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Port site infection (PSI) is a rare complication of laparoscopic surgery that can reduce the benefits of this minimally invasive surgery and increase postoperative complications. As a variety of disposable ports (single-use ports) and reprocessed ports are used in laparoscopic surgeries, this study was conducted to compare the incidence of PSI in disposable ports and reprocessed disposable ports in laparoscopic cholecystectomy (LC).In this prospective cohort study, 473 patients were studied. Two hundred fifteen and two hundred fifty eight were in the disposable port group and reprocessed disposable port group, respectively. The demographic characteristics and incidence of superficial and deep infection were evaluated using the researcher-made checklist of infection assessment standards at intervals of 3 to 5 and 5 to 14 days following LC using call and physical examination on day 14. Data analysis was performed using descriptive statistics and statistical tests in SPSS software.The incidence of PSI, 3 to 5 and 5 to 14 days after surgery in the reprocessed disposable port group was significantly higher than that in the disposable ports group. In both groups, all PSI accrued in the epigastric port area (where the gallbladder was removed) ( P0.05).On the basis of the results, our study suggests using disposable ports instead, and in the case of using reprocessed disposable ports in LC, upgrading of disinfection and sterilization techniques is necessary.

The inter-individual variability of CYP450s enzyme activity may be reduced by comparing the effects of bariatric surgery on CYP-mediated drug elimination in comparable patients before and after surgery. The current research will use a low-dose phenotyping cocktail to simultaneously evaluate the activities of six CYP isoforms and P-gp. The results showed that following weight reduction after surgery, the activity of all enzymes increased compared to the obese period, which was statistically significant in the case of CYP3A, CYP2B6, CYP2C9, and CYP1A2. Furthermore, the activity of P-gp after surgery decreased without reaching a statistical significance (p-value > 0.05). Obese individuals had decreased CYP3A and CYP2D6 activity compared with the control group, although only CYP3A was statistically important. In addition, there was a trend toward increased activity for CYP1A2, CYP2B6, CYP2C9, and CYP2C19 in obese patients compared to the control group, without reaching statistical insignificance (p-value ≥ 0.05). After six months (at least), all enzymes and the P-gp pump activity were significantly higher than the control group except for CYP2D6. Ultimately, a greater comprehension of phenoconversion can aid in altering the patient’s treatment. Further studies are required to confirm the changes in the metabolic ratios of probes after bariatric surgery to demonstrate the findings’ clinical application. As a result, the effects of inflammation-induced phenoconversion on medication metabolism may differ greatly across persons and drug CYP pathways. It is essential to apply these results to the clinic to recommend dose adjustments.

The inter-individual variability of CYP450s enzyme activity may be reduced by comparing the effects of bariatric surgery on CYP-mediated drug elimination in comparable patients before and after surgery. The current research will use a low-dose phenotyping cocktail to simultaneously evaluate the activities of six CYP isoforms and P-gp.The results showed that following weight reduction after surgery, the activity of all enzymes increased compared to the obese period, which was statistically significant in the case of CYP3A, CYP2B6, CYP2C9, and CYP1A2. Furthermore, the activity of P-gp after surgery decreased without reaching a statistical significance (p-value>0.05). Obese individuals had decreased CYP3A and CYP2D6 activity than the control group, albeit only CYP3A was statistically important. In addition, there was a trend to increase activity for CYP1A2, CYP2B6, CYP2C9, and CYP2C19 in obese patients compared to the control group, without reaching statistical insignificance (p-value≥0.05). After six months (at least), all enzymes and the P-gp pump activity were significantly higher than the control group except for CYP2D6.Ultimately, a greater comprehension of phenoconversion can aid in altering the patient's treatment. Further studies are required to confirm the changes in the metabolic ratios of probes after bariatric surgery to demonstrate the findings' clinical application. As a result, the effects of inflammation-induced phenoconversion on medication metabolism may differ greatly across persons and drug CYP pathways. It is essential to apply these results to the clinic to recommend dose adjustments.

Background In acute myocardial infarction (AMI), timely recognition of symptoms and early hospital presentation positively affect patient morbidity and mortality. Due to the high burden of ischemic heart disease in Iran, this study aimed to identify factors affecting the level of knowledge, responses at the time of AMI onset, and sources of health information among the Iranian population. Method This cross-sectional study was conducted in three tertiary hospitals in Tehran, Iran. An expert-validated questionnaire was used to obtain data. A total of 400 individuals were enrolled. Result Among the respondents, 285 people(71.3%) considered “chest pain or discomfort,” and 251 (62.7%) regarded “pain or discomfort in the arm or shoulder” as MI symptoms. Approximately 288 (72.0%) respondents had poor knowledge of the AMI symptoms. Knowledge of symptoms was higher among those with higher levels of education, those with medical-associated jobs, and those who resided in the capital areas. Major risk factors identified by the participants were: anxiety (340)(85.0%), obesity (327)(81.8%), an unhealthy diet (325)(81.3%), and the presence of high LDL levels (258)(64.5%) and Diabetes Mellitus (164)(41.0%) were less appreciated. Calling an ambulance (286)(71.5%) was the most common treatment-seeking behavior in the case of a suspected heart attack. Conclusion It is vital to educate the general population about AMI symptoms, particularly those with comorbidities at the greatest risk for an AMI episode.

Cardiac hydatidosis is a relatively rare complication of echinococcosis, with a potentially life-threatening condition. Here, we reported a large interventricular septal hydatid cyst with bulging in the left ventricle accompanied by a huge cervical lamp with recurrent hepatic cysts that underwent cardiac surgery to excise the cyst uneventfully.

Background Nearly half of the patients with hypereosinophilic syndrome (HES) have cardiovascular involvement, a major cause of mortality. COVID-19 infection can lead to cardiac involvement, negatively impacting the clinical course and prognosis. We reported two patients with HES complicated by COVID-19, with cardiac involvement and valve replacement. Case presentation Our first patient was a 27-year-old woman admitted due to dyspnea and signs of heart failure. She had severe mitral stenosis and mitral regurgitation on the echocardiogram. Corticosteroid therapy improved her symptoms initially, but she deteriorated following a positive COVID-19 test. A repeated echocardiogram showed right ventricular failure, severe mitral regurgitation, and torrential tricuspid regurgitation and, she underwent mitral and tricuspid valve replacement. Our second patient was a 43-year-old man with HES resulted in severe tricuspid stenosis, which was improved with corticosteroid treatment. He underwent tricuspid valve replacement due to severe valvular regurgitation. He was admitted again following tricuspid prosthetic mechanical valve thrombosis. Initial workups revealed lung involvement in favor of COVID-19 infection, and his PCR test was positive. Conclusion COVID-19 infection can change the clinical course of HES. It may result in a heart failure exacerbation due to myocardial injury and an increased risk of thrombosis in prosthetic valves or native vessels due to hypercoagulability.

Atrial fibrillation is associated with low-flow state and increased thrombogenicity in the left atrium (LA). Multiple echocardiographic presentations, including thrombosis, sludge, and smoke formation, have been demonstrated in just one biplane transesophageal echocardiographic view, along with normal structures, i.e., pectinate muscles and Coumadin ridge, which are highly educational for cardiologists.

Background Preoperative cardiovascular risk assessment is one of the main principles before noncardiac surgeries. Cardiac stress imaging, such as myocardial perfusion scan (MPI), is one of the proposed cardiac risk evaluation methods according to the latest guidelines. Yet, its efficacy, along with the cost-effectiveness of the method, has been questioned in previous studies. Our study aims to evaluate the utility of NT-proBNP level measurement in predicting postoperative cardiovascular complications in candidates who have undergone an MPI scan before surgery and compare the results. Methods A cohort of 78 patients with an RCRI score of one or more who were scheduled for high to moderate-risk noncardiac surgeries and met the criteria to undergo an MPI scan for risk assessment were included in the study. All patients underwent an MPI scan one week before surgery. Their preoperative NT-proBNP, troponin levels, and ECGs were obtained one day before surgery. The predictive efficacy of NT-proBNP levels and MPI scans were compared. Results Seventy-eight patients underwent surgery, of which three patients exhibited a rise in troponin level, six showed ECG changes, and pulmonary edema was detected in one patient three days after surgery. There was no mortality. The sensitivity and specificity of the MPI scan for predicting postoperative adverse cardiovascular outcomes were 100% and 66%, respectively. MPI scan also had a positive predictive value (PPV) of 20% and a negative predictive value (NPV) of 100%. A 332.5 pg/ml cut-off value for NT-proBNP level yielded a sensitivity of 100%, specificity of 79.2%, PPV of 40%, and NPV of 100%. Conclusions This study reveals the incremental prognostic value of NT-proBNP level measurement in preoperative cardiac risk evaluation compared to an MPI scan. Given the low feasibility, high costs, and disappointing predictive value of MPI scans, preoperative NT-proBNP level assessment can be substituted. This method can assist anesthesiologists and surgeons with detecting at-risk patients resulting in taking proper measures to reduce morbidity and mortality in the preoperative period.

Background: Endocarditis is an infection of the endocardial layer of the heart known as fatal infection. Gold standard diagnosis of infectious endocarditis is blood culture, which in some cases can be negative. In blood culture-negative endocarditis, the early diagnosis, and treatment are much harder, which can increase morbidities and also mortality. Case presentation: In this case report we are presenting a patient with intermittent fever for three months with a history of aortic and pulmonary valve replacement and also recurrent blood culture-negative endocarditis. According to the pandemic situation, we checked the Covid-19 PCR and also performed a chest computed tomography (CT) -scan, which both were negative and did not represent any pathologic conditions. Other examinations such as transesophageal echocardiography (TEE) and blood cultures were all normal and the only abnormal finding we had was a positron emission tomography (PET) - CT scan with endocarditis and sternum osteomyelitis evidence. Conclusion: After several evaluations based on endemic epidemiology, the Real-time PCR and IFA (IgG phase I; 1:16384, IgG phase II; 1:16384) were positive for Q fever and the patient responded to the proper doxycycline and hydroxychloroquine treatment.

Congenital heart disease is a risk factor for infective endocarditis. Ventricular septal defects and ventricular outflow tract obstructions are the most common causes of endocarditis in this population. We presented a patient diagnosed with leukocytoclastic vasculitis with renal and pulmonary involvement with right-sided infective endocarditis as an etiology for vasculitis.

Purpose: Introducing tricuspid annular systolic excursion (TAPSE)-slope and assessing inter-observer variability of its timing measurements Methods: We performed comprehensive Doppler echocardiographic examinations on 84 healthy subjects (mean age: 36.3 years, range: 30-50 years, 51 women, 33 men). In color-coded M-mode tracing of right ventricle’s free wall, peak systolic excursion was defined. TAPSE and time from initial QRS to peak systole in color-coded M-mode were measured, and TAPSE-slope was calculated based on this formula: TAPSE slope=TAPSE/TAPSE-t. For the evaluation of inter-observer variability, two other cardiologists measured TAPSE-t in offline mode separately. Results: The average (SD) of the “TAPSE-slope” was 7.0(1.0) cm/sec, the average (SD) TAPSE was 2.42(0.3) cm, and an average TAPSE-t of 343(27.6) msec. A significant difference was seen in TAPSE-slope between men and women (P value=0.001). No significant difference was detected in TAPSE-slope in people younger than 40 years old compared with participants older than 40 years. Intra-class correlation coefficient value of the TAPSE-t measurement was 0.886, showing excellent agreement between three different raters. Conclusion: TAPSE-slope may have added value compared to TAPSE alone for the assessment of right ventricular systolic function.

Purpose LV diastolic dysfunction has often been described as a sensitive sign of early graft rejection. Assessment of left ventricular filling pressure by echocardiography in heart transplant (HTx) recipients is challenging. We aimed to investigate the ability of echocardiographic indices to detect elevated Left ventricular end-diastolic pressure (LVEDP) in HTx patients. Methods This descriptive cross-sectional study included 39 HTx recipients who were candidates for endomyocardial biopsy as a part of their routine post-transplantation surveillance. Doppler transthoracic echocardiography was done before the procedure, and left heart catheterization was done during the endomyocardial biopsy. Results Thirty-nine patients (15 female, 24 male), with the mean age of 39.6 years (range 13 to 70), were enrolled. A strong relation was observed between lateral E/e’ and LVEDP (R = 0.64, P-value

Personalized therapy suggests the appropriate drug at the right dose for the first time through genotype-based individualized therapy, instead of prescribing medicines by the traditional one-size-fits-all manner, thereby claiming that it will make medicines safer and more effective. Accordingly, polymorphisms of drug metabolizing enzymes (DMEs), which induce inter-individual variability in the pharmacokinetics of a drug, have attracted great interest in the context of personalized medicine. Obesity is one of the most common chronic diseases in the world, including Iran, and the prevalence is increasing according to predictions. The remarkable role of P450 cytochromes has been verified in the metabolism of numerous drugs, toxins, carcinogen compounds, and the synthesis of some intrinsic compounds, such as steroid hormones. Thus, evaluating the activity of these enzymes is of great importance because any functionality variation can lead to failure in the treatment or unwanted side effects of some drugs. Therefore, any change in the activity of these enzymes in obese patients can also be problematic in the treatment process of these patients in comparison to normal weighted ones. Since only a few human studies have examined the role of inflammation in altering the function of these enzymes, it seems to be necessary to investigate the effect of obesity on the expression and activity of these enzymes; in which the role of inflammatory processes has been proven. Most importantly, it is worth evaluating changes in the activity levels of cytochrome P450 (CYP450) and the inflammatory cytokines after a course of post-surgical treatment and weight loss. To evaluate the activity of CYPs, a multi-drug cocktail is prescribed to obese patients before and after obesity surgery, as well as to healthy volunteers, to provide simultaneous evaluation of different isoforms. A complete demographic data, medical examinations, laboratory tests, and the CYPs genotype of all participants can be extremely important during this investigation.

Background Nearly half of the patients with hypereosinophilic syndrome (HES) have cardiovascular involvement, a major cause of mortality. COVID-19 infection can lead to cardiac involvement, negatively impacting the clinical course and prognosis. We reported two cases of HES with cardiac involvement resulting in valve replacement, which were complicated by COVID-19. Case presentation: Our first case was a 27-year-old woman admitted due to dyspnea and signs of heart failure. An echocardiogram revealed severe mitral stenosis and mitral regurgitation. Corticosteroid therapy resulted in the improvement of her symptoms. However, she deteriorated during her hospital course following a positive COVID-19 test. A repeated echocardiogram showed right ventricular failure with severe mitral regurgitation and torrential tricuspid regurgitation. Therefore, she underwent mitral and tricuspid valve replacement. Our second case was a 43-year-old man with HES resulted in severe tricuspid stenosis. Corticosteroid treatment improved tricuspid stenosis, but he underwent valve replacement due to severe valvular regurgitation. He was admitted following tricuspid prosthetic valve thrombosis. Initial workups revealed lung involvement in favor of COVID-19 infection, and his PCR test was positive. Conclusion COVID-19 pandemic can change the clinical course of HES. It may result in a heart failure exacerbation due to myocardial injury and an increased risk of thrombosis in prosthetic valves or native vessels due to hypercoagulability.

Solid-organ transplantation recipients were assumed highly vulnerable to coronavirus disease 2019 (COVID-19). However, the results of previous studies in patients with orthotopic heart transplantation (OHT) under immunosuppressive therapy are contradictory. Therefore, we aimed to assess the prevalence of COVID-19 infection and associated risk factors, along with the six-month outcomes in COVID-19 positive OHT patients. This single-center telephone-based survey was conducted on OHT patients. Using a detailed questionnaire, exposure to COVID-19, related symptoms, and preventive self-care measures were collected. Outcomes of COVID-19-positive patients were reassessed using another survey six months later. 118 OHT patients (male: n=87, 73.7%) were included with a mean age of 45.3±13.1 years. Sixteen patients (13.5%) reported one or more symptoms compatible with COVID-19, of whom 12 (10.2%) tested positive. Our results indicated no statistically significant association between COVID-19 and comorbidities. Poor adherence to self-care measures and contact with positive index cases were both significantly associated with COVID-19 infection (P

N.A. (Letter)

Background: This study aimed to investigate and compare the characteristics of abdominal pain after bariatric surgery with two techniques of Laparoscopic One-Anastomosis Gastric Bypass (LOAGB) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) in patients with morbid obesity. Methods: This prospective descriptive-analytical study was conducted on 114 patients who were candidates for bariatric surgery. Patients were entered to study in one of two groups of LOAGB and LRYGB by convenient and continuous sampling. The characteristics of abdominal pain of patients were investigated and compared at certain periods (24 and 48 hours and 10, 20, 30, and 90 days after surgery) using McGill Pain Questionnaire. Findings: The frequency of severe abdominal pain in the LOAGB group within 48 hours after surgery was significantly higher than the LRYGB group (P < 0.05). The highest abdominal pain distribution at the first 5 time periods in the two groups was in the left lower quadrant of the abdomen. The frequency of description of ambiguous pain within 48 hours and 10 days in the LOAGB group was significantly higher than LRYGB. The frequency of pattern of periodical (intermittent) pain at the periods of 48 hours and 10 and 20 days after surgery in the LOAGB group was significantly higher than LRYGB. Conclusion: The results of this study showed that there was no significant difference in the frequency of abdominal pain and its distribution between LOAGB and LRYGB groups. However, the definitive decision to choose a bariatric surgery technique for lower abdominal pain requires further study.

Background COVD-19 pandemic has overwhelmed many healthcare systems worldwide. Underlying cardiovascular disease predisposes to greater disease susceptibility and more complications including mortality. Such data is unverified in adults with congenital heart disease (ACHD). The aim of the study is to report the Tehran experience with respect to preventative self-care measures, disease exposure, susceptibility and outcomes after COVD-19 infection in ACHD patients. Methods A telephone-based survey was conducted in ACHD patients, focusing on new onset symptoms that might indicate COVID-19 infection, prevention measures, confirmed infection rates, and outcomes. Results 309 ACHD patients, mean age 29.13 years (14-72 years, SD=10.64), 170 (55%) women, were assessed. The majority (86.7%) had moderate or complex ACHD. Two-thirds (67.3%) of patients practiced high level preventative self-care measures. After community exposure, 33.3% developed COVID-19, and after household exposure 43.7% developed COVID-19. There was only 1 mortality in a post-operative patient. Thirty-seven patients (12%) reported new symptoms including cough (10%), fatigue (8%), fever (7%) and new dyspnea (6.5%). Among 18 (6%) with confirmed COVID-19 there was only 1 mortality in a postoperative patient. Age (adjusted OR=1.19, 95% CI: 1.07-1.31, p = 0.001), contact with confirmed COVID-19 cases (adjusted OR=59.34, 95% CI: 3.68-955.10, p = 0.004) were independently associated with COVID-19 infection. Conclusions Mortality risk associated with COVID-19 infection in ACHD patients with moderate or severe disease appears to be relatively low, similar to the general population. Such risk appears to act through conventional risk factors, and in this cohort, we demonstrated age as a significant risk factor in addition to exposure to the development of COVID-19 infection. Preventative self-care measures are a potentially significant and impactful intervention target for intervention and for improving outcomes. Self-care measures, disease exposure and susceptibility, and symptoms related to COVID-19 were assessed in a survey of 309 ACHD patients in Tehran. Approximately two thirds of patients practiced higher level preventative self-care measures. Thirty-seven patients (12%) reported new symptoms including cough (10%), fatigue (8%), fever (7%) and new dyspnea (6.5%). Of 18 (6%) with confirmed COVID-19, one post-operative mortality was documented, and disease was mild in the remainder. Age and contact with confirmed COVID-19 patients were independently associated with acquiring COVID-19 infection.

Accurate determination of severity of aortic valve stenosis (AS) by aortic valve area (AVA) is essential for choosing the best treatment strategy. We compared AVA quantified by 4 different in vivo echocardiographic methods with AVA measured by 3D ex vivo scanning of the excised AV. The data on 38 patients who underwent aortic valve replacement were assessed. The AVA was determined by 4 echocardiographic methods of planimetry in 2D transesophageal echocardiography [planimetry (2D-TEE)], plainemetry by multiplanar reconstruction approach in 3D transesophageal echocardiography [MPR (3D-TEE)], and two continuity equation (CE) approaches; conventional CE (2D-TTE) in which left ventricular outflow tract [LVOT] area derived by LVOT diameter obtained in 2D transthoracic echocardiography and CE (3D-TEE) in which LVOT area obtained by 3D MPR. After the surgical removal of the AV, AVA was determined by 3D ex vivo scanning. Lowest AVA mean difference with 3D ex vivo scanning was found between CE (2D-TTE), followed by CE (3D-TEE). Planimetry (2D-TEE) in male patients as well as severely and non-severely calcified valves revealed a significant higher AVA mean difference with 3D ex vivo scanning than CE (2D-TTE) and CE (3D-TEE) methods. However, with a nonsignificant effect, CE (2D-TTE) and planimetry (2D-TEE) had the least mean difference with 3D ex vivo scanning possibly due to less frequent bicuspid AV in females. CE (2D-TTE) was more accurate than other methods of AVA calculation. Moreover, CE (3D-TEE) and MPR (3D-TEE) methods had acceptable accuracy in comparison with planimetry (2D-TEE) for definition of AS severity.

Background and Aim: Cardiovascular diseases and medication errors are among the leading causes of morbidity and mortality around the world. Electronic prescribing and Medication Administration(ePMA) systems can prevent medication errors to some extent. This study aimed to determine the information requirements of ePMA systems. Materials and Methods: This descriptive study was conducted in Imam Khomeini Hospital of Tehran and School of Allied Medical Sciences affiliated to Tehran University of Medical Sciences (TUMS) in the summer of 2019 in two phases: literature review and survey-based questionnaire. Information items obtained from reviewing the texts of 100 articles were organized in three questionnaires. In the survey phase, questionnaires were distributed among physicians, nurses, and the experts of health information management(HIM) and medical informatics, using census sampling method. The reliability of the questionnaires was measured using Cronbachchr('39')s coefficient alpha. Statistical analysis was done using SPSS. Results: The findings showed that based on specialists’ point of view, patientschr('39') demographic information items and unique identifiers gained the highest average, above 4.7. Physicians agreed most with clinical information, including medication history and generic names. From the nurses’ point of view, the information items of the patients’ problems and the procedures performed and the types of drug doses obtained a complete average of 5. Conclusion: The need for information items varies among different users of ePMA systems, but there may be items that are common for them. Future studies should further investigate financial and pharmaceutical information requirements based on the perspectives of other hospital pharmacy and accounting staff.

Hepatitis C virus (HCV) causes increased mortality and morbidity in kidney transplant patients. Interferon-based therapies are poorly tolerated and involve the risk of rejection. The new direct-acting antiviral drugs (DAAs) have revolutionized the treatment of HCV infection in transplant patients. This observational study evaluates changes in immunosuppressive therapy during treatment with DAA in renal transplant recipients.In our transplant center, we selected seven HCV-positive patients at the time of transplantation , four men and three women, with an average age of 61 ± 7 years, in therapy with DAA. The dose and the blood levels of the immunosuppressive drugs were evaluated at the beginning and end of antiviral therapy, together with creatinine and proteinuria.Viremia was negativized in all patients within the initial 8 weeks of therapy. Currently, the number of patients is too limited to perform a sta-tistical analysis and obtain significant results. In one patient, the dose of Cyclosporine was lowered to 10 mg, while for the remaining patients it was not necessary to change the dose of immunosuppressive drugs.DAAs give encouraging results in the eradication of HCV in renal transplant recipients, although they are associated with potential adverse drug interactions. The preliminary data of our study suggest that it is not necessary to change the dose of immunosuppressive drugs during therapy and that creatinine and proteinuria remain stationary. We will achieve more significant results in the future, adding more patients to our study. However, further randomized trials are necessary to confirm the safety of DAAs.

Tacrolimus (FK506) is the most widely used anti-rejection drug in kidney transplantation, especially its extended release Tacrolimus formulation (ER-Tac, Advagraf), which is used when target blood levels can be difficult to reach in high metabolizer patients. In this retrospective monocentric study, we analyzed the effect of a switch from ER-Tac to LifeCycle Pharma Tacrolimus (LPCT, Envarsus) on the dose/level ratio of FK506 in high metabolizer patients that cannot achieve target blood levels in the first 6 months after transplantation.We observed a statistically significant improvement in the level to dose ratio after the switch. Renal function remained stable. We also observed a reduction in the development of tremors. Our data suggest that LPCT can be used in a safer way in high metabolizer kidney transplant recipients.

Objective: This study was conducted to evaluate the association of echocardiographic parameters used in left ventricular (LV) diastology with the early results of non-ST elevation acute coronary syndrome (NSTE-ACS) workup in the hospital. Methods: This cross-sectional study was performed on patients presenting with acute chest pain and a diagnosis of NSTE-ACS including only patients with unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI). All patients underwent transthoracic echocardiography in the emergency room (ER) within 12 hours of the last episode of chest pain. An invasive approach was not uniformly pursued in all of the patients so analysis was performed in two different settings. First, analysis was performed in the patients that underwent coronary angiography (CAG) and echocardiographic data were compared between those with normal and abnormal CAG results. Finally, echocardiographic data of the patients with normal diagnostic results (i.e., normal exercise tolerance test (ETT), myocardial perfusion imaging (MPI) or coronary angiography (CAG) results) were compared with the data of the patients with abnormal test results. Results: Eighty patients with a mean age of 54.43 ± 12.38 years were included in the study, of whom 57 (71.2%) were male. Fifty-three patients underwent CAG. In these 53 patients, there was significant difference in mitral annular velocity in early diastole (e’), ratio of mitral inflow velocity to e’ (E/e’), left ventricular end-diastolic diameter (LVEDD) and left ventricular end-diastolic pressure (LVEDP) between patients with coronary artery involvement and those with normal coronary artery (P

Background Osteoporosis is one of the most common bone system diseases that is associated with an increased risk of bone fractures and causes many complications for patients. With age, the prevalence of this disease increases so that it has become a serious problem among the elders. In this study, the prevalence of osteoporosis among elders around the world is examined to gain an understanding of its prevalence pattern. Methods In this systematic review and meta-analysis, articles that have focused on prevalence of osteoporosis in the world’s elders were searched with these key words, such as Prevalence, Osteoporosis, Elders, Older adult in the Science Direct, Embase, Scopus, PubMed, Web of Science (WoS) databases and Google Scholar search engine, and extracted without time limit until March 2020 and transferred to information management software (EndNote). Then, duplicate studies were eliminated and the remaining studies were evaluated in terms of screening, competence and qualitative evaluation based on inclusion and exclusion criteria. Data analysis was performed with Comprehensive Meta-Analysis software (Version 2) and Begg and Mazumdar test was used to check the publication bias and I2 test was used to check the heterogeneity. Results In a review of 40 studies (31 studies related to Asia, 5 studies related to Europe and 4 studies related to America) with a total sample size of 79,127 people, the prevalence of osteoporosis in the elders of the world; 21.7% (95% confidence interval: 18.8–25%) and the overall prevalence of osteoporosis in older men and women in the world, 35.3% (95% confidence interval: 27.9–43.4%), 12.5% (95% confidence interval: 9.3–16.7%) was reported. Also, the highest prevalence of osteoporosis in the elders was reported in Asia with; 24.3% (95% confidence interval: 20.9–28.1%). Conclusion The results of the present study showed that the prevalence of osteoporosis in the elders and especially elders' women is very high. Osteoporosis was once thought to be an inseparable part of elders’ lives. Nowadays, Osteoporosis can be prevented due to significant scientific advances in its causes, diagnosis, and treatment. Regarding the growing number of elderly people in the world, it is necessary for health policy-makers to think of measures to prevent and treat osteoporosis among the elders.

Background & Aims Surgical site infection (SSI) is a common postoperative complication. The observance of the aseptic technique is an effective measure to prevent SSI. The knowledge and performance of surgical technicians and technologists play a pivotal role in the proper implementation of this technique. The present study aimed to compare the knowledge and performance of surgical technicians and technologists regarding the observance of the aseptic technique. Materials & Methods This cross-sectional, comparative study was conducted during 2017-2018 on 235 surgical technicians and technologists in eight teaching hospitals in Isfahan, Iran. The participants were selected via stratified random sampling. Data were collected using a researcher-made questionnaire for the measurement of knowledge, which was completed by the participants. In addition, a researcher-made checklist was completed by the researcher after observing the performance of the participants in three surgical procedures. Data analysis was performed in SPSS version 22.0 using descriptive and analytical statistics. Results The mean score of the knowledge of surgical technicians and technologists was favorable, while their mean score of performance was average. The mean score of knowledge (P=0.047) and performance (P=0.01) was significantly higher in the surgical technologists compared to the surgical technicians. Moreover, a direct correlation was observed between the scores of knowledge and performance in both surgical technicians (P=0.027) and surgical technologists (P=0.032). Conclusion According to the results, improving the knowledge of surgical technicians and technologists regarding the aseptic technique could enhance their performance in this regard. Therefore, the findings of this study could lay the groundwork for the proper supervision of the performance of healthcare providers in order to harmonize their knowledge and performance. Furthermore, considering the higher scores of knowledge in surgical technologists compared to the technicians, it is advisable that the latter be encouraged to continue their education. The implementation of effective training programs should also be considered in order to improve the performance of operating room personnel. Keywords: Knowledge , Practice , Nurse , Operating Room , Infection

Hereditary spastic paraplegia (HSP) is a clinically and genetically heterogeneous neurodegenerative disorder, characterized by lower-limb spasticity and weakness. To date, more than 82 loci/genes (SPG1-SPG82) have been identified that contribute to the cause of HSP. Despite the use of next-generation sequencing-based methods, genetic-analysis has failed in the finding of causative genes in more than 50% of HSP patients, indicating a more significant heterogeneity and absence of a given phenotype-genotype correlation. Here, we performed whole-exome sequencing (WES) to identify HSP-causing genes in three unrelated-Iranian probands. Candidate variants were detected and confirmed in the probands and co-segregated in the family members. The phenotypic data gathered and compared with earlier cases with the same sub-types of disease. Three novel homozygous variants, c.978delT; p.Q327Kfs*39, c.A1208G; p.D403G and c.3811delT; p.S1271Lfs*44, in known HSP-causing genes including ENTPD1, CYP7B1, and ZFYVE26 were identified, respectively. Intra and interfamilial clinical variability were observed among affected individuals. Mutations in CYP7B1 and ZFYVE26 are relatively common causes of HSP and associated with SPG5A and SPG15, respectively. However, mutations in ENTPD1 are related to SPG64 which is an ultra-rare form of HSP. The research affirmed more complexities of phenotypic manifestations and allelic heterogeneity in HSP. Due to these complexities, it is not feasible to show a clear phenotype-genotype correlation in HSP cases. Identification of more families with mutations in HSP-causing genes may help the establishment of this correlation, further understanding of the molecular basis of the disease, and would provide an opportunity for genetic-counseling in these families.

Pre-transplant kidney biopsy is routinely used to decide whether kidneys from marginal donors should be transplanted as single or double trans-plantation. This is a 5-year extension of the follow-up of a previous study. In that study, graft outcomes were compared retrospectively between a group of 44 recipients of a single kidney graft from an extended criteria donor and a Karpinski histological score of 3 or less, and another group of 56 recipients of a single transplant with a Karpinski histological score of 4 or 5. After 5 years of transplantation, there was no difference between the two groups in terms of recipient’s serum creatinine levels (1.8 ± 0.5 vs 1.9 ± 0.6 mg/dL, P = 0.5), creatinine clearance (53 ± 23 vs 49 ± 27.0 mL/min, P = 0.6), or the rates of graft loss (41% vs 49%,P = 0.5). Therefore, the choice between single and double transplant should not be made only on the basis of histological score but should be done together with the evaluation of donor’s clinical parameters, especially the renal function.

Background The X chromosome has historically been one of the most thoroughly investigated chromosomes regarding intellectual disability (ID), whose etiology is attributed to many factors including copy number variations (CNVs). Duplications of the long arm of the X chromosome have been reported in patients with ID, short stature, facial anomalies, and in many cases hypoplastic genitalia and/or behavioral abnormalities. Methods Here, we report on a large Iranian family with X‐linked ID caused by a duplication on the X chromosome identified by whole genome sequencing in combination with linkage analysis. Results Seven affected males in different branches of the family presented with ID, short stature, seizures, facial anomalies, behavioral abnormalities (aggressiveness, self‐injury, anxiety, impaired social interactions, and shyness), speech impairment, and micropenis. The duplication of the region Xq13.2q13.3, which is ~1.8 Mb in size, includes seven protein‐coding OMIM genes. Three of these genes, namely SLC16A2, RLIM, and NEXMIF, if impaired, can lead to syndromes presenting with ID. Of note, this duplicated region was located within a linkage interval with a LOD score >3. Conclusion Our report indicates that CNVs should be considered in multi‐affected families where no candidate gene defect has been identified in sequencing data analysis., We report a duplication on the X chromosome encompassing Xq13.2q13.3 in a large Iranian family with X‐linked intellectual disability. There are seven affected males in ones and twos within two generations of the pedigree who presented with a similar phenotype, including ID, short stature, seizures, facial anomalies, behavioral abnormalities, speech impairment, and micropenis.

During the novel coronavirus pandemic, organ transplant recipients represent a frail susceptible category due to long‐term immunosuppressive therapy. For this reason, clinical manifestations may differ from general population and different treatment approaches may be needed. We present the case of a 36‐year‐old kidney transplanted woman affected by Senior‐Loken syndrome diagnosed with COVID‐19 pneumonia after a contact with her positive mother. Initial symptoms were fatigue, dry cough and coryza; she never had fever nor oxygen supplementation. Hydroxychloroquine and lopinavir/ritonavir were started, and the antiviral drug was replaced with darunavir/cobicistat after two days for diarrhea. Immunosuppressant levels were closely monitored, and we observed very high tacrolimus trough levels despite initial dose reduction. The patient was left with steroid therapy alone. The peculiarity of clinical presentation and the management difficulties represent the flagship of our case‐report. We stress the need for guidelines in transplant recipients with COVID‐19 infection with particular regard to the management of therapy.

Granulomatosis with polyangiitis (GPA), necrotizing vasculitis of small and medium-sized vessels, is traditionally believed to mainly affect respiratory tract with additional focal kidney involvements as its primary manifestations with a relatively rare annual incidence rate of 20-50 cases per million. Six percent of the affected cases have cardiac involvements; among which, aneurysms comprise the lowest penetrance. By this paper, we aim to cast light on clinical diagnostic and treatment methods of a rare case presentation, a 10-year-old male GPA patient, diagnosed with massive thrombosis at his coronary artery aneurysm. GPA should be considered as differential diagnosis of prolong fever and coronary aneurysms in adolescents.

Granulomatosis with polyangiitis (GPA), necrotizing vasculitis of small and medium-sized vessels, is traditionally believed to mainly affect respiratory tract with additional focal kidney involvements as its primary manifestations with a relatively rare annual incidence rate of 20-50 cases per million. Six percent of the affected cases have cardiac involvements; among which, aneurysms comprise the lowest penetrance. By this paper, we aim to cast light on clinical diagnostic and treatment methods of a rare case presentation, a 10-year-old male GPA patient, diagnosed with massive thrombosis at his coronary artery aneurysm. GPA should be considered as differential diagnosis of prolong fever and coronary aneurysms in adolescents.

Background & Aim: Documentation of cares is one of the responsibilities of operating room nurses. One of the possible patient damages caused during surgery is use of electrocautery and tourniquet devices. Despite the need for recording the performance of these devices, there is no specific part on surgery checklists dedicated to this issue. Therefore, this study aimed to change the safe surgery checklist through documenting the application of electrocautery and tourniquet devices. Materials & Methods: This action research was conducted on 30 operating room nurses in Isfahan, Iran in 2017. The solution of choice was adding a researcher-made checklist to the operating room files in order to document the use of electrocautery and tourniquet devices for three months. In addition, a researcher-made survey on the status of operating room file documentation was filled by the subjects before and after the intervention. Moreover, data analysis was performed in SPSS version 22 using descriptive and analytical statistics. Results: In this research, 28 out of 30 participants had a mean work experience of 11.87±8.30 years in operating rooms. Furthermore, there was a significantly higher frequency of positive response to the question of “Do you think that the checklist is useful?” after the intervention, compared to before the intervention (P

Exploring genes and pathways underlying intellectual disability (ID) provides insight into brain development and function, clarifying the complex puzzle of how cognition develops. As part of ongoing systematic studies to identify candidate ID genes, linkage analysis and next-generation sequencing revealed Zinc Finger and BTB Domain Containing 11 (ZBTB11) as a novel candidate ID gene. ZBTB11 encodes a little-studied transcription regulator, and the two identified missense variants in this study are predicted to disrupt canonical Zn2+-binding residues of its C2H2 zinc finger domain, leading to possible altered DNA binding. Using HEK293T cells transfected with wild-type and mutant GFP-ZBTB11 constructs, we found the ZBTB11 mutants being excluded from the nucleolus, where the wild-type recombinant protein is predominantly localized. Pathway analysis applied to ChIP-seq data deposited in the ENCODE database supports the localization of ZBTB11 in nucleoli, highlighting associated pathways such as ribosomal RNA synthesis, ribosomal assembly, RNA modification and stress sensing, and provides a direct link between subcellular ZBTB11 location and its function. Furthermore, given the report of prominent brain and spinal cord degeneration in a zebrafish Zbtb11 mutant, we investigated ZBTB11-ortholog knockdown in Drosophila melanogaster brain by targeting RNAi using the UAS/Gal4 system. The observed approximate reduction to a third of the mushroom body size-possibly through neuronal reduction or degeneration-may affect neuronal circuits in the brain that are required for adaptive behavior, specifying the role of this gene in the nervous system. In conclusion, we report two ID families segregating ZBTB11 biallelic mutations disrupting Zn2+-binding motifs and provide functional evidence linking ZBTB11 dysfunction to this phenotype.

Background Occupational hazards threaten the safety and health of operating room (OR) nurses. In this regard, Lean Six Sigma (LSS) is one of the quality improvement methods that can be utilized to identify and work out a solution for occupational hazards. Methods In this quasi-experimental study with a one-group pre-/post-test research design, (DMAIC 1 ) cycle was employed as the main framework for implementing the LSS. A total number of 45 OR nurses were thus selected via convenience sampling method. Data analysis was consequently performed using descriptive and analytical methods in the IBM SPSS Statistics software (version 22.0). Results The results of data analysis revealed that the frequency of exposure to chemical hazards due to pouring formalin solution into the biopsy container had significantly reduced after preparation of the pathology room (p 0.05). Paired samples t-test had also shown that the mean number of exposures to irritating chemicals and total chemical hazards after the intervention was significantly lower than that before it (p Conclusion The implementation of the LSS method in this study, at the lowest cost, without adding further personnel, with no extra equipment, and in the short term could mitigate occupational hazards that OR nurses face to.

Patients with moderate-severe left ventricular systolic dysfunction undergoing coronary artery bypass graft (CABG) surgery are at high risk of mortality and morbidity. Our aim is to evaluate the right ventricular (RV) diastolic function in these patients, and monitor its effects on postoperation outcomes.In a cohort study, patients with moderate-severe left ventricular systolic dysfunction (ejection fraction ≤35%) who were candidate for CABG were included. Baseline transthoracic echocardiography (TTE) was performed, and RV diastolic function measures were obtained. After CABG, the length of intubation, inotrope dependency, hospital stay in intensive care unit and ward, in-hospital and after discharge mortality, postoperative atrial fibrillation (POAF) were evaluated in all patients.Sixty-seven patients were prospectively included in the study. The mean ± standard deviation age of our patients was 61.4 ± 9.3. There was no difference between grades of RV diastolic function and postoperative outcomes. However, we found significant difference between grades of RV diastolic function and onset of in hospital, and total POAF (We believe that patients with increased tricuspid E

Background : The aim of this study was to compare the PID with bare skin (without PID) regarding bacterial recolonization and bacterial regrowth of the adjacent skin of surgical incision in lumbar spine surgery patients. Methods : This quasi‑experimental study was conducted from February to May 2018 on 88 patients who were candidate for lumbar spine surgery. Patients were assigned to one of two groups, treatment (with PID) and control (without PID). Skin sampling (adjacent of surgical incision) for bacterial culture was done in two steps, immediately after surgical skin prep (IASSP) and immediately after surgical wound closure (IASWC) by researcher. Finally, samples were sent to the laboratory. Results : The mean total bacterial count of patient’s skin in stage IASSP was not significantly different between treatment and control groups (0.34 vs 0.27, P = 0.68). However, mean total bacterial count in stage IASWC in treatment group was significantly higher than control group (2.2 vs 0.93, P = 0.03). The frequency distribution of S. aureus ( P = 0.04) and S. epidermidis ( P = 0.02) was significantly higher in treatment group compared with control group in stage IASWC. Conclusions : The results showed that using PID is unable to reduce recolonization and regrowth of bacteria on patients’ skin adjacent to surgical wound in clean lumbar spine surgeries. However, making a definite decision about using or not using of PID requires further studies. Keywords : Bacteria, lumbar vertebrae, surgical drapes, surgical wound

Autosomal recessive (AR) gene defects are the leading genetic cause of intellectual disability (ID) in countries with frequent parental consanguinity, which account for about 1/7th of the world population. Yet, compared to autosomal dominant de novo mutations, which are the predominant cause of ID in Western countries, the identification of AR-ID genes has lagged behind. Here, we report on whole exome and whole genome sequencing in 404 consanguineous predominantly Iranian families with two or more affected offspring. In 219 of these, we found likely causative variants, involving 77 known and 77 novel AR-ID (candidate) genes, 21 X-linked genes, as well as 9 genes previously implicated in diseases other than ID. This study, the largest of its kind published to date, illustrates that high-throughput DNA sequencing in consanguineous families is a superior strategy for elucidating the thousands of hitherto unknown gene defects underlying AR-ID, and it sheds light on their prevalence.

Objective To report the development of the first robot-assisted kidney transplantation (RAKT) programme from deceased donors, examining technical feasibility and early perioperative and functional outcomes at a referral academic centre. Patients and methods A RAKT programme was developed in 2016 at our institution following structured modular training. Specific inclusion/exclusion criteria for both living and deceased donors were set. Data from patients undergoing RAKT from January 2017 to April 2018 were prospectively collected in an a priori developed web-based data set. RAKT followed the principles of the Vattikuti Urology Institute-Medanta technique, with specific technical modifications based on clinical recipient characteristics, as well as surgeon's skills and preference during the learning curve. Technical feasibility of RAKT from deceased donors and evaluation of perioperative and early functional outcomes were the main study endpoints. Results In all, 17 RAKTs were performed during the study period. Of these, six were from living donors and 11 were from deceased donors. All RAKTs were successfully completed without need of conversion. The median (interquartile range [IQR]) console time was 190 (160-220) min and the median (IQR) estimated blood loss was 120 (110-140) mL. The median times to complete venous, arterial and uretero-vesical anastomoses were 21, 22 and 21 min, respectively. The median (IQR) length of stay was 8 (6-12) days. At a median (IQR) follow-up of 8 (6-11) months, five (30%) complications were recorded. Of these, four (24%) were minor (Clavien-Dindo Grade I-II) and one major (Clavien-Dindo Grade IIIb, requiring graft nephrectomy). Overall, two patients were still on dialysis at last follow-up. A significant improvement in graft function was recorded progressively at all postoperative time points. Conclusion Our preliminary experience outlines that: (i) the development of a RAKT programme is feasible in centres experienced in robotic surgery and open kidney transplantation; (ii) RAKT from deceased donors is feasible from both a technical and logistical perspective; and (iii) RAKT from deceased donors appears to achieve favourable early postoperative and functional outcomes. Larger studies with longer follow-up are needed to confirm these findings and compare the outcomes of RAKT from deceased donors with those from living donors.

Background To determine reference echocardiographic values in a normal population and assess their correlation with body mass index (BMI) and body surface area. Methods An expert cardiologist performed two-dimensional echocardiography with triplicate right ventricle (RV) size measurements in 80 subjects with normal heart condition. Results were correlated with anthropometric data. Results Base-to-apex length in four-chamber view (RVD3) and above-pulmonic valve in short-axis view in males, as well as mid-RV diameter in standard four-chamber view (RVD), basal RV diameter, and mid RV diameter in RV-focused four-chamber view in females, were significantly correlated with BMI. All RV variables were significantly correlated with BMI in 20–30-year-old subjects. All RV variables except RVD3 and above-aortic valve in short-axis view (proximal) were significantly correlated with BMI in 35–55-year-old subjects. All RV parameters were significantly correlated with body surface area, except for RVD and in 20–35-year-old subjects. Conclusions RV echocardiographic values must be adjusted to anthropometric characteristics for proper diagnosis and management of cardiac disorders. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound, 2016

Background Antineutrophil cytoplasmic antibody associated vasculitis (AAV) is a group of diseases associated in most cases with the presence of anti-neutrophil cytoplasmic antibodies (ANCAs). Rituximab- based remission induction has been proven effective in ANCA associated vasculitis but scarce data exist in forms with severe renal involvement. In this case series, we report the outcomes in patients with de novo or recurrent MPO-AAV and severe renal involvement treated with rituximab without cyclophosphamide (CYC). Methods In this single centre retrospective study, we analysed patients with a clinical diagnosis of de novo or recurrent AAV who met the following criteria: detection of P-ANCA, creatinine clearance lower than 30 ml/min, induction of remission therapy with rituximab without concomitant CYC and a follow up period of at least 6 months. The primary outcomes were complete remission after induction therapy, renal function recovery and mortality after the induction treatment. Results Eight patients met the inclusion criteria. The M:F ratio was 1:7, the average age was 54 years old and the median follow up was 10 months (7–72); in 2 patients there was a MPA renal limited vasculitis. A renal biopsy was performed in 7 patients. The median BVAS score at rituximab induction was 14(range 6–21). Two patients required haemodialysis before the induction treatment. Four patients developed end stage renal disease (ESRD) that required haemodialysis. These data show a remission of the disease, associated with a stabilization of the kidney function in 50% of patients. In 3 patients who did not show a response, there was also no response to CYC. Conclusions This study shows a partial efficacy of rituximab in renal function recovery and a low risk of infectious complications in patients with MPO vasculitis with severe renal involvement, in particular in the short term. The optimal treatment in this subgroup of patients still has to be established because data are lacking.

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