Search

Introduction: In recent years, the prevalence of attacks perpetrated by humans against other humans has increased worldwide. The injuries suffered by attack victims are severe and multi-organ. Iran’s neighboring countries have been the scenes of attacks in the recent past. This study assessed the type and severity of injuries sustained by victims transferred to Iran during the time period 2005-2007. Methods: This study was conducted on injured civilians transferred to hospitals in Iran. Data regarding cause of injury, type and severity of injuries, diagnostic-therapeutic interventions, and patient outcomes was collected and statistically analyzed using SPSS version 14 software. Results: In the studied time period, 214 attack victims were transferred to 3 Level 1 trauma centers in Iran. The mechanisms of injury were explosion in 130 cases, gunshot in 48, and other causes in the remaining victims. The mean Injury Severity Score (ISS) was 5.91 ± 4.54 (range = 1-34), and the median was 4; 109 cases (51%) had an ISS between 1 and 8, 73 cases (34%) were scored between 9 and 14, 15 cases (7%) were scored from 16 to 24, and 17 cases (8%) had an ISS ≥25. In terms of the number of injured organs, 42 patients (20%) had one, 124 (58%) had 2, 36 (17%) had 3, and 12 patients (5%) had 4 or more injured organs. Procedures included 86 orthopedic, 25 general surgical, 21 ear, nose, and throat (ENT), 18 plastic, 15 neurosurgical, and 10 ophthalmic operations; 25 patients received psychiatric counseling. The mean (±SD) hospital stay was 13.43 (±19.76) days (range = 1-230). Conclusion: The injury pattern in attacks is more severe and differs from other traumas. The medical team should have adequate knowledge in this respect to provide comprehensive healthcare.

Context: The face is the most exposed part of the body; therefore, the maxillofacial region is vulnerable to trauma. The evaluation of the incidence and etiology of maxillofacial traumas is necessary to disclose the pattern of fractures. Objectives: The study aimed to evaluate the pattern of maxillofacial fractures (MFs) and associated injuries by a literature review. Data Sources: Original papers investigating the pattern of MFs and associated injuries published before November 2018 were examined. Online sources including PubMed, Scopus, Medline, Wiley, ISI Web of Knowledge, and EMBASE were searched for these papers. The extracted data included study characteristics, participants’ characteristics, MFs causes, and distribution of various MFs. Results: In total, 17,055 patients (men: 83.61%; women: 16.38%) were examined. The age range was 21 - 30 years in 40.89% of the patients with MFs. The most common risk factor of fractures was road traffic accidents (45.33%). Mandibular fractures were more frequent than other injuries. Condyle was the most common mandibular fracture (25.89%). Le Fort II was the most common site in the middle-third fractures (30.29%). Conclusions: The results showed that maxillofacial fractures were more frequent in men, in the age of 21 to 30 years, in the site of the mandible, and mainly caused by road traffic accidents.

The location of the mandibular foramen (MF) on digital panoramic radiographs can be an important guide for clinicians when administering the inferior alveolar nerve block (IANB) for dental anesthesia of the mandible. This study, aimed to assess the location of the MF relative to the anterior border (AB) of the ramus and the occlusal plane (OP) from digital panoramic radiographs. An observational case series study was conducted on digital panoramic radiographs from the oral and maxillofacial radiology department archives of patients at least 18 years of age with a 1:1 scale (100%). The samples had to have at least 2 lower molar teeth on both sides without any blurring, previous fracture of the ramus or other artifacts. The distance of the MF to the OP and the AB of the ramus was measured using a caliper. The role of age and gender were also analyzed statistically using the 2-way analysis of variance test. One hundred ninety-four digital panoramic radiographs were included in the analysis. The findings showed that the vertical distance of the MF to the OP was a maximum of 14.52 mm and a minimum of −3.0 mm (mean 4.32 ± 2.34 mm). The distance of the MF to the AB of the ramus was a maximum of 25.52 and a minimum 9.68 mm (mean 16.48 ± 3.28 mm). Based on these findings, the IANB target site for injection should be approximately 5 mm above the OP and approximately 16.5 mm beyond the AB of the ramus to achieve successful anesthesia of the mandible via standard IANB in an Iranian population.

Background: The management of maxillofacial injuries is one of the most common challenges in the healthcare field as surgeons, who treat these patients have additional responsibilities in terms of esthetic reconstruction as well as restoration of the patient’s appearance and function.Objectives: The aim of the present studywas to evaluate the epidemiology and etiology of trauma at BualiHospital of Tehran during 2008 to 2016.Methods: In this retrospective study, the files of all the trauma patients (n = 293) that had referred to Buali Hospital were investigated, and demographic data and etiologic factors were extracted. Radiographs were analyzed with regards to fracture patterns. The results were statistically analyzed using the SPSS 22 software.Results: The mean age was 29.18 ± 14.74 years in males and 34.48 ± 19.81 years in females. Fractures were more frequent at ages between 21 and 30 years (39.9%) and less common among 71- to 84-year-olds (2.4%). Most patients were males (78.8%). Of all 474 fractures in 293 patients, zygomatic fractures were the most common fractures (18.6%), while Lefort III in the maxilla was the least common type (1.3%). The main cause of fracture was motor vehicle accidents (51.5%), whereas workplace injuries were uncommon (11.4%).Conclusions: According to the results, fractures often occur in males in the third decade of life due to their roles in the community. In the current study, similar to other studies carried out in developing countries, the main cause of fractures was motor vehicle accidents. Most of the patients were treated by open reduction. The most frequent side effect was sensory disorders.

Purpose Morbidity and death after facial trauma are substantial issues of concern both in civilians and in military personnel. This cross-sectional retrospective study sought to assess the prevalence, pattern, treatment, and complications of soft and hard tissue injuries of the face in military personnel from 2012 to 2018. Patients and Methods This cross-sectional, retrospective, chart study analyzed the descriptive statistics of 591 patients by use of Microsoft Excel software (version 2013; Microsoft, Redmond, WA); we assessed military casualties treated at our hospital from 2012 to 2018. All military personnel were documented in our trauma registry. The patient records were studied, and information relating to patients' injuries was documented and assessed after compilation of patient data. This study was approved by our local institutional review board; the causes and complications of maxillofacial (MF) trauma were assessed. Statistical analysis was done. This study used descriptive statistics based on a total of 591 patients and Microsoft Excel software (version 2013). Results Among maxillofacial (MF) fractures, midface fractures (49%) were most prevalent, followed by lower face fractures (43%) and upper face fractures (24%). The most common cause of injury was explosives (58%). The most frequent site of fracture in the mandible was the angle region, followed by the mandibular body and condyle. Nasal fractures were seen in 44% of midface fractures. The most commonly used technique for treatment was open reduction–internal fixation, which was used in 89% of patients. Conclusions The pattern of MF injuries and the treatment modalities used to treat these patients showed that the most frequent type of injury was midface fracture and most patients were treated by open reduction–internal fixation.

PURPOSE: Retrospective studies on the types and causes of facial burns are important because the patterns might vary in different societies. Our aim was to assess the burn-related factors of significance that might be useful in healthcare planning and implementing preventive strategies, adding to the body of current data on the subject. MATERIALS AND METHODS: A retrospective cross-sectional study was conducted to assess the data from a major burns referral center during a 5-year period (2009 to 2013). The data relevant to age, gender, cause, source, location, burn degree, extent (body surface area [BSA]) of the burns, and mortality were gathered from comprehensive patient medical records, recorded, and analyzed using SPSS, version 20, software (SPSS, Chicago, IL). RESULTS: Within the study period, we found 808 documented cases of second- and third-degree facial burns. These burns were more common in men (81.9%) and in the 16- to 35-year age group (42.3%). The mean hospitalization was 9.85 ± 8.94 days. In 443 patients (54.83%), 10 to 19% of their BSA was burned, and 3.06% had associated inhalation burns. The most common burn was scalding (19%), and the deadliest was burns from acid, with a mortality rate of 7.4%. Accidents accounted for 776 burns (96.03%). Other causes were attempted homicide (16 cases, 1.98%) and suicide attempts (16 cases, 1.98%). The overall mortality was 1.6%. CONCLUSIONS: The key findings were that second- and third-degree facial burns were more common in males aged 16 to 35 years with burns covering 10 to 19% of the BSA. Accidental scalding was commonly responsible for the second-degree burns, and electrical accidents were commonly responsible for third-degree facial burns. Burn accidents occurred more often at the patient's home. Language: en

Objectives: To investigate the level of bacterial contamination in ventilation devices after being connected to head trauma patients with confirmed ventilator-associated pneumonia. Methods: This prospective, cross sectional study was carried out at Shahid Mohammadi hospital, Bandar-e Abbas, Iran. Samples for assessing the contamination of ventilators were obtainedfromexpiratoryandinspiratory tube insertion sites before connecting the device to the patients. The patients were then observed for the development of ventilator-associated pneumonia and were enrolled in the study if considered eligible. Sampling was repeated after disconnecting the patient. The following variables were assessed in each patient: gender, age, Glasgow Coma Scale upon hospitalization, length of stay in the intensive care unit (ICU), and mortality. Results: A total of 33 patients, including 26 men and 7 women, were enrolled in the study. There was no significant association between ventilation contamination and time of sampling (before or after ventilation) in the evaluated sites (P > 0.05). However, based on McNemer’s test for equality of frequencies, the prevalence of positive culture after disconnecting the device from the patients (60.6%) was not the same as the prevalence before being connected to the patients (21.2%) at inspiratory tube insertion sites (P = 0.002). Also, at both sites, the variety and pathogenicity of microorganisms after disconnecting the device were higher than those of microorganisms, colonized from samples which were obtained before connecting the device. Conclusions: The findings of the present study showed that mechanical ventilation of patients with pulmonary infection leads to the contamination of ventilators. These findings suggest the need for designing and implementing new measures, which are easily available in developing and resource-deficient countries in order to reduce the contamination of ventilation devices and prevent cross-contamination.

Compared with other maxillofacial lesions, oral and maxillofacial (OM) aneurysmal bone cysts (ABCs) are rare, and most studies have been case reports. Because the features or radiographic findings of 1 case could not be representative of the whole, conclusions cannot be drawn and data analyses will not be feasible. Our aim was to assess and describe the clinical and histopathologic characteristics of a large sample of subjects with ABCs. To our knowledge, the present case series of OM ABCs is the largest ever reported.To address our research purpose, we designed and implemented a retrospective case series. A multicenter retrospective cohort study of patient charts dated from 1967 to 2013 (46 years) at 10 major universities in 8 cities was undertaken to assess OM ABCs nationwide. Subjects were included if they had documented chart data and definitive histopathologic slides confirming the diagnosis and treatment of ABC. They were excluded if their histopathologic slides did not confirm the diagnosis of an ABC. Data were collected, and special forms were completed. Variables such as age, gender, site (ie, maxilla, mandible, anterior, posterior), histologic type (ie, solid, mixed, vascular), signs, symptoms, radiographic features (ie, radiolucency, unicystic or multilocular), and outcomes (ie, treatment modal, recurrence, complications) of the lesion were evaluated and documented by OM surgeons and confirmed by OM pathologists for assurance. Data analyses were performed using Statistical Package for Social Sciences, version 20, software (SPSS, Chicago, IL) (P.05).We assessed the medical records and histopathologic slides of 120 patients diagnosed and treated for OM ABCs nationwide. Of these patients, 69 were male (57.5%) and 51 were female (42.5%), with no predilection found. The key findings were as follows. The mean age of occurrence was 20.7 ± 2.5 years (range 4 to 78), and occurrence was significantly greater in the first 2 decades of life (P.001). The incidence was 2.6 cases/year. ABCs were significantly more common in the mandible (P.05) and posterior areas (P.05). The most common histopathologic type was the mixed type (P.05). Firm swelling was the most common clinical presentation (P.05); all cases were radiolucent and commonly unilateral (P.05). Most were treated by excision and curettage. Recurrence was reported in 11 patients (9.2%) during the follow-up period (1 to 45 years).The present retrospective cohort found ABCs with a variable presentation, disease course, and histopathologic type, with no gender predilection. ABCs were significantly more common in childhood and adolescence and in the mandible and posterior areas of the jaws. Of the cases reviewed, 90% were treated by excision and curettage. ABCs had a relatively low recurrence rate (10%), precluding the need to perform aggressive surgery primarily.

Purpose Perforation of the nasal septum is a frustrating problem frequently reported in the literature. Surprisingly, in most reports, iatrogenic perforation during septoplasty and electrocautery are the leading causes of this complication. This article presents the management of septal perforations and the indications for an extracorporeal approach. Materials and Methods Fourteen patients with septal perforations were referred for treatment. Treatment was chosen based on defect size. Flaps, extracorporeal repair, or no treatment was used as indicated. Results Two of 14 perforations were small and were repaired by local flaps, 5 cases were treated by extracorporeal repair, and the 7 remaining cases required no surgical procedure. Conclusions The extracorporeal technique, when indicated, can be used effectively for the repair of nasal septum perforations in selected cases.

Purpose The orbital cavity can be affected in zygomaticomaxillary complex (ZMC) fractures. The aim of this study was to assess the relation between orbital volume changes and enophthalmos in patients with ZMC fractures. Materials and Methods A descriptive study of consecutive adult patients with recent isolated unilateral ZMC fractures who were otherwise healthy was performed from 2016 through 2017. Multislice computed tomographic (CT) scans were taken of all patients and enophthalmos was measured clinically using a Hertel exophthalmometer. In the axial plane, enophthalmos was measured on CT scan using Mimics software. Three-dimensional reconstruction and volume measurement of the orbital cavity also were performed using Mimics software. The correlation between clinical and radiographic amounts of enophthalmos was measured by Pearson correlation coefficient analysis. The association among radiographic enophthalmos, clinical enophthalmos, and volume changes of the orbital cavity was assessed by linear regression. The P value was set at .01. Results Ninety-six patients (77 men, 19 women; mean age, 28.48 ± 8.29 yr) were assessed. Mean volumes of control and fractured bony orbits measured on CT scan were 29.02 ± 1.71 and 32.05 ± 2.22 cm3, respectively (P Conclusion ZMC fractures commonly increase orbital volume and the degree of change is strongly correlated with enophthalmos.

Background: Monocortical miniplate fixation is an accepted and reliable method for internal fixation of mandibular angle fractures. Although placement of a second miniplate may theoretically provide more stability; however, the clinical importance of this issue remains controversial. Objectives: The present study assessed the postoperative complications and outcomes associated with the fixation of mandibular angle fractures using 1 and 2 miniplates in patients with favorable mandibular angle fractures. Patients and Methods: A prospective study of 87 patients (73 males, 14 females) with favorable mandibular angle fractures was done. In the first group, a 4-hole miniplate was placed at the superior border through an intraoral approach. In group 2, patients were treated with 2 miniplates, one placed at the superior border (similar to group 1) and the other on the lateral aspect of the angle at the inferior border through an intraoral and transcutaneous approach using a trocar. Postoperative complications including malocclusion, malunion and sensory disturbances associated with surgery, additional maxillomandibular fixation (MMF) by means of an arch bar and wires for a longer period (for delayed union) and infection were assessed in patients of both groups up to 12 months postoperatively. The data were analyzed using the chi-square test. Results: In the single miniplate group, 25 patients showed lip numbness associated with surgery (55.6%), 22 patients required additional use of MMF (48.9%) and 3 patients developed infections (6.7%). In the double miniplate group 20 patients showed lip numbness associated with surgery (47.6%), 18 patients required additional use of MMF (42.9%) and 1 patient developed infection (2.4%). None of the patients in either group showed malocclusion or malunion. No significant difference was observed between the groups regarding overall complication rate. Conclusions: In this study, use of one miniplate or two miniplates for treatment of favorable mandibular angle fractures was associated with a similar incidence of complications. Thus, it seems that the use of two miniplates in this setting may not be warranted, nor cost-efficient.

Background: Hospital readmission places a high burden on both health care systems and patients. Most readmissions are thought to be related to the quality of the health care system. Objectives: The aim of this study was to examine the causes and rates of early readmission in emergency department in a Tehran hospital. Patients and Methods: A cross-sectional investigation was performed to study readmission of inpatients at a large academic hospital in Tehran, Iran. Patients admitted to hospital from July 1, 2014 to December 30, 2014 via the emergency department were enrolled. Descriptive statistics were used to summarize the distribution demographics in the sample. Data was analyzed by chi2 test using SPSS 20 software. Results: The main cause of readmission was complications related to surgical procedures (31.0%). Discharge from hospital based on patient request at the patient’s own risk was a risk factor for emergency readmission in 8.5%, a very small number were readmitted after complete treatment (0.6%). The only direct complication of treatment was infection (17%). Conclusions: Postoperative complications increase the probability of patients returning to hospital. Physicians, nurses, etc., should focus on these specific patient populations to minimize the risk of postoperative complications. Future studies should assess the relative connections of various types of patient information (e.g., social and psychosocial factors) to readmission risk prediction by comparing the performance of models with and without this information in a specific population.

Background: There is significant prevalence of physical injuries sustained by civilian recruits at military training garrisons. Civilian recruits sustain these injuries mostly during the intensive and rigorous military combat-training period. Objectives: We sought to determine the prevalence and causes of oral and maxillofacial injuries as the first step in reducing and preventing them in civilian recruits (males aged over18 years) during their 2-year mandatory military service. Materials and Methods: In this 2-year study, we referred to 11major military training garrisons in 8 provinces and collected data from available medical records of military clinics at each garrison. Injuries occurring in civilian recruits during the intense 2-month military combat training period were documented. Data regarding the number of civilian trainees, percentage of those injured, site where the injury was sustained, type of injury and its causes, etc. as well as demographic data were collected. Results: The number of civilians called to military service was 153, 886. The ratio of those injured was 4419/153,886. The percentage of maxillofacial injuries was 20.4% (903/4419). The majorities of maxillofacial injuries occurred during the first month (38%) and were due to nonmilitary (86%) rather than military (14%) causes. From among the military causes, bullets (66%) were the most common cause of injury, while falls (73%) were the major cause of nonmilitary injuries. Mountainous terrain was the main cause of falls (51%). The most common military incidents which led to injury were related to artillery fire and explosions (33%). Nasal bone fracture was the most common maxillofacial fracture (49%), and lacerations were the most common soft tissue injury (54%). Among dental injuries, tooth fracture was most common (66%). Conclusions: The large number of general and maxillofacial injuries in civilian recruits during the 2-month combat-training period at military garrisons is disconcerting. This issue warrants further research to implement methods for identifying, decreasing, and preventing injuries in civilians at military-training garrisons.

Background: Correction of digit deformities at or near the Joints is performed easily ; however, maintaining the result is often difficult either due to noncompliance of the patient to wear the postoperative splints or problems related to unequal growth of bones or normal tissues compared to the scarred or operated side. Objectives: The aim of this study was to overcome the above mentioned problems for which we propose the "Distal d Digit Syndactyly" technique. Materials and Method: This method is based on the concept of suturing the distal phalanx of the deformed digit to the normal adjoining finger to help prevent the recurrence of the anomaly during the child’s growth period or the very important three or four postoperative months of scar maturation in the adult. After the correction of deformity of the finger or toe, "Distal Syndactyly" is created by two flaps on the adjoining digits; one base is dorsally hinged and the other one volar and after elevating the flaps they are sutured together. During the three postoperative weeks care is taken that this attachment is not disrupted and after healing a "distal syndactyly" is created which is very durable and in children it stretches with growth and does not impede the digit’s growth. Results: Eleven patients with congenital and traumatic digit anomalies were treated. The recurrence of the problem was prevented in 9 patients; in 2 patients with intact Syndactyly the contracture recurred by stretching the Syndactyly skin. The period of the “Joining” ranged from 6 months to three years and cosmetic appearance was acceptable to the patient and parents. Conclusion: This technique by joining a deformed digit to a normally growing adjacent digit prevents the postoperative recurrence of the contracture or growth-induced deviation in the digits of noncompliant patients especially children.

Background: With the growing interest in long bone distraction several types of distractors have been introduced; all have the same principle of an outer structure which acts like a scaffold and the distracting mechanism is a separate device which is mounted on this outer structure. Objectives: We have used a simple and very light weight external fixator we designed and discuss the results of distraction and advantages of this device . Materials and Methods: We applied our distractor to treat 14 men and four women, with a mean age of 39 years. There were three thumbs and 23 fingers; 26 digits (18 patients) lengthened by distraction callotasis and second stage bone grafting evaluated accordingly. Results: All patients but one were satisfied with the results and a stable pinch and grip was obtained. After lengthening, all patients maintained sensation of the finger pulp, as assessed by the Semes - Weinstein test. Conclusions: The superiority of this device for manoplasty lies in its simplicity of construction in addition to being, lightweight and also eases of application.

Background Accessory cartilages are small nasal cartilages between the lateral crus and piriform aperture of the nose bilaterally. These cartilages are among the supporting structures of the nasal tip. Study Design This prospective cross-sectional study was conducted on Iranian fresh cadavers for evaluation of ethnic differences. Seventy-two sesamoid cartilages in 41 cadavers (mean age 42 years) were dissected to evaluate anatomy and anthropometry of the sesamoid cartilages. Elevation of the dorsal nasal flap after a collumellar incision was done. After the separation of the lower lateral cartilages and sesamoid cartilages on each side, the anatomy and anthropometry of the cartilages were assessed. Results In 12% (5) of the cadavers there were no sesamoid cartilages, and in 88% (36) of the cadavers there was 1 sesamoid on each side. The shape of the sesamoid cartilages was rectangular in 66% (27) and triangular in 22% (9). The mean length, width, and thickness were 3 mm, 2 mm, and 0.75 mm, respectively. Conclusions This cartilage was single on each side of the nose and its shape was an irregular rectangle or triangle and has an important role in preserving nasal alar contour and tip projection. These findings confirm ethnic variations in the sesamoid nasal cartilages when this Iranian population is compared with other populations assessed in earlier reports.

Necrotizing fasciitis of the upper extremity is reported.Necrotizing fasciitis is a rare, life-threatening infection most commonly seen in patients with diabetes mellitus, intravenous drug abuse, and immunocompromised conditions. The extremities are the primary sites of involvement in as many as two thirds of the cas-es. In a significant proportion of patients, the extremities are involved as a result of trau-ma, needle puncture or extravasation of drugs. The infection is usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation. We present a patient with necrotizing fasciitis of the upper limb and pre-sent our experience with this often lethal condition.

Severe combined burn-blast injury is a great challenge to surgical teams due to its high mortality. It also results in unsightly traumatic tattoos. The aims of these case reports were to clarify the clinical characteristic of the dynamite explosion burn-blast facial injuries and discuss appropriate management of these patients. We report two patients suffering from facial burn-blast injury following dynamite explosion in which after primary stabilization, silver sulfadiazine cream was applied to the wounds and 12 hours later the wounds were cleaned under general anesthesia with vigorous saline solution irrigation and brushing. The foreign particles were meticulously removed from wounds and simultaneous repairing of defects was done with nylon 6-0 sutures. We conclude application of silver sulfadiazine cream on facial burn-blast injury tattoos several hours before surgical removal of particles is highly efficacious in facilitating particle removal and attaining a good result following surgical intervention, and primary repair. Treatment of combined burn-blast tattoos is different from other types of tattoos not associated with burns. Debridement and removal of foreign particles under general anesthesia from skin immediately and primary reconstruction of wounds is essential. We recommend application of the topical agent silver sulfadiazine to wounds about 12 hours before surgical intervention.

Objectives: This article sought to review and compare data of major earthquakes of the past decade and their aftermath in order to compare the magnitude, death toll, type of injuries, management procedures, extent of destruction and effectiveness of relief efforts. Materials and Methods: A retrospective study of the various aspects of management and aftermath of 5 major earthquakes of the past decade (2000–2010) was undertaken. This included earthquakes occurring in Bam Iran, Sichuan China, Port-au-Prince Haiti, Kashmir Pakistan and Ica Peru. A literature search was done via computer of published articles (indexed in Pubmed). The issues assessed included: 1)Local magnitude,2)Type of building structure 3)Time of the earthquake (day/time/season), 4)Time to rescue, 5)Triage, Transfer, and Treatment 6) Distribution of casualties (dead/ injured), 7)Degree of city damage, 8)Degree of damage to health facilities, 9)Field hospital availability, 10)International aid, 11)Air transfer, 12) Telecommunication systems availability, 13) PTSD prevalence, 14) Most common injury and 15) Most common disease outbreak. Results: The Bam earthquake had the lowest (6.6 Richter’s) and the Sichuan earthquake had the greatest magnitude (8.0 Richter’s). Mortality in Haiti was 212,000 and it was the deadliest earthquake of the past decade. Collapse of heavy clay roofing structures was a major cause of death in Iran and Pakistan. Earthquakes occurring at night and nonworking days carried a high death toll. The time to rescue and treat was the lengthiest in Haiti (possibly contributing to the death to injured ratio). However, the worst dead to injured ratios were in Bam (51%) and in Pakistan (47%); the best ratio was in China (15%). Iran and Pakistan suffered the highest percentage of damage to the health facilities (90%). Field hospital availability, international aid and air transfer were important issues. Telecommunication systems were best in China and worst in Pakistan. PTSD prevalence was highest in Iran. Respiratory infection was the most common infection following all 5 earthquakes. Conclusions: Earthquake damage, death toll, managerial protocols etc. vary in different countries and are influenced by many factors including the hour the earthquake hits and the day of the week. Additionally, social, structural and geographic factors as well as the medical, governmental and NGO respondents are influential. Engineered residential construction remains to be of importance in reducing mortality in developing countries. It is essential that hospitals, fire departments and police stations, water, telephone and electrical facilities be made earthquake proof.

Context: Despite the ongoing advances in surgical procedures and promising progress in bioengineering techniques, auricular reconstruction remains a significant challenge in plastic surgery. There are different causes for acquired auricular defects, including trauma, tumor ablation and burns. The management options for upper, middle and lower third auricular defects are briefly reviewed in the current paper. Evidence Acquisition: Original research papers investigating the plastic surgeons, otolaryngologists and maxillofacial surgeons in approaching the complicated issue of auricular reconstruction published from January 1995 to December 2014 were aggregated and used in the current study. Results: Utilizing autologous stem cell populations to treat craniofacial defects is a promising field of ongoing investigations. Studies show that cartilage stem/progenitor cells (CSPCs) are highly chondrogenic and can produce elastic reconstructive material with long-term tissue restoration. Conclusions: Auricular reconstruction surgery is a challenging plastic procedure that requires great expertise and expert knowledge of the various techniques available. Novel techniques in the fields of reconstructive bioengineering and regenerative medicine are promising but further research is required before widespread clinical application.

Background: Upper tibia defects ,type3b Gustilo, due to huge size and volume are very difficult to reconstruct; usually several operations are needed for bone and soft tissue defects and the definite one stage reconstruction is yet to be found. Objectives: In this article we reintroduce the rib- latissimus flap as an acceptable method to reconstruct tibia defects in selected cases. Materials and Methods: The latissimus muscle with one or two ribs revascualrized by reverse flow from perforators is harvested; the ribs are bisected after harvest yielding four to six struts of vascularized bone to fill the huge upper tibia defect. Internal fixation is very important and we favor LCP plates for long bone fixation and the rib struts are fixed in place by small titanium screws to maintain the “picket fence” design. The muscle is then wrapped around the ribs and the defect is completely reconstructed. Results: During the past 9 years we have used the rib-latissimus dorsi (RLD) muscle flap, without serratus muscle, in 7 patients with combined bone and soft tissue defects of the upper tibia. All the flaps healed without any major complications and only one stress fracture was seen and treated. The ribs healed and in a median of 14 months hypertrophied to the size of the upper tibia. Nonunion was not observed and patients with lower extremity defects were able to bear full weight within an average of seven months. Conclusions: The fractures of tibia type 3a and 3b Gustilo are devastating injuries requiring several operations. Several combinations of RLD-Serratus have already been reported but a rib-LD muscle with “picket fence” design has not been reported .The RLD transfer with two ribs divided into four struts for bone coverage and muscle to cover all the upper tibia soft tissue defect can be a useful tool in the armamentarium of the surgeon treating combined defects in a single stage.

Degloving injury of the hand and fingers is one of the most severe and debilitating hand injuries and an operation of choice is yet to be found. In this study, we introduce a modified abdominal flap, the "compartmented abdominal flap," for coverage of degloving injuries of the fingers and hand. The flaps reported up to now are diverse, and 2 or even 3 flaps in 1 session have been used to cover the hand and fingers. Often, the flaps used have mismatching colors and the donor defect is huge when 2 large flaps are used in 1 setting. In this study, we present a 1-flap solution to treat degloving injuries of the hand and fingers.The compartmented abdominal flap was used in 6 patients with different hand and/or finger degloving injuries, which were covered by a 1-flap procedure. The single flap is designed in 2 layers: the flap that is an abdominal flap is elevated as usual and at the next stage of dissection, we create a separate compartment for each finger in the superficial fatty layer of the skin flap making pockets that encircle each finger separately. An external fixator device is placed to hold the fingers in their respective pockets. The flap is severed in 3 to 4 weeks time in a serial manner. The volar surface of the fingers, which is covered by fatty tissues by then, is skin grafted at a later date.All the flaps survived and the contour of the hand and sensation was superior to the earlier flaps reported in the literature and in our earlier patients. The grasp and pinch function is better owing to the adherence of tissues to the volar surfaces of the fingers. The slippery feel of flaps over the volar surfaces of the fingers in handling objects is not felt or seen.The "compartmented abdominal flap" is a modification of the routine abdominal flap for degloving injury of the hand and fingers. The flap is designed in 2 layers: 1 layer is to cover the dorsum of the hand and the other is created in the fatty layer in separate compartments for each finger. At a later date and after flap separation, the raw volar surface is left to granulate and is then covered by a split thickness skin graft.

Purpose The forehead is acknowledged to be one of the best, if not the best, donor sites for reconstruction of postoperative nasal defects after ablation in cancer patients. The versatility, color match, and texture are among the benefits of this flap. However, it has 2 major disadvantages: 1) it is stiff, flat, and thicker than normal nasal skin, and thus molding from a 2-dimensional to a 3-dimensional shape is difficult, and 2) there is a donor-site defect that requires coverage using a split-thickness skin graft. Patients and Methods In this 5-year study (2004–2009), we modified the 2-stage technique and added an operation before tissue transfer and pedicle division in 48 patients with nasal defects. During the first stage, the tumor was completely excised, and a tissue expander was inserted in the subgaleal plane. After 3 weeks, expansion was initiated. The second operation was performed 12 weeks later. A full-thickness forehead flap was elevated and transposed with primary closure of the donor site. In a third or final stage 3 weeks later, the pedicle was divided. Patient satisfaction and donor site scar was evaluated. Results Over the past 5 years, 48 reconstructions for nasal defects were performed using this technique. Nasal defects of the dorsum, alar, tip, columella, and septum were successfully treated. Graft take was successful in all patients. Conclusions The forehead flap technique, in conjunction with tissue expander for nasal repair, has both advantages and disadvantages. The esthetic benefits of this technique must be weighed against the disadvantages.

Botulinum toxin type A (BTX-A) has been used to treat migraine and occipital neuralgia. We report preliminary results of an ongoing study that assesses the efficacy of BTX-A on trigeminal neuralgia (TN) patients refractory to medical treatment.We treated 15 patients (8 men and 7 women) between 28 and 67 years of age who were suffering from drug-refractory TN from February 2008 to January 2010. Symptoms, including pain duration, provoking factors, affected nerve branch, frequency of TN attacks, and severity of pain just before injections, were evaluated 1 week, 1 month, and 6 months after injection. We injected 50 U reconstituted BTX-A solution at the trigger zones. The overall response to treatment was assessed via a 9-point patient global assessment scale and compared with values at baseline. Statistical analysis was performed by the analysis of variance (ANOVA) test for frequency of TN attacks, the Friedman test for severity of pain, and the Wilcoxon signed-rank test for PGA, and all with the use of SPSS software.Eight men and 7 women aged 28-67 years (mean 48.9 y) suffering from TN from 6 months to 24 years all improved regarding frequency and severity of pain attacks; in 7 patients, pain was completely eradicated and there was no need for further medication. In 5 patients, nonsteroidal antiinflammatory drugs were enough to alleviate pain attacks, and 3 patients again responded to anticonvulsive drugs after injection. All patients developed higher pain thresholds after injections. The ANOVA test showed a significant difference in frequency of attacks before injection and at 1 week, 1 month, and 6 months after injection (P.001). Friedman test and pair comparison of pain severity scores with Bonferroni correction adjustment showed a significant difference (P.001) between severity of pain before and after injection. Wilcoxon signed-rank test showed significant improvement in all patients up to 6 months after injection (P.001). Complications included transient paresis of the buccal branch of the facial nerve in 3 patients.This study supports other similar studies and shows that BTX-A is a minimally invasive method that can play a role in treating TN before other more invasive therapies, i.e., radiofrequency and surgery.

Purposes The aim of this study was to evaluate the role of opium in causing oral cancer. Patients and methods Eighty patients and 80 selected matched controls who were referred to the ear-nose-throat department of an academic hospital were included in this study between October 2008 and September 2010. In addition to demographic data, information regarding alcohol, tobacco, and opium use was documented in the subjects. Finally, the effect of each risk factor was assessed. Results There was no significant difference in patient demographics between the 2 groups. Smoking (P = 0.042) and poor oral hygiene (P = 0.016) significantly correlated with cancer. Finally, opium addiction showed a significant relationship with oral cavity cancer with an odds ratio of 4 (95% confidence interval, 1.2-13.6). Conclusion Opium use is among the possible risk factors for oral cancer.

Aim: This study was designed to assess the prevalence, distribution, and patterns of injury among athletes engaged in combat sports and compare the prevalence, pattern, and types of oral and maxillofacial trauma in these athletes. Materials and Methods: A total of 120 male athletes engaged in four combat sports (boxing, taekwondo, kickboxing, and Muay Thai) who had sustained bodily trauma were studied; 95 subjects with at least one traumatic injury to the face requiring treatment were referred to us by the physician team. The type of injury (facial laceration, facial fractures, jaw dislocation, etc.), site of facial injury (jaw, nose, malar bone, teeth, etc.), dental injuries (tooth fracture, displacement, luxation, and avulsion), causative sport (boxing, taekwondo, kickboxing, and Muay Thai) as well as demographic data were recorded. Injuries were examined clinically and radiographically, and treated accordingly by a specialist. Treatment data and demographics were recorded for each subject. Recorded data were assessed, and c2 , ANOVA, and Kruskal-Wallis tests were used to statistically analyze and compare the data. Results: Of 120 subjects, 95 male subjects (79.2%), aged 18-25 years (avg. 20 years), had at least one traumatic injury to the face requiring medical treatment. These injuries included facial laceration, bone fractures (nose, mandible, and zygoma), dental injuries (displacement, luxation, fracture, and avulsion), and mandibular dislocation which were recorded in 83 (69.2%), 55 (45.1%), 53 (44.2%), and 8 (6.7%) cases respectively. Statistically significant differences were encountered among various injuries and the sports; kickboxing caused the most maxillofacial injuries and was identified as more injurious. Tooth fractures (59.7%) were the most common dental injuries, and the nose (84.7%) was the most frequently fractured facial bone. Lacerations were more common in Thai-boxers (93.3%). Injuries were significantly greater in professional rather than amateur athletes. Conclusion: In this study, prevalence of facial injuries from combat sports professionals was significantly high (roughly 80%), especially in kickboxing (in part due to use of less protective gear). Because the nose and teeth sustained the most injuries, they require more attention with regard to prevention. Kickboxing was the most injurious of these combat sports and caused the most significant number of maxillofacial trauma. More safety apparel and protective guards seem warranted in athletes of combat sports if facial injury is to be prevented.

Aim : The literature focuses little attention on factors that influence third molar post extraction pain (PEP). One factor that may play a role in PEP is saliva. We undertook a study in patients subjected to third molar extraction with the aim of assessing the influence of salivary pH on PEP. Materials and Methods: Thirty-one healthy patients with one impacted inferior lower third molar with mean age of 21.02 th + 2.05 years, underwent surgery for similar impactions. The process of pH measuring was carried out without delay after saliva collection, with a combination electrode connected to a PHM 62 pH meter. Pain assessment was done at 4, 8, 12, 18 and 24 hours on the first day. The scale ranged from 0 to 10 in which 0 and 10 denoted 'no pain' and 'maximum pain,' respectively. Results: The multivariate analysis suggests that the factors that influence pain are patients' sex (B = - 0.466) and the saliva pH (B = - 1.093). According to the findings of our study, PEP intensity is assumed to have a reverse correlation with salivary pH and is also assumed to be greater in females. Conclusion: Due to the fact that no previous study has indicated such findings so far, further studies are needed to assess the importance of preoperative pH value and its clinical significance on the level of PEP.

Aim : The first step in the management of Temporomandibular Disorders (TMD) is usually noninvasive, especially if the disorder is in the early stages. Clinically, pain and clicking are early signs and symptoms of TMD. The management of TMD usually includes splint therapy and analgesics. In this study, we report our long-term outcomes in the treatment of patients suffering from early TMD. Materials and Methods: We assessed the records of 138 patients who were referred for management of TMD. Selection was based on pain and/or clicking of the Temporomandibular Joint (TMJ), no pathologic lesions of the TMJ, no anterior disc displacement without reduction (closed lock), no Degenerative Joint Disease, no history of migraine, trauma, osteoarthritis, metabolic disease, or malocclusion (deep bite, cross bite, jaw deformity, etc). The patients were treated with an acrylic maxillary Interocclusal Splint (IOS) cuspid-rise type and were told to refrain from biting, yawning and chewing hard food. The outcome of the treatment, potential etiologic factors (Bruxism), signs and symptoms and patient demographics (such as age, sex, treatment duration, etc.) were assessed. The data were analyzed using the Chi-square test to correlate significance. Results: One hundred thirty-eight patients (26 males and 112 females) with early signs and symptoms of TMD (pain and/or click of the TMJ) were treated from 2001 to 2010; 81% were females and 19% were males. All the 138 patients used the IOS at night only. The patients were followed-up for 1-9 years. Data analysis showed that 64% of the patients were completely relieved of signs and symptoms; 22% were moderately relieved (decreased severity of signs and symptoms) and 14% had no noticeable post-treatment changes in clicking or pain (P = 0.001). Patients with bruxism and those presenting with both pain and clicking showed a better response to IOS treatment (P = 0.046 and P = 0.001, respectively). The results also showed that age, sex, severity of symptoms and duration of the treatment did not influence treatment results in this group of patients with early TMD. Conclusion: In this population, TMD was significantly higher in females. Treatment of early TMD with IOS was effective and moderately effective in long-term in over 80% of the patients during the follow-up period of 1-9 years. Bruxism had a significant etiologic role in TMD; occlusal attrition of the dentition, pain of all the teeth, early morning pain of the masticatory muscles and the TMJ are signs and symptoms to suspect nocturnal bruxism. Use of an IOS is recommended to prevent potential damage to the dentition, periodontium and the TMJ in early TMD.

Immediate implantation after extraction is advantageous when clinical circumstances allow it. However, it is often problematic. The most common problem in such cases is confronting bone loss after tooth extraction because of long-standing periodontitis. Although there are many techniques designed to manage these complications, autogenous grafts are considered to be the gold standard in grafting procedures because of their osteoinductive properties. There are many sites from which to harvest bone for grafting procedures, each possessing advantages and disadvantages. We present a new site for bone harvesting and a new graft design for osseous reconstruction in implant dentistry.

Twenty-four cases of ectopic single-finger transplantation are reported using our new "piggyback" technique for finger transfer that simplifies, with a high success rate, the hazardous second-stage transfer. Twenty-four patients (mean age, 20 years) were treated for severely crushed proximal stumps with a replantable distal part (zones 1 and 2a). In this method, after a successful ectopic transplantation, the transplanted part is transferred to the original site not as a free tissue transfer but as a pedicle flap in which the transplanted finger is piggybacked to the groin flap and then the composite tissue (groin and finger) is transferred to the stump. After a waiting period of 3 to 4 weeks, the flap is severed sequentially or in 1 setting. Graft take, complications, sensitivity, patient satisfaction, and demographic data of the patients were evaluated.Graft take was 75% in the first stage and 100% in the second stage. There were no cases of infection, and minor complications such as edema subsided with time. Distal finger amputations have the best indication for replantation. A Pearson Educational Measurement score was obtained from the patients who participated in 6-month and 1-year follow-ups, and at the end of 1 year, 85% of the patients scored above 45 points. Eighty-seven percent of the patients were satisfied with their results and stated they would choose this procedure again if indicated and also would recommend it to other patients.The piggyback method of transfer of the ectopic single-finger transplantation has simplified the arduous and risky second-stage transfer to a low-risk and highly successful operation. The advantages include a less bulky tissue transfer, no severed major artery, and 2 short surgical procedures replacing 1 lengthy, potentially risky free vascularized procedure. The only drawback of this technique is the 3-week waiting period for the pedicle flap, wherein the hand is attached to the groin. The reconstruction of the nerve, artery, and tendon and, sometimes, when it is not possible to accomplish proper bone fixation at the second stage, can be achieved with ease after severing the pedicle.

Major complications after maxillary orthognathic surgery are fortunately uncommon when executed properly. However, segmental necrosis has been reported. When this occurs, comprehensive reconstruction of the maxilla becomes difficult because both hard and soft tissues are lost. Use of a free flap such as the fibula for this purpose is difficult because it is bulky. We report a 40-year-old woman who presented with a defect of the anterior maxilla that occurred after necrosis of the premaxilla, which we treated with a modified prefabricated osteocutaneous free fibula flap and dental implants with long-term follow-up. The modified prefabricated free fibula flap is suitable for maxillary reconstruction.

Background:In December 2003, the residents of Bam, Iran experienced an earthquake that measured 6.6 on the Richter scale and destroyed >90% of the city. After the assessment and initial treatment of injuries at national and international field hospitals, a considerable number of victims (approximately 12,000) were transferred to tertiary referral hospitals around the country. Objective: This report evaluated the injuries of 854 victims transferred to 12 referral hospitals in Tehran.Methods:The demographic data, injury patterns, injury severity score (ISS), diagnosis, treatment, and outcome data of 854 Bam earthquake victims were assessed.Results:There were 467 (54.7%) males and 387 (45.3%) females. The mean age of the patients was 29.0 years. Transportation by aircraft was the most common method used for evacuation, which was used to evacuate 555 patients (65%). Fifty-four percent of the victims required initial medical aid at field hospitals before transportation to Tehran. There were 1,322 patients with injuries, of which, fractures of the lower extremities were the most common (331; 25%). Limb fixation was the most commonly performed primary procedure in emergency wards (389 cases, 39.9%). The mean value ±SD for ISS was 6.7 ±5.2. Orthopedic operations were the most frequent surgical procedures performed (195/260 operations, 75%) and the overall mortality rate was 1.6% (n = 14).Conclusions:Along with the crucial importance of aid provided by national and international field hospitals in disasters, suitable triage of casualties and preparedness of tertiary referral centers in unaffected regions also play an important role in providing medical care to disaster victims. During these situations, the number of victims cannot be predicted accurately, and sufficient medical care, particularly for orthopedic problems, can be provided by referral centers.

Purpose We report our 11-year experience with a new technique to prefabricate the osteocutaneous free fibula flap to reconstruct defects of the maxilla and mandible not amenable to conventional methods of treatment. Material and Methods We treated 11 patients aged 17 to 47 years with jaw defects using prefabricated free fibula grafts from 1994 to 2005. We prepared the fibula on the leg with a 6- to 8-mm muscle cuff; next we transferred the bone flap to the surface of the leg without severing the pedicle, and then covered the muscle almost circumferentially by partial thickness skin graft. The bone flap was left in place with its pedicle intact for 2 to 3 months, after which the skin graft had taken and the flap was free of inflammation. The fibula flap was then transferred to the face, fixed in place with plates, and microvascular anastomosis was performed. Implant placement was completed 4 to 6 months after transfer of the flap to the oral cavity. Results Graft take was unremarkable in all cases. There were no cases of infection and only minor complications. Edema of the flap may be encountered, which subsides with time. If the mandible is not edentulous the mandibular teeth may bite into the flap, but these wounds heal by the time the patient is ready for implant insertion (3 to 6 months). Implants placed in the fibula were successful during the follow-up period (2 to 13 years). Conclusion The prefabricated fibula with a “banking time” on the leg for flap maturation seems to be a better choice compared with other methods of using the fibula for reconstruction and has passed the test of time. We hereby report this new technique to add to the armamentarium of jaw reconstruction surgery.

We aimed to assess the prevalence of peripheral neuropathy in chemical warfare victims. We speculated that peripheral neuropathy is a late complication of exposure to chemical warfare agents. Late complications of exposure to chemical warfare agents are not well known and are poorly discussed in the existing literature. Scientific data regarding delayed complications are sparse, but this warrants recognition, especially when the clinician has to treat chemical warfare victims. The hazards of organophosphate pesticides and several toxins, although recognized to some extent, are, however, different from the hazards of chemical warfare agents which are far more serious. In this study, 100 chemical warfare patients, with varying degrees of exposure and an average age of 37.2+/-9.0 years, were examined clinically and studied electrodiagnostically from January 2002 to January 2003. Five of these patients proved to be suffering from axonal neuropathy. This rate was significantly higher than that found in the normal population. Our data indicate that chemical warfare agents may cause peripheral neuropathy in chemical warfare victims. In conclusion, organophosphorous agents used against Iranian troops during the war on Iran correlate with delayed neuropathy in these victims.

The Dizin Ski Resort is unrivaled in the Middle East and is the third of a series of national getaways chosen by the Editor for recuperation, rest and re-invigoration of the “stressed-out” trauma surgeon. If you are a weary surgeon wishing to take leave for a winter vacation and know how to ski, Dizin is the place to be The Dizin Ski Resort Dizin was first opened in 1969. This Ski Resort is the first ski and winter sports resort in Iran officially recognized by the International Ski Federation for its capability in organizing and conducting official international competitions. It is known for its slopes, versatile course lengths and feasibility to hold ski competitions as well as its amenities and recreational facilities. The ski amenities include two hotels, 19 cabins and five restaurants. Dizin is nestled on the Alborz mountain range, 73 km north of Tehran. The Dizin Ski Resort. It has three gondola lift routes, two chair-lift routes, seven dish tele-ski routes and one hammer tele-ski route. The lowest elevation is 2650 m, while its highest peak is 3600 m. The highest ski lift reaches the 3600 m peak, making it one of the 40 highest ski resorts in the world (1). Both powder skiing and compact snow skiing rivals that of Europe and Rocky Mountain areas (Figures 1 - ​-3).3). The Damavand volcano can be seen from the summit (Figure 4). Figure 1. Powder Skiing Figure 3. View of the Dizin Ski Resort and Various Ski Piste Routes Figure 4. View of the Damavand Volcano From Dizin The snow quality at Dizin is fantastic. Dizin’s climatological condition offers one of the longest seasons for skiing, from November through the end of May. The recreational activity in Dizin is not confined to the winter season. There are many other activities in spring, summer and fall such as tennis, mountain climbing, mountain biking and grass skiing. Ski instruction courses are available for the novice. At present, the Dizin Ski Resort is governed by the Iran Ski Federation. Figure 2. View of the Main Ski Piste Open Hours The piste is open daily from 8 am to 4 pm; it is flocked with skiers on weekends (Thursday and Friday) while during weekdays it is less populated. Most skiers take the gondola up to the peak and ski to the restaurant in the middle of the slope and spend the day reclining in the sun while sipping tea. The scenery is absolutely spectacular. Others try all the various in addition to the main piste. Getting There There are two ways to reach Dizin from Tehran. The longest and safest is via the Karaj motorway, this road is usually open but it takes about 2.5 hours. The quickest however is via Shemshak; this road is steep and is often closed due to frequent avalanches. It is strongly advised to take the road from Karaj. Make sure you check the weather and snow forecast before you set out. Accommodation The hotels are conveniently located just 20 m from the slopes. The parking area is just 50 m away. Several ski shops and ski rentals are also located around the car park. Two hotels are situated just below the ski slopes (Figure 3). Cabins may also be rented (Figure 5). They have spectacular views from rooms facing the slopes. There is also a hotel in Shemshak. Figure 5. View of the Cabins at Dizin Skiing and Snowboarding Dizin is an excellent place for skiing and snowboarding (Figure 6), with a total of 22 lifts. A snowboard can be rented for 100000 Rials (3.00 USD) per day, but can go as high as 300000 Rials per day depending on where you rent and quality of the equipment. Cheaper rentals are available in Shemshak or at the parking lot at the top of Dizin. It is possible to rent both ski and snowboard equipment at three places: the pro-shop at the hotel, which has the newest and thus much more expensive equipment, the rentals by the parking lot of the hotel and several shops at the parking lot at the summit. The latter is about half the price compared to the ones at the bottom of the slopes. The same applies to rentals in Shemshak. Ski instructors are available for hire. It is also possible to hire an experienced guide who can take you to other mountains for off-piste powder skiing. You can get a taxi from the top of the slope down to Shemshak, which is another ski resort, located just 15 minutes away. Shemshak is steeper and very good for experienced skiers (2). Figure 6. Snowboarding at Dizin Dining During the day there is a SFC (Iranian version of KFC) in the middle of the slope and a snack bar at the summit. The latter also serves breakfast. At night there are only two restaurants (also open for breakfast and lunch); one is the Dizin Hotel and the other is the lower hotel restaurant. The Gajereh Hotel is about a five minutes drive from the Dizin Hotel. This hotel is slightly cheaper and will have a higher chance of vacancy on weekends. It has a free shuttle bus to the slopes (2). In the winter, Dizin is the Editor’s choice for a national getaway for relaxation, recuperation and winter sports.

As we all well know, the trauma surgeon is oftentimes over-stressed because of high workload and numerous professional responsibilities; thus, it is not surprising that he or she unknowingly neglects the much-needed occasional release of physical and mental stress. A buildup of stress is detrimental to health and impairs both manual and mental function. It has been reported that doctors practicing in stressful medical professions are often over-stressed with limited ability to work efficiently (1-3). It is therefore imperative that surgeons take time off periodically to get away and release stress. Where can the surgeon go to recuperate? How about back to nature? In this issue, we present part two of a series of editorials wherein we will introduce national resort destinations and attractions for relaxation and recuperation of the weary and over-worked trauma surgeon. The Northern Provinces If you love nature, you will love the northern provinces of Iran; northern Iran includes the Southern Caspian regions including the provinces of Gilan, Mazandaran, and Golestan (the ancient kingdom of Hyrcania, historical region of Tabaristan). These provinces are within a 3-6 hour drive from the capital, Tehran. The provinces border the Caspian Sea. Due to the moderate climate, lush green foliage and dense forestry can be seen near the sea shore. These provinces have three different climate zones. Climate Zones Moderate climate: The moderate climate zone covers the central and western plains of Mazandaran. The average annual rainfall is in the range of 1200 to 1300 millimeters; the amount of rainfall decreases as we proceed to the east. Mountainous climate: The high mountains and northern parts of the Alborz heights have weather that is cold with most of the precipitation in the form of snow. Semi-arid climate: This climate prevails in some parts of Gorgan valley (north of Gorgan Rud as far as the Turkmenistan border). In this area, the average annual rainfall stands at 500 millimeters (4). Provinces of Northern Iran Northern Iran is a trendy spot, especially amongst foreign tourists. It is a resort destination with numerous attractions and all types of modern recreational facilities as well as natural resources and a tourism infrastructure. The major provinces, Gilan and Mazandaran, border the Caspian’s impressive shorelines and are covered with dense forests and snow-covered mountain peaks. The major cities are Amol, Babol, Anzali, Rasht, Calus (also Chalous) and Sari. Northern Iran has scenic villages, particularly Massule, which is widely-appreciated by travelers and tourists. Attractions and Recreations 1- Natural Forest Parks and Reserves Back to nature: The Gilan and Mazandaran, provinces have beautiful dense forests and national parks that are ideal for camping, hiking and biking; the beauty and solitude is euphoric (Figures 1 - ​-44). Figure 1. Dense Misty Forest With a Calm, Peaceful and Serenic Atmosphere – Perfect for Hiking Figure 4. Two Trauma Surgeons Exploring the Wilderness and Woodlands of Kelard Dasht Northern Iran While on Vacation; Trail Riding and Hill Climbing Figure 2. Spectacular Colorful Foliage of Mazandaran Forests in Autumn Figure 3. The Mountainous Region of Ramsar with Beautiful Foothills of the Alborz Mountain Range, Covered With Dense Forests and Meadows. The Lush Green Forestry and Calm Are Perfect for Relaxation (http://www.irantourcenter.com/Mazandaran/default.aspx) 2- Cable Car Ride The tourist city of Namak Abroud near Chalous has cable cars that ascend a near vertical peak; A restaurant, coffee shop and a nook with mounted binoculars are available at the summit. The summit is so high that the neighboring cities many kilometers away may actually be seen from that height (Figures 5 - ​-77). Figure 5. Arial View of Namak Abroud Cable Car Ride in the Summer. (http://www.exploringtourism.com/iran-sightseeing-and-activities/) Figure 7. Breath-Taking View of the Namak Abroud Cable Car Ride in the Winter (http://fbstatus.mihanblog.com/post/599) Figure 6. Namak Abroud Cable Car Ride in the Winter 3- Natural Lakes Natural lakes like the Valasht lake is a beautiful natural reserve; it is an ideal place to hike, camp-out or trail-ride. Valasht lake is located just after Marzan Abad about 10 km from Kelardasht. The lake is crystal clear and perfect for rowing and fishing. The solitude is great for relaxation and meditation clearing the mind (Figure 8). Figure 8. The Splendid Valasht Lake (http://commons.wikimedia.org/wiki/File:Valasht.jpg) 4- Scenic Drive to Chalous There are many routes to the northern provinces. The most scenic, without a doubt, is the road to the northern city of Chalous known as the Chalous Road. This road winds through the mountains and is indeed a joy to drive on and the scenery is absolutely breath-taking (Figures 9 - ​-1010). Figure 9. The Spectacular Chalous Road in the Summer (http://karimkhanzand.com/detail/88) Figure 10. The Magnificently Colorful Chalous Road in Autumn 5- Natural Water Falls There are many delightful waterfalls and refreshing natural springs to enjoy throughout the northern provinces; the sound is music to the ears (Figures 11 - ​-1313). Figure 11. Beautiful Waterfalls Near Chalous City, Iran Figure 13. Lawton Falls in Gilan, Iran Figure 12. Beautiful Waterfalls in Shir-Abad, Golestan Province, Iran 6- The Caspian Sea The Caspian Sea is the largest enclosed inland body of water on Earth by area; it is the world's largest lake or a full-fledged sea. The sea has a surface area of 371,000 km2 (143,200 sq mi) and a volume of 78,200 km3 (18,800 cu mi). It is has no outflows and is bounded to the northeast by Kazakhstan, to the northwest by Russia, to the west by Azerbaijan, to the south by Iran, and to the southeast by Turkmenistan (5). The Caspian Sea has a shoreline bordering the northern provinces. Besides swimming, water-skiing, jet-skiing, boating and wind-surfing are among the popular and more attractive water sports in this region. Figure 15. Azadi Hotel at Dusk 7- Hotel Resorts There are many resort hotels; some of the most popular are the Azadi Hotel in Chalous, the Ramsar Hotel in Ramsar and the Aryan Hotel Apartment in the city of Noor. The latter brings freshly baked Iranian bread, still hot from the oven, directly to your door with breakfast (Figures 14 - ​-1616). Figure 14. Azadi Hotel Overlooking and Bordering the Caspian Sea (http://www.southtravels.com/middleeast/iran/caspianazadi/index.html) Figure 16. Ramsar Hotel Resort Nestled in the Mazandaran Mountains. 8- Architecture and Monuments in Northern Iran The northern provinces also have fine museums, parks, restaurants, and striking architectural landmarks and monuments (Figure 17). The city of Masuleh has a unique architecture and is surrounded by forests from valleys to peaks. Masuleh is a city in the Sardar-e Jangal District of Fuman County, Gilan, Iran. Masuleh is approximately 60 km southwest of Rasht and 32 km west of Fuman (Figure 18). Figure 17. Mazandaran Savad Kooh Bridge (http://commons.wikimedia.org/wiki/File:Mazandaran_Sevatcow_Dowab.jpg?uselang=en) Figure 18. City View of Masuleh (http://en.wikipedia.org/wiki/Masuleh) 9- Rudkhan Castle (Also Rood-khan Castle) Rudkhan Castle is a medieval brick and stone structure in Fuman, Iran. The castle is located on a mountain 25 km southwest of Fuman city in the Gilan province of northern Iran. It used to be a military fortress, which had been constructed during the Seljuk Dynasty by followers of the Ismaili sect. The castle covers an area of 2.6 hectares (6.4 acres). Its architects used the natural mountainous features to their benefit in the construction of the fort. The Rudkhan Castle River originates from the surrounding mountainous heights and flows from the south to the north. After crossing a mountainous winding trail in dense forests, the first thing that is noticed about the castle is its entrance gate. Rudkhan Castle sits between two peaks of a mountain at elevations of 715 and 670 m and contains strong fortifications and battlements spanning a length of 1,550 m. The castle's 42 towers still stand intact (Figure 19 - ​-2121). Figure 19. The Parke-Ghale-Rud Khan in Gilan Province of Northern Iran is a must-see site (fa.wikipedia) Figure 21. Rud-Khan Castle (http://en.wikipedia.org/wiki/Rudkhan_Castle) Figure 20. Rood-Khan Castle Gate in Gilan Province of Northern Iran (Mansour Nasiri-http://nasiriphotos.com and at fa.wikipedia) These popular attractions and more make the northern provinces the editor’s second choice destination for a recuperating vacation.

Background: Providing health services is described as an important moral measure, since its major aim is to ensure the welfare of the people who need treatment and care. Moral sensitivity is the ability to identify the existing moral problem and understand the moral consequences of the decisions made on the patient’s part. Physicians are always exposed to moral distress due to various circumstances. Objectives: In this survey, we evaluated moral sensitivity and moral distress among physicians and the relationship of these ethical factors on them. Hence, we assessed y relationship between moral sensitivity and moral distress in physicians will facilitate their sound management so as to provide high-quality and safe health services. Moreover it will confirm proposed theories regarding this subject. Materials and Methods: This cross-sectional descriptive-analytic study aimed at investigating the relationship between moral sensitivity and moral distress among 321 specialist physicians working in hospitals affiliated to Tehran Medical Universities in Tehran. The samples were selected through two-stage random cluster sampling method. A three-partite questionnaire comprising of demographic characteristics, moral distress, and moral sensitivity was used for collecting data which then were analyzed using SPSS-20. Results: There was a negative significant relationship between moral sensitivity and moral distress frequency; there was a positive significant relationship between moral sensitivity and moral distress intensity. Participating in medical ethics courses increased moral sensitivity and decreased the frequency of moral distress. Conclusions: Participating in medical ethics courses increased moral sensitivity and decreased the frequency of moral distress.