Publications by authors named "Mohammad Naghavi-Behzad"

78 Publications

Prognostic Value of Dual-Time-Point F-Fluorodeoxyglucose PET/CT in Metastatic Breast Cancer: An Exploratory Study of Quantitative Measures.

Diagnostics (Basel) 2020 Jun 11;10(6). Epub 2020 Jun 11.

Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark.

This study aimed to compare the prognostic value of quantitative measures of [F]-fluorodeoxyglucose positron emission tomography with integrated computed tomography (FDG-PET/CT) for the response monitoring of patients with metastatic breast cancer (MBC). In this prospective study, 22 patients with biopsy-verified MBC diagnosed between 2011 and 2014 at Odense University Hospital (Denmark) were followed up until 2019. A dual-time-point FDG-PET/CT scan protocol (1 and 3 h) was applied at baseline, when MBC was diagnosed. Baseline characteristics and quantitative measures of maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), corrected SUVmean (cSUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and corrected TLG (cTLG) were collected. Survival time was analyzed using the Kaplan-Meier method and was regressed on MTV, TLG, and cTLG while adjusting for clinicopathological characteristics. Among the 22 patients included (median age: 59.5 years), 21 patients (95%) died within the follow-up period. Median survival time was 29.13 months (95% Confidence interval: 20.4-40 months). Multivariable Cox proportional hazards regression analyses of survival time showed no influence from the SUVmean, cSUVmean, or SUVmax, while increased values of MTV, TLG, and cTLG were significantly associated with slightly higher risk, with hazard ratios ranging between 1.0003 and 1.004 ( = 0.007 to = 0.026). Changes from 1 to 3 h were insignificant for all PET measures in the regression model. In conclusion, MTV and TLG are potential prognostic markers for overall survival in MBC patients.
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http://dx.doi.org/10.3390/diagnostics10060398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344801PMC
June 2020

Relationship Between Serum Vitamin D Level and Ectopic Pregnancy: A Case-Control Study.

J Family Reprod Health 2019 Sep;13(3):167-172

Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.

To compare the difference in Vitamin D level between women with ectopic pregnancy and control group. In the present case-control study, 150 patients with ectopic pregnancy were included as case group and 150 women with normal pregnancy as a control group. Then, serum vitamin D levels were measured in both groups and they were then compared with each other. P less than 0.05 was considered statistically significant. The mean age in ectopic pregnancy group was 28.12 ± 5.91 and 27.35 ± 6.21 years old in control group; the difference between two groups was not statistically significant (p = 0.43). The vitamin D level in control group was higher than that of ectopic pregnancy group (p = 0.002). Of all patients, 182 patients (60.66%) had vitamin D deficiency and 64 patients (21.33%) had vitamin D insufficiency. Serum vitamin D level among patients with ectopic pregnancy was statistically lower than women with normal pregnancy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7072032PMC
September 2019

Effects of Iranian healthcare transformation plan on discharge against medical advice rate and related factors in 2012 and 2016.

BMJ Open 2019 09 4;9(9):e024291. Epub 2019 Sep 4.

Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran

Objective: Discharge against medical advice (DAMA) is a critical problem in hospitals and has several consequences for healthcare systems. The aim of this study was to determine and compare the rate of DAMA and its related factors before and after executing the healthcare transformation plan (HTP) in Iran.

Methods: In a two-phase, cross-sectional study, the DAMA information of 200 patients in 2016 (after HTP) and the patients of a previous study in 2012 (before HTP) was compared. Samples were randomly selected from the main referral centre in the north-west of Iran. Data were collected using a validated and reliable questionnaire and analysed using the SPSS V.16 software.

Results: In the post-HTP plan period, the rate of DAMA was 3.9%, while this rate was 5.49% in 2012 (p=0.029). A total of 15% (108 out of 721) of patients in the postreform group and 13.5% (101 out of 747) in the prereform group were rehospitalised (p=0.411). The three main categories of reasons for DAMA in 2012 and 2016 were as follows: patient-related factors, 27% vs 45%; staff-related factors, 33% vs 30%; and hospital-related factors (basic amenities), 40% vs 25%. In both periods, the average scores of patient satisfaction were almost the same; however, satisfaction regarding environmental and human factors in hospitals had changed significantly after HTP (p<0.05).

Conclusions: There was a decrease in the rate of DAMA after HTP in Iran. Considering DAMA as a multifactorial phenomenon, this might be due to the higher relative satisfaction after HTP, indicating an increase in public confidence in general hospitals.
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http://dx.doi.org/10.1136/bmjopen-2018-024291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731801PMC
September 2019

Effect of Flushing the Endometrial Cavity With Follicular Fluid on Implantation Rates in Sub-Fertile Women Undergoing Invitro Fertilization: A Randomized Clinical trial.

J Family Reprod Health 2018 Dec;12(4):184-190

Department of Emergency Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.

To examine the effectiveness of intrauterine injection of follicular fluid in in vitro fertilization (IVF). A parallel randomized control clinical study was conducted on 110 patients attending Al-Zahra Educational-Medical Center of Tabriz University of Medical Sciences. Female candidates for IVF were categorized into intervention (n = 55) and control (n = 55) groups using Randlast software (version 1.2). Following an identical protocol of gonadotropin-releasing hormone (Gnrh) antagonist stimulating ovulation, in the intervention group a total of 2mL of follicular fluid was injected as intrauterine after the accomplishment of follicular puncture. Embryo transfer was carried out after 2-3 days. The rates of implantation, as well as chemical and clinical pregnancy were compared between the two groups. There were no significant differences in chemically proven pregnancy (19 in intervention group (34.5%) vs. 23 (41.8%) in control group p = 0.43), or in clinical pregnancy (30.9% vs. 38.2%, respectively p = 0.42), and in implantation rates (11.52 ± 2.57 % (range, 0-66.7) vs 18.79 ± 3.72 % (range, 0-100), respectively). Injection of follicular fluid into the uterine cavity in candidates for IVF neither improves nor adversely affects the outcome of the therapy.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581657PMC
December 2018

Comparison Between Effect of Letrozole Plus Misoprostol and Misoprostol Alone in Terminating Non-Viable First Trimester Pregnancies: A Single Blind Randomized Trial.

J Family Reprod Health 2018 Mar;12(1):27-33

Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.

To evaluate the effect of letrozole plus misoprostol to terminate non-viable pregnancies in first trimester compared with the use of misoprostol alone. In a single-blind clinical trial, 128 women over 18 years old referred to Educational-Medical centers of Tabriz University of Medical Science (Tabriz, Iran), for abortion in first trimester of non-viable pregnancies, were randomly selected in two intervention and control groups using Rand list (version 1.2) software. To complete abortion both groups received 600 mcg of misoprostolorally. The intervention group received letrozole 10 mg daily for 3 days before receiving misoprostolorally. Complete abortion rate and the side effects of both groups were recorded. Mean pregnancy age based on LMP in intervention group and control group were 7.74 ± 0.95 and 8.52 ± 1.29 weeks respectively. Complete abortion rate in the intervention group was 93.7%, and in control group was 68.7% which was significantly higher in intervention group (p = 0.001). Abdominal pain in the intervention group is also significantly lower than that of the control group (p = 0.013). Intervention group also had significantly lower duration of bleeding rather than control group (p = 0.006). Based on the findings of this study, letrozole pretreatment with misoprostol for first-trimester medical abortion can increase complete abortion rate significantly without increasing side effects compared to use of misoprostol alone.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329994PMC
March 2018

Organizing palliative care in the rural areas of Iran: are family physician-based approaches suitable?

J Pain Res 2019 18;12:17-27. Epub 2018 Dec 18.

Managerial Epidemiology Research Center, Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Maragheh, Iran,

Introduction: The provision of palliative end-of-life care (P/EOLc) for patients, wherever they live, is an increasingly important service, particularly given the increasing rates of cancer and other life-threatening diseases in Iran. However, unfortunately, those living in the rural areas of Iran are greatly disadvantaged with respect to this type of care. Therefore, the present study explored the feasibility of organizing P/EOLc in the rural areas of Iran.

Methods: In this qualitative study, two focus group (FG) discussions were held in Tabriz (Iran) with rural family physicians (FPs, n=23) and key P/EOLc stakeholders (n=13). The FG sessions were recorded, transcribed, and the transcriptions checked by participants before the data were subjected to content analysis.

Results: While most FPs indicated that they did not have sufficient involvement in providing P/EOLc, they emphasized the necessity of providing P/EOLc through four main themes and 25 subthemes. The four main themes were labeled as "structures and procedures," "health care provider teams," "obstacles," and "strategies or solutions." Furthermore, according to the main themes and subthemes identified here, the key stakeholders believed that the Iranian health system and the FPs' team have the potential to provide P/EOLc services in rural areas.

Conclusion: The most feasible strategy for providing P/EOLc in Iranian rural areas would be to use the current health care framework and base the process around the FP.
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http://dx.doi.org/10.2147/JPR.S178103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6302809PMC
December 2018

End-of-life Care: Beliefs, Attitudes, and Experiences of Iranian Physicians.

Indian J Palliat Care 2018 Oct-Dec;24(4):431-435

Social Determinent of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Context: Most of the patients suffering from cancer are diagnosed at late stages of cancer, which curative interventions are unable to improve their quality of life.

Aim: To survey Iranian physicians' attitudes and practices toward end-of-life (EOL) care.

Subjects And Methods: We conducted a cross-sectional survey among physicians participating in a national annually conducted educational seminar.

Results: The survey results show that 80% of physicians had between 1 and 3 EOL patients. About 72% of patients received medical care in hospitals. The difference in best setting for care of terminally ill patients was statically significant after controlling for the length of practice and physician belief. The results also showed that that the participants believed that that the level of physicians' knowledge in this field was unacceptable.

Conclusion: Physicians of our study were interested to participating in continuing education programs focused on EOL patients.
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http://dx.doi.org/10.4103/IJPC.IJPC_74_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6199833PMC
November 2018

Association of Hypothyroidism and Anti-Thyroid Antibodies With Preterm Delivery: A Cross Sectional Study.

J Family Reprod Health 2017 Dec;11(4):191-196

Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Preterm delivery is a common and eventful phenomenon with long standing complications, heavily burdening the health system. Many risk factors have been suggested to increase the likelihood of this event, one being hypothyroidism and high levels of anti-thyroid antibodies. The present study sought to explore the association between hypothyroidism and anti-thyroid antibodies with preterm delivery. A case control study was conducted on 400 patients attending Educational-Medical centers of Urmia University of Medical Sciences (Urmia, Iran) between November 2013 and April 2016, in which 200 patients with term deliveries and 200 patients with preterm deliveries were compared for differences in hypothyroidism, existence of anti- thyroperoxidase (TPO) antibodies based on blood samples obtained from the patients which were tested using chemi-luminescence method. In the group of patients with preterm delivery, 85 patients had hypothyroidism (42.5%), and from the term delivery group, 67 patients (33.5%) had hypothyroidism, the difference was not statistically significant (p = 0.14). But, when groups of early and late preterm deliveries were compared in terms of having anti-TPO antibodies, there was a significant difference between them, with early preterm delivery having 8 patients positive out of 44 patients and late preterm delivery having 7 positives out of 141 patients (p = 0.004). Hypothyroidism had an insignificant effect on preterm delivery rates, but the existence of anti-TPO antibodies in the serum had a significant increasing effect on early preterm deliveries and could be regarded as a risk factor.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6168755PMC
December 2017

Effect of Progesterone on Latent Phase Prolongation in Patients With Preterm Premature Rupture of Membranes.

Acta Med Iran 2017 Dec;55(12):772-778

Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Preterm premature rupture of membranes (PPROM) is a condition leading to an increased risk of maternal and neonatal morbidity and mortality in pregnant women. To prevent this complication, some studies have proposed using prophylactic progesterone. However, due to lack of sufficient relevant data, there is still need for further studies in this regard. This study was performed to determine the effect of rectal progesterone on the latent phase and maternal and neonatal outcome variables in females with PPROM. During the present randomized clinical trial study (IRCT201512077676N4), a total of 120 patients with PPROM at pregnancy ages between 26 and 32 weeks were randomly assigned to 2 equal intervention and control groups. In the intervention group, progesterone suppositories (400 mg per night) were administered until delivery or completion of the 34th gestational week and was compared with placebo effect in control group. The latent phase and maternal and neonatal outcome variables were compared between the two groups. The mean age of patients was 29.56±5.66 (19-42) and 29.88±5.57 (17-40) years in the intervention and control group, respectively. The two groups were almost identical in the confounding factors. The median latent phase was 8.5 days in the intervention group vs. 5 days in the control group in the 28th-30th weeks of gestation, which was significantly higher in the intervention group (P=0.001). Among maternal and neonatal outcome variables, only the mean birth-weight was significantly higher in the intervention group than that in the controls (1609.92±417.28 gr vs. 1452.03±342.35 gr, P=0.03). Administration of progesterone suppository in patients with PPROM at gestational ages of 28 to 30 weeks is effective in elongating the latent phase and increasing birth-weight with no significant complications.
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December 2017

Effects of atorvastatin on proteinuria of type 2 diabetic nephropathy in patients with history of gestational diabetes mellitus: A clinical study.

Niger Med J 2017 Mar-Apr;58(2):63-67

Department of Gynecology and Obstetrics, Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Gestational diabetes is known as one of the diseases through pregnancy. In the present study, changes in proteinuria after atorvastatin administration among patients with history of gestational diabetes were studied.

Materials And Methods: In this randomized clinical trial, 42 patients were included in the study. Atorvastatin was administered for 21 patients, and 21 patients were designated as control group. Lipid profile, protein, and 24 h urine creatinine (uCr) levels were determined in the beginning and 3 months after intervention. < 0.05 was considered statistically significant.

Results: Lipid profile in intervention group was enhanced; low-density lipoprotein (LDL) had decreased while triglyceride had not changed and high-density lipoprotein had been increased. There was no statistically significant change in serum Cr, serum urea, estimated glomerular filtration rate, uCr, urine volume, 24-h urine protein level, or urine protein/Cr ratio on both groups during the study; also, there was no statistically significant difference between groups.

Conclusions: Although LDL level decreased after atorvastatin therapy, atorvastatin therapy had no effect on the level of proteinuria or other parameters related to kidney function.
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http://dx.doi.org/10.4103/0300-1652.219348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726175PMC
December 2017

Persistent hypocalcemia and hungry bone syndrome after parathyroidectomy and renal transplantation in a patient with end-stage renal disease.

Niger Med J 2017 Jan-Feb;58(1):50-52

Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.

Hungry bone syndrome (HBS) defines as persistent and severe hypocalcemia after parathyroidectomy surgery. It is treated by oral or venous discrimination of calcium carbonate. The present treatment is mostly effective. Hereby, we describe a 60-year-old man who had developed hyperparathyroidism secondary to end-stage renal disease and then parathyroidectomy was performed for him twice before renal transplantation. Up to 500 vials of calcium gluconate (100 mg/ml calcium gluconate 10%) were administered for him to control serum calcium level after parathyroidectomy and renal transplantation. Furthermore, high-dose calcium carbonate was administered for his outpatient care. Therefore, HBS, which was resistant to standard treatment, was detected for him.
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http://dx.doi.org/10.4103/0300-1652.218416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715567PMC
December 2017

Clonidine Sedation Effects in Children During Electroencephalography.

Acta Med Iran 2017 Sep;55(9):568-572

Department of Pediatrics, Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

It is very important to have proper management in children with Seizure. Electroencephalography (EEG) as a diagnostic instrument has a key role in determining the management method of seizure in children. Because of poor cooperation of some children (especially children with attention deficit hyperactivity disorders and developmental disorders) in performing EEG, it is the best choice to sedate children before EEG. The aim of present study is to evaluate the sedation efficacy of clonidine in children before EEG. In a randomized clinical trial, 45 children age 2 to 12 with seizure, who referred to Children Hospital of Tabriz University of Medical Sciences and candidate for EEG, were studied. Sedation before EEG induced by 0.5 to 2.0 mg clonidine orally. Sedation score (0 to 5) measured by using eyes condition, response to voice, and response to touch. Successful sedation, EEG performing, and hemodynamic stability were evaluated during sedation. Of all patients, 40 patients (88.88%) were sedated successfully, and EEG was performed for all of the children. Mean onset time of clonidine effect was 35.47±13.56 minutes and mean time of that the patients' level of consciousness back to the level before administrating of clonidine was 77.55±26.87 minutes. Hemodynamic states of all patients were stable during the study, and there were no significant changes in vital sign of patients. In conclusion, clonidine can be considered as a safe alternative medication for sedation for EEG, which is fortunately associated with no significant change in vital signs, which may complicate overall status of patients.
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September 2017

Relationship between Plasma Levels of Zinc and Clinical Course of Pneumonia.

Tanaffos 2017 ;16(1):40-45

Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Pneumonia is a common disease and is more prevalent among children and the elderly. Zinc (Zn) is an essential substance for the human body and plays an important role in regulating the immune system. Studies have shown a possible relation between the Zn plasma levels and pneumonia.

Materials And Methods: In a cross-sectional study, 100 patients with pneumonia, who were referred to the Educational-Medical Centers of Tabriz University of Medical Sciences, were included in the study. The plasma levels of Zn of all patients were measured. The patients were divided into two groups of normal and low plasma levels of Zn. The severity and clinical course of pneumonia, including the durations of fever, tachycardia, and tachypnea were evaluated and compared between the two groups.

Results: The plasma levels of Zn were normal in 56 patients and low in 44 patients. The mean duration of fever, tachycardia, and tachypnea in the group with normal plasma levels of Zn were 1.58±0.68, 2.04±0.81, and 2.78±0.84 days, respectively; and those in the group with decreased Zn plasma levels were 1.72±0.70, 2.18±0.90, and 2.97±0.91 days, respectively. There were no statistically significant differences between the two groups (P>0.05). However, the incidence of severe pneumonia was significantly less in the group with normal Zn plasma levels (P=0.001).

Conclusion: Based on the findings of the present study, there was no statistically significant relationship between the plasma levels of Zn and the clinical course of pneumonia. However, Zn lowered the incidence of severe pneumonia.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473381PMC
January 2017

Effects of Helicobacter pylori treatment on rosacea: A single-arm clinical trial study.

J Dermatol 2017 Sep 28;44(9):1033-1037. Epub 2017 Apr 28.

Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Rosacea is a chronic dermatological disease. Helicobacter pylori has been discussed as one of its causative factors. In this clinical trial study, we attempted to evaluate the effect of H. pylori standard eradication protocol on the rosacea clinical course. In this single-arm clinical trial, patients ascertained to have H. pylori infection based on serological studies were assessed to examine existence of rosacea. Patients with concurrent rosacea and H. pylori infection were included in the study and underwent standard H. pylori eradication therapy. Rosacea was evaluated using the Duluth rosacea grading score at the beginning, 2 months later and at the end of the trial (day 180). Of 872 patients positive for H. pylori, 167 patients (19.15%) manifested the clinical features of rosacea. The patients with concurrent rosacea were younger (P < 0.001) and with a female sex predominance (P = 0.03) when compared with rosacea-free patients. Of 167 patients, 150 received H. pylori eradication therapy, demonstrating a 92% (138/150) cure rate. The rosacea Duluth score grading on day 0, 60 and 180 among 138 patients significantly decreased in most of the criteria except for telangiectasias (P = 0.712), phymatous changes (P = 0.535) and the existence of peripheral involvement (P = 0.431). The present study concluded that H. pylori eradication leads to improvement of rosacea.
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http://dx.doi.org/10.1111/1346-8138.13878DOI Listing
September 2017

Comparison of IIF, ELISA and IgG avidity tests for the detection of anti-Toxoplasma antibodies in single serum sample from pregnant women.

Infez Med 2017 Mar;25(1):50-56

Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

A valid estimate of test efficiency is needed to choose adequate screening and detecting strategies in diagnosis of acute toxoplasmosis. Therefore, in the present study we evaluated the efficiency of diagnostic laboratory methods to detect anti-toxoplasma antibodies in single serum samples of pregnant women by indirect immunofluorescence test (IIF), enzyme-linked immunosorbent assay (ELISA) and IgG avidity tests in north-western Iran. In an analytical-descriptive study, during March 2010 to April 2013, 391 pregnant women aged 21 to 35 years who were referred by gynaecologists or infectious disease specialists for anti-toxoplasma antibody evaluation were studied. A peripheral blood sample was collected from individuals and serum was prepared immediately for anti-toxoplasma antibody evaluation by IIF, ELISA and IgG avidity tests. ELISA and IgG avidity tests were used as gold standard. Evaluation of anti-toxoplasma antibodies by IIF revealed that 280 cases (71.61%) were seropositive and 111 (28.38%) seronegative, while evaluation by ELISA revealed that 267 cases (68.28%) were seropositive and 124 (31.70%) seronegative; 65 (16.62%) were IgM positive by both IIF and ELISA tests. There were 45 (69.23%) and 7 (10.76%) IgM positive suspected cases respectively in IIF and ELISA confirmed by the IgG avidity test for recent toxoplasmosis. This study highlights how to manage and evaluate pregnant women who are suspected to be infected with toxoplasmosis by using diagnostic tests, especially in a single serum sample indication.
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March 2017

Spontaneous Rupture of Pyometra in a Nonpregnant Young Woman.

Case Rep Obstet Gynecol 2017 19;2017:4572379. Epub 2017 Feb 19.

Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

A 40-year-old woman presented with severe vaginal bleeding. Initial workup with an abdominal sonography revealed endometrium for about 3 mm and free fluid in the abdomen. Hemodynamic instability with abdominal pain and free fluid in the abdomen prompted blood transfusion and laparotomy. There were about 1000 cc blood and clots in the abdomen at laparotomy. There was a longitudinal rupture from fundus up to cervix at the left side of the uterus. Tearing was in full thickness from serosa to endometrium. Scar of previous cesarean was transvers and not associated with this tearing. There was not any myomectomy scar.
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http://dx.doi.org/10.1155/2017/4572379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337346PMC
February 2017

Evaluation of the Pathogenesis of Tumor Development from Endometriosis by Estrogen Receptor, P53 and Bcl-2 Immunohistochemical Staining

Asian Pac J Cancer Prev 2016 12 1;17(12):5247-5250. Epub 2016 Dec 1.

Departments of Pathology, Imam Reza Teaching Hospital, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.

Objective: Endometriosis, one of the most common estrogen dependent gynecological disorders, can present as both benign and malignant disease. The prevalence of tumoral transformation is 0.7-1.6% and the most common tumors are clear cell and endometrioid carcinomas. Unfortunately, the pathogenesis of transformation is unknown. For this purpose, we examined molecular alterations in ovarian endometriosis and endometriosis-associated tumors. Methods: Using the data bank of Alzahra hospital pathology department and paraffin blocks from appropriate cases were identified. Sections were cut and stained for 3 markers: estrogen receptor, P53 and bcl2. Correlations between findings were investigated. Results: Nineteen cases of endometriosis-associated tumor and 19 cases of endometriosis were identified. Staining for bcl2 was documented in 14 of 19 (73.7%) of endometriosis-associated tumor cases and also 7 of 19 (36.8%) endometriosis cases (P=0.02). Only 3 of the 19 (15.8%) endometriosis-associated tumors exhibited positive staining for estrogen receptors, compared with 14 of 19 (73.7%) endometriosis cases (P<0.001). Positive staining for P53 was noted in 5 of 19 (31.6%) endometriosis-associated ovarian tumor samples but was absent in endometriosis samples (0%), (P =0.008). Conclusions: Endometriosis-associated tumors appear to be associated with overexpression of bcl2 and P53 and reduced expression of Estrogen receptor. These finding may help to diagnose tumoral transformation with a background of endometriosis.
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http://dx.doi.org/10.22034/APJCP.2016.17.12.5247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454666PMC
December 2016

Cervical Cancer Prevention Knowledge and Attitudes among Female University Students and Hospital Staff in Iran

Asian Pac J Cancer Prev 2016 11 1;17(11):4921-4927. Epub 2016 Nov 1.

Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran. Email:

Background: Cervical cancer is a major preventable cancers. The, current study aimed to assess relevant knowledge and attitude of female students and hospital staff in Iran. Method: This cross-sectional study was conducted in Medical and Nursing faculties and hospitals of East-Azerbaijan Province of Iran. Participants were medical and paramedical female students and female staff in hospitals selected by stratified random sampling techniques. Tools for data collection were questionnaires for which validity and reliability had been verified (α=0.8). Descriptive and inferential statistics were used to analyze data with SPSS.16. Result: Response rates were 71 % (426 from 600) and 63.5% (254 from 400) for students and staff, respectively. Some 29.1% admitted that they had no information about cervical cancer, only 70 (10.3%) thinking their knowledge as high, 360 (52.9%) as intermediate, and 237 (34.9%) as low. While 93% of participants considered cervical cancer as a severe health problem, the only statistically significant relationships with knowledge were for education (p<.001) and occupation (p<.001) variables. Conclusion: Given the importance of the roles of medical students and personnel as information sources and leaders in health and preventive behavior, increasing and improving their scientific understanding seems vital. Comprehensive and appropriate education of all people and especially students and personnel of medical sciences and improving attitudes towards cervical cancer and its monitoring are to be recommended.
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http://dx.doi.org/10.22034/APJCP.2016.17.11.4921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454697PMC
November 2016

Serum thyroid-stimulating hormone level and relation with size of hippocampus in patients with mild cognitive disorders.

Niger Med J 2016 Nov-Dec;57(6):353-356

Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Cognitive disorders and dementia are common problems, and Alzheimer's disease is one of the major leading causes of death worldwide. Thyroid hormone disorders as a common problem effect on hippocampus size which as a prognostic factor in dementia. The aim of the present study was to investigate the relationship between serum thyroid-stimulating hormone (TSH) level and the size of hippocampus in patients with mild cognitive disorders.

Materials And Methods: In a descriptive-analytical study, 41 patients with symptoms of mild cognitive disorders whom referred to take the brain magnetic resonance image (MRI) in a radiology center under the direction of Tabriz University of Medical Sciences (Tabriz, Iran) were evaluated. The right and left hippocampal and brain volume was calculated by MRI at coronal T1-weighted. Serum TSH level was also measured in these patients. Correlation between serum TSH level and hippocampal volume size was evaluated.

Results: Male to female ratio was 1.05:1 with mean age of 54.09 ± 3.11 years. Mean serum TSH level of patients was 1.55 ± 1.45 uU/ml. The right and left hippocampal volumes were 1.61 ± 0.42 and 1.62 ± 0.39 ml, respectively. There were slight negative correlations between the right and left hippocampal volumes with TSH level ( = -0.133 and = -0.092, respectively). Correlations between the right and left hippocampal volumes with TSH level were not statistically significant ( = 0.406, = 0.566, respectively).

Conclusion: Based on findings of the present study, there was a weak negative correlation between serum level of TSH with the right and left hippocampal and brain volume ratio, but the correlation was not statistically significant. It seems that controlling of clinical or subclinical hypothyroidism may have a role in slowing of dementia progression and also have a preventive role.
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http://dx.doi.org/10.4103/0300-1652.193862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126749PMC
December 2016

Gentamicin-mediated ototoxicity and nephrotoxicity: A clinical trial study.

Niger Med J 2016 Nov-Dec;57(6):347-352

Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Aminoglycosides and mainly gentamicin are the most important antimicrobial agents. Two different methods of administration exist: Single and multiple doses. There has always been a controversy about the less harmful administration method, to minimize adverse effects of gentamicin - deafness and renal insufficiency. In this study, it was aimed to compare two different methods of administration to figure out the least harmful treatment method.

Materials And Methods: In a clinical study, eighty patients aged 12-55 years who were admitted with sepsis syndrome were included in the study; they were divided into two groups: The first group received single-dose treatment (5 mg/kg) whereas the second group was treated with multiple doses (1.7 mg/kg three times a day) of gentamicin.

Results: The results show that blood urea nitrogen (BUN) and creatinine (CR) levels were decreased in the first group. Both blood urea nitrogen and creatinine and also mean glomerular filtration rate was increased in the same group. In the second group, mean BUN and CR levels were increased while the GFR was decreased in the same group. There was also a gradual increase in GFR in the first group. GFR <80 was decreased from 20% to 5.1% in the first group while increased from 5% to 27.5% in the second group. Results of audiometric studies show 6.1% hearing problem in the first group and 12.8% in the second one.

Conclusions: Results of the present study showed that nephrotoxicity and ototoxicity are minimized in single-dose administration compared to multiples doses.
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http://dx.doi.org/10.4103/0300-1652.193861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126748PMC
December 2016

Study of pentoxifylline effects on motility and viability of spermatozoa from infertile asthenozoospermic males.

Niger Med J 2016 Nov-Dec;57(6):324-328

Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: The quality of semen is one of the major parameters in male infertility. Pentoxifylline, a methylxanthine derivative, is an agent primarily used in the treatment of intermittent claudication and other vascular disorders. Studies have shown that pentoxifylline enhances the quality and quantity of sperms. In this study, we have investigated the effects of pentoxifylline on viability and motility of spermatozoa in samples of infertile oligoasthenozoospermic males.

Materials And Methods: In this observer-blinded clinical trial, semen samples of 25 infertile oligoasthenozoospermic males were collected in Alzahra Educational Medical Center of Tabriz University of Medical Sciences from August 2010 to August 2012. After the isolation of spermatozoa by the swim-up method, they were randomized into four groups in ISM1 environment: The controls treated normally: Group 1 treated by pentoxifylline at a dose of 50 μg/ml, Group 2 treated by pentoxifylline at a dose of 100 μg/ml, and Group 3 treated by pentoxifylline at a dose of 200 μg/ml. Sperm viability and motility were compared among the groups on 45 min, 24 h, 36 h, and 48 h intervals.

Results: Mean percentages of live sperms were 98.40%, 51.40%, 20.60%, and 6.00% in control group and 98.40%, 69.20%, 38.60%, and 14.60% in Group 3 on the mentioned intervals, respectively. This mean percentage decrease of live sperms was significantly lower in Group 3 comparing with that of other groups ( = 0.01). Mean percentages of motile sperms were 54%, 8.40%, 2.80%, and 0% in control group; and 54%, 16%, 4.80%, and 1.40% in Group 3 on the mentioned intervals, respectively. There was not a significant difference between the four groups in this regard ( = 0.19).

Conclusion: Pentoxifylline can enhance the viability of sperm of infertile oligoasthenozoospermic males with no significant effect on its motility.
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http://dx.doi.org/10.4103/0300-1652.193857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126744PMC
December 2016

Short-term effects of lovastatin therapy on proteinuria of type 2 diabetic nephropathy: A clinical trial study.

Niger Med J 2016 Sep-Oct;57(5):253-259

Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Diabetic nephropathy (DN) is characterized by albuminuria, hypertension, and a progressive decline in glomerular filtration rate. The 3-hydroxy-3-methylglutaryl coenzyme A is a well-known agent that is active in lowering total plasma and low-density lipoprotein cholesterol (LDL-C) levels in cases with hypercholesterolemia. Hence, in this study, proteinuria changes at the beginning and after the withdrawal of lovastatin in patients with type 2 DN (T2DN) were studied.

Materials And Methods: Lovastatin was administered for thirty male patients with T2DN and then was withdrawn. Twenty-four hours, urine creatinine and protein levels were determined.

Results: The mean levels of total cholesterol and LDL-C were reduced without any change in the triglyceride (TG) level while the high-density lipoprotein cholesterol (HDL-C) level was increased. There was a reverse linear correlation between the changes in the level of HDL-C and the changes in the level of 24 h urine protein after 90 days of lovastatin therapy ( = 0.007, = -0.484).

Conclusions: Short-term 3-month lovastatin therapy has no effect on proteinuria levels in patients with T2DN despite the antihyperlipidemic effects and reverse correlation of proteinuria with HDL-C.
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http://dx.doi.org/10.4103/0300-1652.190600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036295PMC
November 2016

Effects of adenotonsillar hypertrophy corrective surgery on nocturnal enuresis of children.

Niger Med J 2016 Jan-Feb;57(1):69-73

Department of General Surgery, Qazvin University of Medical Sciences, Qazvin, Iran.

Background: Nocturnal enuresis is considered a common urological complaint especially among children. Respiratory obstructive diseases have been one of the possible etiologies of such a condition. The most common type of upper respiratory obstructive diseases in childhood is adenotonsillar hypertrophy. In this study, it was tried to estimate the prevalence of nocturnal enuresis in adenotonsillar hypertrophy as an upper obstructive airway disease and cure rate after corrective operation.

Materials And Methods: In this longitudinal study, 184 children with adenotonsillar hypertrophy as case group and 200 healthy children as control group were randomly compared for nocturnal enuresis incidence and risk factors. Then they were followed after 6 months to estimate the cure rate after corrective operation.

Results: In case group, nocturnal enuresis was more common than control group (26% vs. 17%, P = 0.1). Factors which had a role in enuresis in case group were family history (P = 0.03) and male sex (P = 0.05). Three months after surgery, 48% of children totally cured from enuresis (P = 0.001) and 71% cured both partially or totally (P = 0.03). The response rate after moderate obstruction relieving was 100% while that in severe cases was 60% (P = 0.2).

Conclusions: Nocturnal enuresis due to upper obstructive airway disease occurs more in male and in the presence of family history. The cure rate after 6 months of operation was more prominent in moderate obstruction which suggests enuresis in severe airway obstruction may need a longer time to subside. Cure rate of primary enuresis due to obstructive airway disease after 6 months of relieving was 48% in children over 5 years old.
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http://dx.doi.org/10.4103/0300-1652.180558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859118PMC
May 2016

Immunohistochemical profile of uterine leiomyomas; a comparison between different subtypes.

Niger Med J 2016 Jan-Feb;57(1):54-8

Students' Research Committee, Tabriz, Iran; Medical Education Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Background: Of all Smooth muscle tumours originating from uterus are leiomyomas are the most common ones. Benign nature and smooth muscle origination of leiomyomas can be easily documented via histological examination. In present study it was tried to examine immunohistochemical profile of leiomyomas with different subtypes.

Material And Methods: In this cross-sectional study 64 cases of smooth muscle tumors originating from uterus were included in study. As a control group 12 cases of conventional leiomyomas were selected. Then estrogen receptor, progesterone receptor, p53 and ki-67 were assessed. Statistical analysis was conducted using SPSS 16.0.

Results: P 53 and ki-67 antibody status was diffusely positive in 12 out of 24 cases (50%) of leiomyosarcomas. Leiomyomas with bizzare nuclei were stained with Ki67 proliferative marker less than those in obviously malignant cases (P < 0.001). Estrogen and progesterone receptors had a reverse correlation with tumours malignancy potential.

Conclusion: Since p53 is known as an important inhibitory trigger for proliferative cycle of cells, in current study it was concluded that p53 inhibitory role decreases as malignancy potential increases, also tumors dependence on steroids via steroid receptors decreases as malignancy potential increases.
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http://dx.doi.org/10.4103/0300-1652.180567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859115PMC
May 2016

The relationship between histologic grades of invasive carcinoma of breast ducts and mast cell infiltration.

South Asian J Cancer 2016 Jan-Mar;5(1):5-7

Students' Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.

Introduction: Breast carcinoma is the most prevalent tumors among women. Transformation of inflated cells in immune response leads to increase in inflammatory cells such as macrophages, mast cells (MC) and fibroblasts. The aim of this study was to determine the relationship between grades of invasive carcinoma of the breast ducts and MC infiltration around tumoral cells.

Methods: During the present study, 75 female patients suffering from invasive ductal carcinoma who underwent surgery or diagnostic biopsy during 2010 and 2013 in Educational-Medical centers of Tabriz University of Medical Sciences, were included in the study. Based on Bloom-Richardson grading system, 25 cases were selected from each grade. To better observe of MCs, samples were stained by Toluidine blue and MCs were counted in 10 40 × 10 fields.

Results: The mean age was 47.56 ± 10.84 and the number of MCs was between 6 and 96 and their overall average was 43.01. Average count of MCs in grade 1, 2 and 3 were 15.92 ± 10.07, 45.32 ± 10.47, and 67.8 ± 20.70, respectively. There was a significant relationship between the number of MCs and increase in disease grade (P < 0.001). With increasing grade of malignancy, the number of MCs had grown. No significant relationship was observed between age and grade of disease or age and number of MC.

Conclusion: According to obtained results, number of MC around tumoral cells increased significantly with an increase in the grade of disease. In order to treat in the first stages of the disease, recognizing primary changes in the stroma of cells could be helpful.
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http://dx.doi.org/10.4103/2278-330X.179699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4845609PMC
May 2016

Renal Collecting System Anatomy in Living Kidney Donors by Computed Tomographic Urography: Protocol Accuracy Compared to Intravenous Pyelographic and Surgical Findings.

J Clin Imaging Sci 2016 28;6. Epub 2016 Jan 28.

Department of Diagnostic Radiology and Nuclear Medicine, University of California Davis Medical Center, Sacramento, CA, USA.

Objectives: To evaluate the accuracy of triple-bolus computed tomography urography (CTU) as a surrogate of intravenous pyelography (IVP) for determining the anatomy of the urinary collecting system in living kidney donors.

Materials And Methods: In an analytic descriptive cross-sectional study, 36 healthy kidney donors were recruited during 12 months. Preoperative IVP and CTU were utilized to evaluate kidneys' anatomy; major and minor calyces and variation were used as anatomical indices to compare the accuracy of CTU and IVP; the images were then compared to surgical findings.

Results: Thirty-six kidney donors (92% male; mean age: 28 ± 6 years) were enrolled in this study. The kappa coefficient value was significant and almost perfect for the CTU and IVP findings in detecting the pattern of calyces (kappa coefficient 0.92, asymptotic 95% confidence interval 0.86-0.97). Anatomic variations or anomalies of the urinary collecting system included the bifid pelvis (5.6%), duplication (8.3%), and extra-renal pelvis (2.8%). Both the sensitivity and specificity of CTU in the detection of the anatomy and variations were 100%; the sensitivity and specificity of IVP were 83.3% and 100%, respectively.

Conclusions: The triple-bolus preoperative CTU can be considered an alternative to IVP for assessing the anatomy of the urinary collecting system.
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http://dx.doi.org/10.4103/2156-7514.175079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4766870PMC
March 2016

Comparative Study of Dermatoscopic and Histopathologic Results in Facial Basal Cell Carcinoma and Melanocytic Nevi.

Asian Pac J Cancer Prev 2016 ;17(1):425-9

Department of Dermatology, Tabriz University of Medical Sciences, Tabriz, Iran E-mail :

Background: Dermatoscopy can be applied to diagnose pigmented skin lesions. The aim of the present study was to compare dermatoscopic and histopathologic results in basal cell carcinoma (BCC) and melanocytic nevus of theface.

Materials And Methods: In an analytical-descriptive study, 61 patients suspected of BCC or melanocytic nevi of face were randomly selected. The skin lesions of patients were evaluated with dermatoscopic method from February 2012 to February 2014 and results were compared with pathological features of samples.

Results: In this study, mean age of patients was 49.5±18.9. Some 25 (41%) were men and 36 (59%) were women. In 27 cases (44.3%) there was diagnosis of melanocytic nevus, in 28 cases (45.9%) diagnosis of BCC, and in 3 cases (4.9%) there was mixed diagnosis. The relationship between patients' gender and dermatoscopic diagnosis of the patients was statistically significant (P=0.001). For BCC the sensitivity and specificity of dermatoscopic method were 100% and 97% respectively and for melanocytic nevi 96.4% and 97%.

Conclusions: Dermatoscopic study not only can be helpful in improving clinical diagnosis while guiding missed malignant lesions to pathologic evaluations, but also could be useful in evaluating further suspicious or recurrent cases.
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http://dx.doi.org/10.7314/apjcp.2016.17.1.425DOI Listing
November 2016

Comparative study of intralesional steroid injection and cryotherapy in alopecia areata.

Niger Med J 2015 Jul-Aug;56(4):249-52

Department of Dermatology, Sina Hospital, Tabriz, Iran.

Background And Objectives: Alopecia areata (AA) is a common, non-scarring type of hair loss, affecting approximately 2.1% of the population, many modality of treatment recommended like steroid injection, topical Immunotherapy and several systemic therapies. The aim of this study was to compare intralesional steroid injection and cryotherapyoutcomes in AA.

Materials And Methods: In an analytical-descriptive study, 120 AA patients treated with intralesionalsteroid injection and 120 AA patients treated with cryotherapy were randomly selected. These two groups matched for location, duration and size of lesion and also matched for age and gender. From March 2011 to September 2013, the effect and complications of the therapies after 3, 6, 9 and 12 weeks were assessed and results were compared between the two groups.

Results: Mean age of patients in steroid injection group was 30.2 ± 6.8 and in cryotherapy group was 31.8 ± 7.1. Sexual distribution in both groups was 56.7% and 43.3 % for male and female, respectively. Location of disease in 80% was in scalp and 20% was in face in both groups. The time of beginning response in steroid group was 4.13 ± 2.13 weeks and in cryotherapy group was 6.14 ± 0.29 weeks, difference between two groups was significant (P = 0.001). In term of clinical response at the end of study, in steroid group,20 patients (16.7%) no response, 32 patients (26.7%), moderate response and68 patients (56.7%) had a complete response, and also in cryotherapy group was, 52 patients (43.3%) no response, 40 patients (33.3%) moderate response and 28 patients (23.3%) had a complete response. There was significant different in complete response rate and steroid injection was more effective than cryotherapy(P < 0.05).

Conclusion: As the cryotherapy isa considerable treatment of AA, alsothis study proposes intralesional injection of corticosteroid, as a replacement of AA therapy; particularly the short-term complications are not significantly different.
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http://dx.doi.org/10.4103/0300-1652.165034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697211PMC
January 2016

Complications and Carcinogenic Effects of Mustard Gas--a Systematic Review and Meta-Analysis in Iran.

Asian Pac J Cancer Prev 2015 ;16(17):7567-73

Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Iran E-mail :

Background: Catastrophic effects of mustard gas as a chemical warfare agent have always been a major problem for those exposed to this agent. In this meta-analysis it was tried to evaluate carcinogenesis, ocular, cutaneous and respiratory complications of mustard gas exposure among Iranians who had been exposed to this agent during the Iran-Iraq war.

Materials And Methods: In this meta-analysis, the required data were collected using keywords "mustard gas", "sulfur mustard", "cancer", "neoplasm", "respiratory complications", "ocular complications" , "lung disease", "chronic complication", "eye", "skin", "cutaneous complication", "carcinogenesis" and their combination with keywords "Iran", "Iranian", "prevalence", "mortality" and their Farsi equivalent terms from the databases of SID, Iranmedex, Magiran, Pubmed, Science Direct, Google Search engine, Gray Literature and Reference of References. To determine the prevalence of each complication and perform meta-analysis, CMA: 2 (Comprehensive Meta-Analysis) software with a randomized model was used.

Results: Of the 542 articles found, 7 national articles, consistent with the aims of this study were selected. Meta- analysis of seven papers revealed that cancer risk, especially cancer of the respiratory system was elevated, so that the relative risk (RR) of cancer role of mustard gas was inconsistent from 2/1 to 4 in this survey. Also prevalence of delayed skin disorders due to sulfur mustard was 94.6%, pulmonary complications 94.5% and ocular complications 89.9%. The incidence of various cancers in victims exposed to mustard gas was 1.7% worldwide where the rate was 2.2% in Iranian victims of the Iraq-Iran war.

Conclusions: Based on present study the prevalence of delayed mustard gas related cutaneous, pulmonary and ocular complications is above 90% and risk of carcinogenesis is higher in comparison to worldwide statistics. This may suggest need for long-term and persistent follow-up and rehabilitation procedures for populations exposed to this agent.
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http://dx.doi.org/10.7314/apjcp.2015.16.17.7567DOI Listing
September 2016

Perspective of patients, patients' families, and healthcare providers towards designing and delivering hospice care services in a middle income Country.

Indian J Palliat Care 2015 Sep-Dec;21(3):341-8

Department of Midwifery, Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Introduction: In view of the recent surge in chronic disease rates and elderly population in the developing countries, there is an urgent felt need for palliative and hospice care services. The present study investigates the views and attitudes of patients and their families, physicians, nurses, healthcare administrators, and insurers regarding designing and delivering hospice care service in a middle income country.

Materials And Methods: In this qualitative study, the required data was collected using semi structured interviews and was analyzed using thematic analysis. Totally 65 participants from hospitals and Tabriz University of Medical Sciences were selected purposively to achieve data saturation.

Results: Analyzing the data, five main themes (barriers, facilitators, strategies, attitudes, and service provider) were extracted. Barriers included financial issues, cultural-religious beliefs, patient and family-related obstacles, and barriers related to healthcare system. Facilitators included family-related issues, cultural-religious beliefs, as well as facilitators associated with patients, healthcare status, and benefits of hospice service. Most participants (79%) had positive attitude towards hospice care service. Participant suggested 10 ways to design and deliver effective and efficient hospice care service. They thought the presence of physicians, nurses, and psychologists and other specialists and clergy were necessary in the hospice care team.

Conclusion: Due to lack of experience in hospice care in developing countries, research for identifying probable barriers and appropriate management for reducing unsuccessfulness in designing and delivering hospice care service seems necessary. Input from the facilitators and their suggested solutions can be useful in planning the policy for hospice care system.
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http://dx.doi.org/10.4103/0973-1075.164898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617043PMC
November 2015