Tehran University Medical Journal
Year:2023 | Volume:80 | Issue:11|Papers Count:10

Background: Access to healthcare is a fundamental right of every individual, regardless of their geographic location or socioeconomic status. In many countries, deprived areas often face a shortage of physicians and other healthcare professionals. This study aimed to investigate the approaches essential to attract and retain physicians in the deprived and rural areas. Methods: The present study is a systematic review using appropriate keywords in Persian and English language. The main databases including Google Scholar, Scopus, Web of Science, PubMed, SID, and IranMedex were searched from May 2005 to September 2022 in both languages. Different approaches implemented by countries to attract and retain doctors were classified using thematic analysis. Results: A total of 18 articles were selected for inclusion in the study. Educational, regulatory, motivational, and personal and professional support drivers have been used to attract and retain physicians. The successful interventions implemented were mainly educational and supportive,such as admitting native medical students, providing relevant curricula on working in the deprived and rural areas, and conducting training courses in these regions. Those studying the topics and courses related to serving in the rural areas during their academic education or internship and residency programs had served more time in these areas. Assimilating the topics related to providing services in rural areas into the curriculum, holding fellowship courses and related graduate studies, awarding scholarships to the physicians working in deprived areas, providing free amenities, reducing working hours, and considering special holidays are considered among the recommended solutions. Conclusion: Various drivers were used for attracting and retaining physicians in the deprived and rural areas. Besides, the challenge to retain doctors in such areas was fairly common. Most countries have put more priority on the use of financial incentives, nevertheless, a combination of interventions was preferred. It is worth mentioning that a range of economic, political, and social factors could play a key role in the success of recommended interventions.

Background: In this study, the effect of intravenous dexamethasone on pain, nausea and vomiting after laparoscopic ovarian surgery was investigated. Methods: This randomized clinical trial was conducted from June 2019 to March 2019 on patients undergoing laparoscopic ovarian cystectomy in Beheshti Hospital, Isfahan. In this study, 88 patients aged 18 to 45 years were included in the study. Patients were randomly divided into two groups receiving dexamethasone (D) and normal saline (S). Two minutes before induction of anesthesia, the first group received 8 mg (2 ml) of dexamethasone and the second group received normal saline (2 ml). The duration of surgery and stay in recovery, the frequency of pain and nausea and vomiting, the need for analgesic and anti-nausea drugs, and the cardiovascular response during the study were evaluated and recorded. Results: No significant difference was seen in terms of demographic characteristics between the two groups (P>0. 05). The frequency of pain during recovery (P=0. 4) was not significantly different between the two groups, but at 2 hours (P=0. 005), 12 hours (P<0. 001) and 24 hours after the operation (P=0. 005) (P=0) was significantly lower than S group. The frequency of nausea in group D during recovery (P=0. 003), 2 hours later (P<0. 001), and 12 hours (P=0. 002) was significantly lower than group S, but 24 hours after the surgery, there was no significant difference between the two groups (P=0. 15). During recovery, there was no vomiting in both groups (P=1), the frequency of vomiting in 2 hours (P=0. 003), 12 hours (P<0. 002) and 24 hours after the operation (P=0. 48) in group D was lower than S. At the time of the study, the dose of diclofenac and metoclopramide received in group D patients was lower than group S. There was no significant difference in cardiovascular response between the two groups during the study (P>0. 05). Conclusion: Dexamethasone with a dose of 8 mg before induction of anesthesia can be effective in reducing pain, nausea and vomiting after laparoscopic ovarian surgery and reducing the need for analgesics and anti-nausea drugs.

Background: chorea-acanthocytosis is a form of the autosomal recessive disease. The onset of disease symptoms usually starts from the third decade of life and presents with chorea, other abnormal movements such as eating dystonia, tongue and lip biting, vocal and motor tics, seizure, and behavioral impairment. In this study, the clinical presentations and brain imaging of these patients were reported. Methods: In this descriptive study, information about patients with a specific movement disorder who were referred to a tertiary center in the Rasool Akram hospital (Tehran) from March 2018 to February 2019 were recorded. The inclusion criteria were the presence of chorea (a form of abnormal movement) and the presents of acanthocyte cells higher than 10% in a peripheral blood smear. The exclusion criteria were the evidence of secondary causes of the chorea or endocrine disorders. The clinical symptoms and brain imaging findings were evaluated by two expert neurologists and recorded in the patient's electronic files. Results: Twenty-seven eligible patients were included. 18 patients were male and 9 were female. Sixteen patients had seizures and 90% of them were categorized as generalized tonic-clonic seizures. 21 patients had eating dystonia (71 percent were male and 29 percent were female) and 18 patients had complex motor and vocal tics, 11 patients presented extra ocular movement disorders, and 11 patients had evidence of tongue and lip biting. The absence of the deep tendon reflex was detected in 23 patients. Considering all the patients' movement disorders, the prevalence of eating dystonia was significantly higher in men than in women. (P=0. 049). Other abnormal movements were not different between men and female. All patients had caudate atrophy and increased signal intensity in T2/Flair sequences in caudate nuclei and putamen in the brain imaging. Conclusion: The most common abnormal movement after chorea was eating dystonia. The male gender was more susceptible to present eating dystonia than the female. However, this superiority was not seen in other movement disorders.

Background: Atrophy of hippocampal subfields is one of the diagnostic biomarkers of Alzheimer's disease, which has also been observed in many patients with mild cognitive impairment. There is still no clear understanding of the atrophy pattern of hippocampal subfields in Alzheimer's disease and its differentiation from mild cognitive impairment. In this cross-sectional study, hippocampal subfield atrophy in Alzheimer's patients were compared with patients with early (EMCI) and late (LMCI) cognitive impairment and the control group. Methods: This was a cross-sectional study conducted from September 2021 to September 2022 in the radiology department of Tabriz Paramedical Faculty. MRI images of Alzheimer's patients, EMCI patients, LMCI patients, and normal controls (NCs) were obtained from the ADNI database. Different hippocampus subfields of hippocampal fissure, dentate gyrus head, dentate gyrus body, first cornu ammonis body, cornu ammonis head, subiculum body, and subiculum head were isolated using the hippocampus segmentation tool in FreeSurfer 7. 0 software. The volume of all subfields was calculated bilaterally and normalized. The volume difference of each hippocampus subfield between the groups participating in the study and the pair volume difference between the groups was analyzed using the Kruskal-Wallis H Test and post-hoc Dunn's test. The P<0. 05 was considered as the significance level. Results: The most significant volume difference between the four groups participating in the study was related to the whole hippocampus, DG body, subiculum body, and subiculum head subfields (P<0. 0001). Also, when examining pairs, the most significant difference was observed between the NC/AD pair (P<0. 0001) and the least significant difference between the pair of LMCI/AD group (P<0. 05) and in the subfield subiculum body showing the progressive course of hippocampal subfield atrophy with cognitive progress towards Alzheimer's disease. Conclusion: In most subfields of the hippocampus, a significant difference in atrophy can be seen, increasing the severity of atrophy as the disorder progresses toward Alzheimer's. Such findings can help guide future studies to improve diagnostic performance to identify individuals at high risk of Alzheimer's disease.

Background: One of the major challenges in intensive care unit (ICU) patients is sepsis. The incidence of sepsis in patients admitted to the ICU has been reported from 13. 6-39. 3%. Many factors affect patient mortality, including acute phase proteins such as albumin. Methods: The present study was a retrospective study in which patients with a diagnosis of sepsis referred to Golestan Hospital in Ahvaz from March to August were collected. In the present study, patients with sepsis admitted to the ICU who did not show improvement for more than 7 days were evaluated for length of hospital stay, survival and the relationship with albumin levels. During the study, albumin was checked every 72 hours and its validation was done. Based on albumin levels less than 2. 6, they were treated with albumin. The patients who did not have an increase in the level of albumin remained in the study. Results: 124 patients including 64 women (51. 6) and 60 men (48. 4) with a mean age of 66. 4±, 15. 4 were included in the study. The mean duration of hospitalization was 31. 4±, 18. 9 days, in which 24 patients (19. 4%) died and 100 patients (80. 6%) were discharged. Age, albumin and protein levels were associated with disease prognosis (P<0. 001). Also, the duration of hospitalization in the deceased patients was longer than the recovered patients (27. 7±, 25 vs. 32±, 17. 1) (P=0. 04). After further investigations, it was found that there is no difference between the deceased people (66±, 15. 7) and the recovered people (67. 7±, 14. 1) (P=0. 7). Conclusion: The results of the present study showed that albumin has a direct effect on the severity of sepsis and this issue affects older patients more. Therefore, it is recommended that albumin be considered as a risk factor and one of the influential factors in choosing the best treatment strategy, which is associated with a reduction in mortality, hospitalization and treatment costs.

Background: Febrile seizures (FS) are the most common cause of seizure in children. In order to prevent FS and their recurrence, the recognition of the related factors to recurrence of FS is important. According to the high prevalence of FS and iron deficiency anemia (IDA) in children and that IDA is a possible risk factor for FS, as well as controversies in previous studies in this field, in this study, the relationship between iron deficiency anemia and FS in children was investigated. Methods: This is a case-control study that investigates the relationship between febrile seizures with anemia in 150 patients aged six months to five years with fever who were admitted to Imam Sajjad Yasouj Hospital, from April to August of 2014. In this study, 75 patients with febrile seizures (case group) and 75 febrile patients without seizures (control group) were compared. Cause of fever (urinary infection, gastrointestinal infections, upper respiratory infection, lower respiratory infection and other causes), Information about blood cell count (white blood cell (WBC) and red blood cell (RBC), hemoglobin (HB), mean red blood cell volume (MCV) and serum ferritin level in patients with hemoglobin below 11 were recorded. Results: The mean age of the study population was 21. 4 14 months. 34. 7% of the study population were girls and 65. 3% were boys. In this study, 10. 7% of the cases and 8% of the controls had IDA. Although the prevalence of IDA was higher in the FS group, this difference was not significant (P=0. 58). Also, HB and MCV were not significantly different in the two groups (P=0. 49, P=0. 69). In addition, the mean serum ferritin level in the FS group with anemia and the FS group with anemia did not show a statistically significant difference (P=0. 94). Conclusion: According to the result of this study, IDA is not a risk factor for seizures in febrile children.

Background: Double lumen tube (DLT) is used in lung surgeries. Classically, the patient should undergo fiberoptic bronchoscopy (FOB) to confirm the location of the DLT and its proper function. However, the sensitivity of ultrasound and clinical methods in diagnosing the correct position of DLT has not yet been definitively determined. This study was designed to assess the accuracy of point-of-care ultrasound and auscultation versus Fiberoptic Bronchoscope in determining the position of the Double-Lumen Tube. Methods: This cross-sectional study of diagnostic value measurement type was conducted on patients who were candidates for double lumen implantation. After induction of anesthesia, DLT with the appropriate size was implanted, and then the position of DLT was evaluated. In the first step, the lungs were examined by auscultation, then the ultrasound was performed, and two signs of lung pulse sign and lung sliding sign were examined as signs of normal lung and ventilated lung. FOB was performed by an anesthesiologist. At the end, by opening the chest after surgery, the surgeon's opinion about the quality of lung collapse was recorded. Results: In our study, the correct placement of the tube was correct in 37 cases and wrong in 3 cases, which were checked and corrected by FOB. Vital signs of the patients were stable before and during the operation. There were no problems with anesthesia during the surgery. Diagnostic sensitivity of lung auscultation clinical examination was 64. 9% and chest ultrasound was 91. 9%. The sensitivity of ultrasound compared to auscultation was not significant (P=0. 242), but there was a clinically significant difference in the positive predictive value of the two, so that the positive predictive value of lung auscultation was 88. 9% and lung ultrasound was 91. 9%. In terms of surgeon satisfaction level, 22 cases (59. 5%) had excellent satisfaction and 15 cases (40. 5%) had moderate satisfaction. The sensitivity of ultrasound was not significant in comparison with the surgeon's satisfaction. Conclusion: Ultrasound can be a good substitute for FOB. Although ultrasound cannot have all the functions of FOB, but having advantages such as lower cost, speed of operation, and non-invasiveness, makes it more practical than FOB.

Background: Given the limited resources of health system, economic evaluations studies can provide appropriate evidences for resource allocation by clarifying the possible consequences of a decision. Present study aimed to evaluate the implemented approaches for economic evaluation studies of pharmacoeconomic in Iran. Methods: This study was carried out using the critical review method. All studies related to economic evaluation studies of pharmacoeconomic in Iran, indexed in PubMed and SID databases and Google Scholar search engine, were searched by using appropriate keywords and search strategies until 2021. Further, published papers from Iranian researchers in the field of health economics and pharmacoeconomics and pharmaceutical administration were extracted with the scientometric system of the Health Ministry. Then, retrieved papers were screened by title, abstract, and the whole text. Finally, papers were evaluated by applying the Drummond quality assessment checklist, and finally appropriate ones were selected. Finally, 29 papers were selected and analyzed. Results: Out of total available papers (n=1324), 29 papers had inclusion criteria to evaluate. The selected papers were analyzed based on 10 parameters, including type of analysis, type of comparator, source of clinical effectiveness, time horizon, used model, perspective of the analysis, measured expected outcomes, discounting of costs and outcomes, sensitivity analysis, and subgroup analysis. Most studies have used cost utility analysis. Shortcomings were found in some aspects as follows: some studies did not mention the applied model, or the time horizon. Moreover, some studies had time horizon more than one year, while the cost and consequences were not discounted. Conclusion: In recent years, economic evaluation studies in the field of pharmacoeconomic in Iran have been center attention in line with global trend. In order to make a decision regarding the allocation of resources based on the findings of economic evaluation studies, these studies should be conducted with the systematic and transparent approach. Therefore, it is necessary to develop a standard framework for implementing and reporting the results of economic evaluation studies in Iran.

Background: Mendelian randomization (MR) is a new generation in the statistical method that uses genetic variants as instrumental variables in data from nonexperimental studies to evaluate and estimate the causal effects of risk factors. Methods: The weakness of observational studies to detect causality, the difficulties of conducting clinical trials, the dramatic advancement of Genome-Wide Association Studies (GWAS) have led to the emergence of a new type of study called MR. It is increasingly being used to determine causality MR is an approach based on metaanalysis methods. The main idea of the MR is based on using the instrument variable (IV) to find the causality between exposure and outcome. This variable does not need to adjust the confounding effects found in observational studies. Results: Data for this study were collected from the beginning of January 2003 to October 2020 in PubMed. Our results showed that MR has an increasing trend. The data used in MR includes summarized statistical data, individual-level data, and metaanalysis. Choosing the suitable IV is essential to successfully conduct an MR. For an unbiased estimate, three main hypotheses should be considered: 1) The IV has a strong relationship with the desired exposure (i. e., potential risk factor), 2) The IV is not related to the confounding variable, and 3) The IV is not directly related to the outcome and should only relate to the outcome through exposure. If these conditions are not met, one solution is to use robust methods. Besides, this research introduced the study designs, estimation methods, limitations, software packages, and some applications of MR in medical research. Conclusion: When we seek to find a causal relationship, but it is not possible to use a clinical trial as a standard method, the MR design can be used in observational studies. Therefore, it is possible to obtain causal relationships between exposure and outcome using the MR.

Background: Sporadic lymphangioleiomyomatosis (S-LAM) is a rare disease that generally affects young women and involves the abnormal proliferation of smooth muscle cells (LAM cells) in the lungs (pulmonary LAM). There are two types of LAM, sporadic and LAM with tuberous sclerosis, which is an autosomal dominant genetic disease caused by mutations in the Tsc1 and Tsc2 genes. The most common manifestation of this disease is pneumothorax due to cyst rupture. Median transplantfree survival for pulmonary LAM is 23 years from diagnosis. Factors associated with a poor prognosis are often those associated with a more rapid decline in lung function. Case Presentation: The patient was a 24-year-old woman who presented with pneumothorax and multiple bullae in both lungs. The patient had no family history of respiratory disease, and the patient herself had no symptoms other than mild shortness of breath following activity from a year ago. A lung CT scan was performed for the patient and multiple bullae were evident in both lungs, which confirmed the diagnosis. There was no evidence of involvement of other organs but the lung. For the patient in the ICU with the diagnosis of left pneumothorax, a chest tube was inserted and she underwent mechanical ventilation. Finally, after 24 days of hospitalization, oxygen therapy of the patient was performed with a normal mask, and she underwent left lung pleurodesis with talcum powder, and a few days later, right lung pleurodesis was performed on the patient. On the 36th day of hospitalization, her general condition improved and she was discharged from the ICU. The patient was discharged in good general condition and had no problem on her four months follow-up. Conclusion: Fortunately, with the diagnosis of LAM for the patient according to the CT scan of the patient's lung, she was treated with insertion of a chest tube and by performing pleurodesis, the recurrence of pneumothorax was prevented. In a young woman with spontaneous pneumothorax, sporadic LAM is one of the differential diagnoses.