP. Conclusion: Mean IOP of individuals in this study was higher than average based on other studies. Age, was negatively and systemic blood pressure, BMI and presence of diabetes mellitus were positively associated with mean IOP of elderly Iranian population. Sex and tobacco smoking were not correlated with IOP.

Background: Cone beam computed tomography (CBCT) is considered a common examination for dentistry problems. Cellular biology can be affected by exposure to ionizing radiations procedures. In this study, we aimed to assess the genotoxicity and cytotoxicity effects of CBCT dental examinations at two different fields of view (FOVs) in exfoliated buccal epithelial cells. Methods: Sixty healthy adults participated in the current study. They were divided into two identical groups,CBCT with FOV of 6*6 cm2 and 8*11 cm2. Exfoliated oral mucosa cells were prepared immediately before and after 10-12 days of CBCT exposure. The cytological smears were stained with the Papanicolaou technique. The amounts of micronuclei and other cytotoxicity cellular changes (Pyknosis, Karyolysis, and Karyorrhexis) were evaluated. The variables of the parameters before and after CBCT examination in the two investigated FOVs were performed using Wilcoxon test and paired-samples t-test in SPSS software. Results: The micronuclei and other cytotoxic changes parameters before and after CBCT exposure for both FOVs (6*6 and 8*11 cm2) increased significantly (p<0. 001). Furthermore, a significant difference (p<0. 05) was observed between the investigated parameters at the two FOVs. Notably, the FOV of 8*11 cm2 had more side effects than that of 6*6 cm2. There were no statistically significant among males and females for both FOVs. Conclusion: CBCT examinations of dental disorders would increase the risks of inducing genetic damage. The cytotoxicity and chromosomal damage were considered in males and females in both investigated FOVs (6*6 and 8*11 cm2). In this regard, the use of CBCT must be following the ALARA principle.

Background: Head and neck cancers (HNCs) include 5. 3% of all cancers and they are the cause of the same 5. 3% of cancer deaths. Oxidative stress has a crucial role in cancer progression and cancer therapy. Ionizing radiation causes cell malfunction and death by creating reactive oxygen species. Due to its antioxidant activity, immune system power enhancement and role in apoptosis, zinc is a crucial trace element in oncology including HNCs. We decided to compare serum zinc level of HNC patients before and after RT, to assess the potential effects of ionizing radiation therapy on serum zinc. Methods: Fifty-seven HNC patients, who were candidates for curative radiation therapy (RT), were enrolled and their serum zinc level just before and 2 months after completion of RT were checked in a single laboratory. RT was prescribed by linear accelerator with 60 to 70 Gy by conventional method. Data were analyzed by SPSS 20. Results: Mean serum zinc prior to RT and following RT were 77. 64±, 13. 45 mg/dl and 68. 28±, 11. 93 mg/dl, respectively, which was lower following RT (p<0. 001). Patients’,sex, age and duration from diagnosis to treatment and site of disease didn’, t have any impact on serum zinc difference. Conclusion: This study showed that RT of HNCs leads to serum zinc reduction, which is greater in nodal disease because of either larger field or higher dose of radiation. Taking zinc supplements while being treated by RT, may be necessary.

Background: Spondylodiscitis is a rare illness and serious complication of the vertebral column. The suitable type of surgery is debatable for these patients. This study describes a series of cases that are treated with modified interbody fusion for the treatment of spondylodiscitis by combining allograft and autograft bone chips with posterior segmental fusion. Methods: This was a retrospective study. The clinical deficit was evaluated with ASIA, VAS, and JOABPEQ scores before and after surgery. Radiological parameters were assessed with local kyphosis angle (degree), segmental height correction, and loss of correction. Post-operative bone union was evaluated as suggested by Tan et al. Results: The mean age of patients (n=34) was 52. 3(SD=13. 6) years and 67. 6% were males. The mean follow-up duration was 25. 8 (2. 3) months. In the last follow-up, VAS back pain 4. 9(0. 77), VAS leg pain 4. 6(0. 78), JOABPEQ low back pain 68. 1 (9. 3), JOABPEQ lumbar function 81. 3 (8. 9), and JOABPEQ walking ability 72. 8 (8. 3) shows a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients deteriorated neurologically (all p<0. 0001). The average segmental height correction and loss of correction were observed 7. 5(3. 7) % and-1. 8(3. 6) %, respectively, indicating improvements in the patients. A high union fusion rate (82. 4%) was observed in the last follow-up. Conclusion: This modified method can be a safe and effective technique for surgical intervention in patients with spondylodiscitis.

Background: Small intestine volvulus occurs more commonly among younger children. It often poses diagnostic challenges when it occurs in older children and adults. For good clinical outcomes, it is essential to have prompt presentation, diagnosis and early intervention. Anasarca is not a common clinical manifestation of small intestine volvulus. Case Presentation: We report this unusual presentation of small intestine volvulus in an 11year old Nigerian boy who first presented only with anasarca. While being investigated for the cause of the anasarca, he developed features of acute abdomen thought to be spontaneous bacteria peritonitis initially. He had surgery where the diagnosis of small intestine volvulus was made. Conclusion: The diagnosis and management of both anasarca and small intestine volvulus could be fraught with challenges. It is possible that anasarca can be the first manifestation of small intestine volvulus.

Background: Sickle cell disease (SCD) is associated with an under-recognized and wellknown complication of bone marrow necrosis known as cerebral fat embolism (CFE). Case Presentation: We report a case of successfully treated SCD patient suffering from nontraumatic cerebral fat embolism (NCFE) who came with initial manifestation of localized pain followed by loss of consciousness and absence of cardiac shunt. This was an unusual case of fat embolism in SCD patient with the absence of right-to-left cardiac shunt indicating the biochemical etiology. Patient initially showed localized pain followed by loss of consciousness, suggesting that any such initial manifestation in patient of SCD should be suspected for CFE. MRI served as an accurate diagnostic tool showing the characteristic neuroradiologic sign. Treatment with exchange-transfusion recovered the patient successfully. Conclusion: Overall, this case suggested that prompt diagnosis using MRI and treatment with RBC exchange could lead to better outcomes in SCD patients suffering from CFE.

Background: Carcinoid tumors of the testis are rare and orchiectomy is the preferred treatment. This type of testis tumors is rare and their differentiation from sex cord-stromal tumors is difficult. Case presentation: A 29‑,year‑,old man presented with right testicular mass and underwent radical orchidectomy. Histological examination showed neuroendocrine tumor, confirmed by mmunohistochemistry and electron microscopy (Ethic code: IR. MUMS. REC. 1400. 237). Conclusion: Primary testicular neuroendocrine tumor is very rare. It is crucial to submit the entire gross specimen for histopathologic examination to rule out an existing of other germ cell elements. Our patient had a well-differentiated carcinoid tumor and after two years of follow-up (every three months), there was no recurrence or metastasis.

Background: Kleine-Levin syndrome (KLS) is a rare sleep disorder with at least two episodes of hypersomnia coincidence with at least one cognitive, eating, perceptive and disinhibited symptoms and normal inter-episodes. These symptoms are not explained by another sleep, medical, neurological, psychiatric disorders and substance or drug use. Case Presentation: Here we report a young female with personality disorder and obsessivecompulsive disorder who had KLS. Her symptoms appeared in the past 1. 5 years ago, while she had an episode of hypersomnia lasting for 5 days. She had 4 attacks,each one lasted up to 2-7 days. We found that overriding KLS symptoms on underlying main psychiatric or personality disorders complicates diagnosis. All neurological examinations during episode and further investigation were in normal range. Conclusion: We suggest that taking a complete history and mental state examination in the episode and inter episode phase helps to diagnosis both KLS and comorbid psychiatric disorders.