Medical Journal of the Islamic Republic of Iran最新文献

Background: The health system (HS) is characterized by its complexity and the interconnectivity of its various components, which can lead to unpredictable outcomes when faced with changes in the environment. Understanding these interactions is crucial for effective management and improvement of the system. To navigate this complexity, this study emphasizes the importance of adopting a real-world perspective and utilizing system modeling techniques. These approaches allow for a thorough analysis of the current state of the HS and enable the testing of different policy alternatives to identify potential improvements. Ultimately, the aim of the research is to pinpoint the key components and drivers within the HS. By modeling the dynamics of these elements, the study aims to provide insights that can inform better decision-making and enhance the overall effectiveness of health care delivery.

Methods: We designed a mixed methods study in 4 phases, consisting of sequential quantitative and qualitative analyses. In the first phase, to create a comprehensive and holistic view, we will identify key variables and indicators in the HS within the framework of the Balanced Scorecard framework (BSC), which includes population & population health; service delivery; financing; growth & development; and governance & leadership, through a review of documents and a scoping review. In the second and third phases of the study, using a foresight and systemic approach, expert opinions will be purposefully gathered through cross-impact analysis (CIA) and scenario writing to identify key drivers and levers of Iran's HS and obtain compatible future scenarios. Finally, in the quantitative phase of the study, based on the outputs of the previous phases, a dynamic model of the HS will be designed in the Vensim software, and the current situation along with other possible scenarios for the system will be examined for a period of 10 years.

Conclusion: It is anticipated that the results of this study could offer a methodological foundation for formulating the health component of the Islamic Republic of Iran's economic, social, and cultural development plan, intended for use by the Ministry of Health, Treatment, and Medical Education.

Background: Midaortic syndrome (MAS) is a rare medical condition characterized by thoracoabdominal aortic stenosis or occlusion, resulting in decreased blood supply to the organs and tissues in the lower half of the body. We report a very rare presentation of MAS in a 14-year-old female that was found to have severe stenosis extending from the descending aorta to the level above the bifurcation.

Case presentation: A 14-year-old female with Williams syndrome presented with complaints of headache and chest discomfort on mild exertion. Examination revealed dysmorphic features of William syndrome and different blood pressure between the upper and lower limbs with weak femoral pulses. An ECG showed sinus rhythm with left ventricular hypertrophy. 2-D color flow Doppler echocardiogram revealed mild central mitral regurgitation, minimal aortic regurgitation, and concentric left ventricular hypertrophy. CT angiogram revealed a hypoplastic descending thoracic aorta, an aberrant right subclavian artery, and an arterio-venous fistula communicating between the bronchial artery and the left brachiocephalic vein. The patient was started on two antihypertensive medications, and vascular surgery was consulted for possible future intervention.

Conclusion: Management of midaortic syndrome necessitates a holistic approach customized to the specific patient's requirements and risk assessment. Early detection and intervention are critical in averting severe complications and enhancing long-term prognoses. Continuous investigation and advancement of novel therapies may present supplementary possibilities for addressing this complex and rare ailment.

Background: Rectal cancer (RC) is one of the most commonly occurring cancers in Iran in recent years. Dietary intakes of Omega-3 (ω-3), Omega-6 (ω-6), and fiber have been thought to diminish the risk of RC. Therefore, this study was conducted to evaluate the association of dietary ω-3, ω-6, and fiber with the risk of RC.

Methods: In this case-control study, dietary intakes of ω-3 and ω-6 were estimated using a 148-item food frequency questionnaire (FFQ) between 363 people (162 cases, 201 control) aged 20-80 years old. Cases were patients with RC, and controls were healthy people. Odds ratios (OR) and 95% confidence intervals (CI) were assessed using logistic regression models.

Results: According to the multiple logistic regression model with the backward method, dietary fiber intake was inversely associated with RC as a protective factor (OR=0.3; 95%CI= 0.1-0.9; P=0.038). Also, it was observed that dietary ω-3 had an inverse borderline association with RC (OR= 0.5; 95%CI= 0.3-1.02; P=0.060), after adjusting for other studied variables. However, the association of ω-6 with RC was not statistically significant (OR=1.1; 95%CI= 0.7-1.8; P=0.730).

Conclusion: Although no association between ω-3 and ω-6 intake was observed with the risk of RC, adequate daily intake of dietary fiber may protect us against RC risk.

Background: Phantom limb pain (PLP) is a debilitating condition leading to the experience of pain in a limb that has been amputated. Pharmacological interventions have been proposed to prevent chronic PLP. However, results of these interventions are still controversial. This systematic review and meta-analysis clarifies the effectiveness of preemptive pharmacological interventions in prevention of chronic phantom pain by evaluating incidence and intensity of PLP, residual limb pain (RLP), quality of life (QoL), depression, and anxiety.

Methods: We systematically searched the PubMed, Embase, Scopus, Web of Science, and Cochrane Library databases for published randomized clinical trials with the outcomes of incidence and intensity for PLP, RLP, QoL, depression, and anxiety in amputation candidates due to any reason. We used the Risk of Bias tool (ROB2) to assess the quality of evidence. Relative risks and mean differences were calculated by a fixed-effects model, and sensitivity analysis was conducted post-hoc for risk of bias. We presented the results using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) tables.

Results: Overall, 20 studies were found to address outcomes of interest at 6 months or longer. In 18 studies, intervention was planned for lower limb amputations. Peripheral vascular disease was the most studied cause for amputation. Intervention showed a mean reduction of 0.63 (0.10- 1.15) in 6-month intensity of PLP with low certainty of evidence. Evidence for Ketamine, Gabapentin, Valproic Acid, Calcitonin, Amide local anesthetics such as bupivacaine via epidural and perineural catheters did not support reduction in PLP.

Conclusion: Imprecision due to small sample sizes, inadequate blinding, and publication bias downgraded the quality of evidence in this clinical scenario. Overall, preemptive perioperative pharmacological interventions do not seem to prevent phantom pain or stump pain compared with conventional perioperative pain control methods. Further robust studies are required for the effectiveness of Memantine in the prevention of chronic PLP.

Background: Magnetic cell targeting holds significant promise for advancing cell therapy. This study reviewed recent experimental research on the use of magnetic particles for targeting mammalian cells in animal models, focusing on trends and therapeutic outcomes over the past five years.

Methods: A systematic search of PubMed, Cochrane Library, and eLibrary (2019-September 2024) was conducted using keywords: "magnetic cell targeting," "magnetic cell delivery," "magnetic cell localisation," and "magnetic cell guidance," excluding "drug." Inclusion criteria: original animal studies using mammalian cells labeled with magnetic nano- or microparticles and targeted via magnetic fields. Exclusion criteria included reviews, subcellular structures targeting, hyperthermia, tissue engineering, and in vitro-only studies.

Results: Of 10,908 studies, 39 met the criteria. Research focused on the nervous system (39%), cancer (10%), eye (10%), urinary tract (10%), heart (8%), and musculoskeletal diseases (8%). Targeted cells included mesenchymal stromal cells (59%), immune cells (15%), endothelial cells (13%), and others. Superparamagnetic iron oxide nanoparticles (37 studies) or microparticles (2 studies) were used, with sizes of 10-170 nm (95%) or 1-2.8 μm. Common coatings included poly-L-lysine, dextran, polydopamine, and silica. Labeling concentrations ranged from 20-100 μg Fe/ml (81%), with 4-24 hours incubation. Permanent magnets (95%, primarily neodymium) with 0.005-1.45 T induction were used. Magnetic targeting increased local cell concentration by 1.16-20 times in 19 studies and enhanced therapeutic effects in 85% of cases, though one study reported inferior results.

Conclusion: Magnetic cell targeting demonstrates significant potential for enhancing cell therapy efficacy, with improved local cell retention and therapeutic outcomes in diverse disease models. Further research is needed to optimize protocols and expand clinical applications.

Background: Timely diagnosis of small bowel obstruction (SBO) is essential to prevent complications. While computed tomography (CT) is the gold standard for diagnosing SBO due to its high sensitivity and specificity, it has notable limitations, including radiation exposure, high cost, delayed diagnosis, and limited accessibility. Recently, ultrasound has gained attention as a potential alternative in emergency departments (ED) because it is radiation-free, cost-effective, and accessible. This multi-center study seeks to assess the diagnostic accuracy of ultrasound in identifying SBO among patients presenting to the ED.

Methods: This multicenter cross-sectional study included 100 patients with suspected SBO, examined by a trained ED physician using ultrasound and confirmed by CT. Ultrasound findings evaluated were excessive gas, bowel wall thickening, interloop free fluid, lumen diameter ≥2.5 cm, and decreased peristalsis. Sensitivity, specificity, and likelihood ratios were calculated for each finding.

Results: We found that the most efficient parameters were lumen size greater than 2.5 cm (efficacy: 73%, 95%CI: 63% - 81%), and a decrease in peristalsis (efficacy: 73%, 95%CI: 63% - 81%), The most specific parameters were excessive gas (specificity: 89%, 95%CI: 75% - 97%) and thickening of the bowel wall (specificity: 82%, 95%CI: 66% - 92%). The most sensitive parameters were interloop free fluid (sensitivity: 77%, 95%CI: 65% - 87%) and lumen diameter ≥ 2.5 cm (sensitivity: 77%, 95%CI: 65% - 87%) among other diagnostic findings.

Conclusion: Ultrasound may be a useful diagnostic tool for SBO in the ED, offering a potentially efficient and accessible option for diagnosis.

Background: Hematopoietic stem cell transplantation (HSCT) is a critical therapeutic option for patients with specific malignancies. This study aimed to elucidate the epidemiological profile of HSCT to address existing gaps in understanding regional trends and outcomes over 14 years at a single center.

Methods: This retrospective cohort study analyzed the medical records of all patients who underwent HSCT at the Bone Marrow Transplant (BMT) ward of Urmia Imam Khomeini Hospital in Iran, from December 2010 to December 2024. Comprehensive evaluations of clinical and demographic characteristics were conducted during the pre-HSCT period. Data collection focused on post-transplant clinical outcomes and complications, adhering to standardized definitions to ensure unbiased estimates.

Results: This study examined 280 HSCT patients, predominantly men (59.6%), with a mean age of 45.85 years (SD, 13.70). Autologous HSCT comprised 76.43% of cases, followed by allogeneic (21.78%) and haploidentical donor HSCT (1.79%). The primary indications were multiple myeloma (48.9%) and acute myeloid leukemia (24.3%). The median overall survival (OS) was 77 months (95% CI: 62.05-91.95), and a 5-year OS rate of 54%. The mean disease-free survival (DFS) was 86.21 months (95% CI: 74.62-97.81), with a 5-year DFS rate of 67%. The cumulative incidence of acute graft-versus-host disease (acute GVHD) was 59.2% at 100 days post-transplant (61% in allogeneic and 40% in haploidentical patients), with skin being the most affected organ (78.12%). Last, 20.2% of the mortality in the total population with available acute GVHD was attributed to having grades 3 and -4 acute GVHD.

Conclusion: These findings underscore the viability of hematopoietic stem cell transplantation in resource-limited settings, highlight areas for improvement in post-transplant care-particularly regarding severe acute GVHD-and offer valuable insights to guide clinical practice and health policy in similar regional centers.

Background: While microalbuminuria is established in left heart dysfunction prognostication, its relationship with right ventricular (RV) function remains unclear. We investigated whether microalbuminuria predicts early-stage RV dysfunction in patients with normal coronary arteries.

Methods: This cross-sectional analysis involved 117 patients with angiography-verified non-obstructive CAD. Comprehensive RV echocardiography (including E/e' ratio) and morning urine albumin-creatinine ratio (UACR) measurements were performed. The study patients were categorized into 67 with normal albuminuria (mAlb (-): UACR <30 mg/g) and 50 with microalbuminuria (mAlb (+): UACR 30-300 mg/g). Multivariable logistic regression evaluated microalbuminuria's relationship with RV metrics, adjusting for sex, age, and BMI. A P<0.05 denoted statistical significance.

Results: The mAlb (+) group demonstrated significantly higher RV E/e' ratios (P=0.026), persisting after adjustment. Logistic regression revealed that microalbuminuria independently predicted elevated RV filling pressure (OR 2.88, 95% confidence interval 1.22-6.84, P=0.016). Male sex showed non-significant trends (OR 1.69, P=0.286). RV systolic dysfunction prevalence was comparable between groups (16.4% overall, p=NS).

Conclusion: Microalbuminuria independently associates with elevated RV filling pressures in non-obstructive CAD patients, suggesting shared microvascular pathophysiology. This supports albuminuria screening's potential role in identifying subclinical RV dysfunction, though longitudinal studies are needed to establish causality.

Background: Hemodialysis (HD) patients frequently experience uremic pruritus, a condition that is both irritating and prevalent. Although its pathogenesis is not entirely understood, it is believed to be multifactorial. The objective of this investigation was to evaluate the renal osteodystrophy indices in patients undergoing hemodialysis with and without pruritus.

Methods: This cross-sectional study categorized HD patients in 3 university hospitals in Mashhad, northeast Iran, during 2022 and 2023 into 2 groups: those with and those without pruritus, as determined by the diagnostic criteria. The visual analog scale parameter was employed to evaluate the severity of pruritus. Each patient's blood urea nitrogen, creatinine, calcium, phosphorus, and intact parathyroid hormone (iPTH) levels were evaluated. The data were analyzed using SPSS software Version 16. An independent sample t test and the Mann-Whitney U test, as well as the Spearman correlation test, were used for analysis.

Results: A total of 120 participants with a mean age of 57.91 ± 16.03 years were included in the study. The findings showed that the mean blood levels of calcium (P < 0.001), phosphorus (P < 0.001), creatinine (P < 0.001), alkaline phosphatase (P = 0.002), and calcium phosphate product (P < 0.001) were significantly higher in the pruritic group. However, the mean blood urea nitrogen (P = 0.458) and iPTH levels (P = 0.139) did not differ significantly between the 2 groups, but there was a significant relationship between iPTH level and the severity of pruritus (P < 0.001).

Conclusion: The itching severity in HD patients is substantially correlated with their iPTH levels, and the majority of the indices of renal osteodystrophy are significantly higher in patients with this complication. However, additional studies are suggested.

Background: The femoral head's blood supply, primarily provided by the medial circumflex femoral artery (MCFA), is vulnerable to mechanical interruptions caused by traumatic or iatrogenic events. Disruption of this blood flow is associated with an inherent risk of avascular necrosis (AVN), which significantly impairs the surgical outcomes. This study aimed to evaluate the impact of using the Bennett retractor on femoral head vascular integrity during simulated fracture reductions.

Methods: A descriptive cadaveric study was conducted on 10 specimens to assess vascular injury induced by the Bennett retractor. Methylene blue dye angiography was performed to visualize perfusion patterns after retractor application. The MCFA perfusion disruption was documented. The effect of MCFA location and anatomical variations in this disruption was also investigated. No statistical analysis was performed due to the small sample size and descriptive nature of the study.

Results: Vascular disruption was observed in 9 out of 10 cadaveric specimens (90%), as demonstrated by reduced MCFA perfusion in angiographic evaluation. In 1 case without MCFA compromise, the MCFA was located along the medial border of the femoral neck. Anatomical variations in the MCFA's origin (90% profunda femoris, 10% femoral artery) and position were noted, although these variations did not influence the incidence of injury incidence.

Conclusion: The Bennett retractor poses a significant risk of iatrogenic MCFA injury during femoral neck fracture reduction, emphasizing the need for alternative techniques or devices to minimize vascular compromise. Further research is required to explore the clinical implications of anatomical variations and develop strategies to mitigate AVN risk.