Comparing the Efficacy of Surgery and Medical Therapy for Pain Management in Endometriosis: A Systematic Review and Meta-analysis.

BACKGROUND: Pain is considered as one of the main symptoms of endometriosis. The treatment for endometriosis remains controversial. OBJECTIVES: The aim of this study is to compare the effect of medical or surgical treatments for pain-relief in patients with endometriosis. STUDY DESIGN: Systematic review and meta-analysis. SETTING: Published papers about evaluating pain treatment in endometriosis in PubMed, Scopus, and Google Scholar. METHODS: After searching all studies evaluating pain treatment in endometriosis in PubMed, Scopus, and Google Scholar, there were 23 related studies, containing 1,847 patients enrolled in our study. We used a variety of tests: fixed and random effects models, Q Cochrane test and I2 index, Egger and Begg tests, forest and funnel plots, Trim and fill method, and meta-regression in our analysis. RESULTS: There was no statistically significant difference in pain improvement between surgical and medical treatment. Interestingly, pain relief was more prominent longer after treatment. Both clinical trials and cross sectional studies showed higher improvement in pain than cohort studies. High quality studies and lower body mass index (BMI) had a greater effect on pain relief. All studies were heterogeneous, but there was no publication bias. LIMITATIONS: There was a higher probability of risk of bias in blinding, random sequence generation, and selective outcome reporting in clinical trial studies entered in our meta-analysis. CONCLUSIONS: Our results could not demonstrate the preference of each medical or surgical treatment effect for dysmenorrhea in endometriosis. Additional data is required before a standardized medical protocol can be offered, but we believe this study may encourage clinicians to consider a less invasive alternative for treating their patients' chronic pelvic pain in the near future.Key words: Endometriosis, pain, meta-analysis, therapy, disease management.

Comparing Diagnostic Accuracy of Direct Questioning Versus Schematic Evaluation of Chronic Pain Localization.

None of the previous studies localized pain in comparison with graphic scheme. Our aim was to investigate the validity of direct questioning about the main pain localization in comparison with schematic evaluation. In this cross-sectional study, 331 patients, mean age 49.4±10.72 years, localized their main pain site anatomically with manikin and by direct questioning. Two methods were employed to localize pain: direct questioning and schematic evaluation (manikin). Sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) and odds ratio (OR) were used to compare these two methods. Study patients answered in both methods. The sensitivity and PPV were mostly in a weak range, while accuracy, specificity and NPV were mostly in good range. Kappa index was in the marginal reproducibility range. Pain in the left part of the body had a higher OR (OR=9). PLR for pain in the right part of the body was 28.03. NLR for all questions was located in the small and rarely important change probability group. Negative answer in direct questioning was more reliable than a positive one. Pain localization in the left side of the body was more reliable.

Ultrasonography of inferior vena cava to determine central venous pressure: a meta-analysis and meta-regression.

Background Until now, no valid alternative exists for predicting central venous pressure (CVP) with lower invasiveness than central venous catheter. Purpose To explore inferior vena cava diameter (IVCD) measurement accuracy by ultrasonography as a surrogate variable for determination of central venous pressure (CVP). Material and Methods A systematic review and meta-analysis of all published studies in PubMed, Scopus, Web of Knowledge, and Google Scholar were conducted from inception to July 2013. We used the STROBE checklist for quality assessment and meta-regression. Results Thirty-seven papers with 2843 cases were identified. The correlation coefficients between each one of IVCD, inspiratory IVC (iIVC), IVC collapsibility index (IVCCI), and expiratory IVC (eIVC) with CVP, were 0.68, 0.60, 0.54, and 0.44, respectively. There was no evidence of publication bias ( P = 0.28). Based on meta-regression, male gender was an important source of heterogeneity (OR = 1.01; 95% confidence interval, 1-1.03), which resulted in a higher correlation between IVCD and CVP. The present study showed a higher strength of association with CVP pertaining to IVCD, iIVC, IVCCI, and eIVC, respectively, and they were higher in men. Conclusion This study does not support the measurement of IVCD by ultrasonography as an acceptable surrogate variable to determine CVP among critical patients.

Determining the lymphadenopathy characteristics of the mediastinum in lung CT scan of children with tuberculosis.

OBJECTIVE/BACKGROUND: Most tuberculosis cases in children are primary infection, with difficult and imprecise diagnosis mainly based on the existence of mediastinal lymphadenopathy. Here, we investigated the characteristics of mediastinal lymphadenopathy in lung computed tomography (CT) scans of children with tuberculosis. METHODS: This cross-sectional study was performed on 75 children with tuberculosis referred to Masih Daneshvari Hospital in Tehran, Iran, from 2009 to 2013. Their medical records were investigated, and CT-scan characteristics were extracted by a radiologist. RESULTS: Mean±standard deviation age of cases was 11.2±4.6years. CT-scan results indicated 94.7% of cases had lymphadenopathy, with lower paratracheal, upper paratracheal, hilar, and subcarinal forms observed in 81.7%, 69.1%, 53.5%, and 47.9% of cases as the most involved stations in lymph nodes, respectively. In 74.6% of patients with mediastinal lymphadenopathy, perilymph node fat inflammation (matting) was observed, with 52.11% exhibiting conglomeration. Bronchial pressure was observed in 4.23% of children with tuberculosis, and bilateral-, right-, and left-parenchymal involvement was observed in 42.7%, 25.3%, and 8% of these cases, respectively. Left- and right-pleural effusion and calcification was reported in 6.7%, 12%, and 5.6% of patients, respectively. Additionally, nearly 80% of patients exhibited mediastinal lymphadenopathy and lung-parenchyma involvement simultaneously. Lung-parenchyma involvement was significantly correlated with subcarinal (p<.001), hilar (p<.001), subaortic (p=.030), lower paratracheal (p=.037), and axillary (p=.006) stations. CONCLUSION: Situation of mediastinal lymphadenopathy and its synchronicity with lung-parenchyma involvement can help in differential diagnosis of pulmonary tuberculosis from other lung diseases.

Mediastinal lymphadenopathy in pediatric tuberculosis in computed tomography scan.

BACKGROUND/OBJECTIVES: Pediatric tuberculosis is usually a primary infection presenting mainly as mediastinal or hilar adenopathy in computed tomography (CT) scan. In this study, we study the distribution and other CT scan characteristics of mediastinal lymphadenopathy in childhood tuberculosis. METHODS: Chest CT scans of 75 cases of pediatric tuberculosis at Masih Daneshvari Hospital in Tehran, Iran, from 2009 to 2013 were studied regarding characteristics of mediastinal lymphadenopathy. RESULTS: Mean±standard deviation age of cases was 11.2±4.6years. Lymphadenopathy (mediastinal/hilar) was detected in 94.7% of cases. Most of the lymphadenopathies were located in the lower paratracheal (81.7%), upper paratracheal (69.1%), hilar (53.5%), and subcarinal (47.9%) stations. Perilymph node fatty stranding, lymphadenopathy conglomeration, bronchial pressure by the lymph nodes, and lymph node calcification were noted in 74.6%, 52.11%, 4.23%, and 5.6% of cases, respectively. Bilateral, right, and left lung parenchymal involvement were reported in 45%, 25%, and 8% of cases, respectively. Lung parenchymal involvement was significantly correlated with lymphadenopathies in subcarinal (p<0.001), hilar (p<0.001), subaortic (p=0.03), lower paratracheal (p=0.037), and axillary (p=0.006) stations. Right- and left-sided pleural effusions were observed in 12.7% and 7% of cases, respectively. CONCLUSION: Attention to distribution and characteristics of mediastinal lymphadenopathy can help differentiate tuberculosis from other causes of pediatric mediastinal lymphadenopathy.

The effect of adjuvant vitamin C after varicocele surgery on sperm quality and quantity in infertile men: a double blind placebo controlled clinical trial.

Varicocele is one of the most common causes of male infertility and spontaneous pregnancy rate after varicocelectomy is only about 30%. The most important seminal antioxidant is vitamin C but recent studies about the effects of vitamin C on spermatogenesis are controversial; therefore, we decided to evaluate its role after varicocelectomy. In a double blind randomized controlled clinical trial, 115 men with infertility and clinical varicocele with abnormal semen analyses were recruited. After surgery, the intervention group received vitamin C (250 mg bid) and the control group received placebo for three months. Mean sperm count, motility, and morphology index of two semen analyses (before and after surgery) were compared between the two groups. Univariate general linear model and stepwise linear regression were used in analysis. The mean age (± SD) of participants was 27.6 ± 5.3 years. Vitamin C group had statistically significant better normal motility (20.8 vs. 12.6, P=0.041) and morphology (23.2 vs. 10.5, P<0.001) than placebo group. Considering the values prior to surgery as covariate, vitamin C was not effective on sperm count (P=0.091); but it improved sperm motility (P=0.016) and morphology (P<0.001) even after excluding the confounding effect of age (P=0.044 and P=0.001, respectively). Vitamin C was also an independent factor in predicting motility and normal morphology after surgery. Ascorbic acid can play a role as adjuvant treatment after varicocelectomy in infertile men.

The effect of adjuvant vitamin C after varicocele surgery on sperm quality and quantity in infertile men: a double blind placebo controlled clinical trial

Varicocele is one of the most common causes of male infertility and spontaneous pregnancy rate after varicocelectomy is only about 30%. The most important seminal antioxidant is vitamin C but recent studies about the effects of vitamin C on spermatogenesis are controversial; therefore, we decided to evaluate its role after varicocelectomy. In a double blind randomized controlled clinical trial, 115 men with infertility and clinical varicocele with abnormal semen analyses were recruited. After surgery, the intervention group received vitamin C (250 mg bid) and the control group received placebo for three months. Mean sperm count, motility, and morphology index of two semen analyses (before and after surgery) were compared between the two groups. Univariate general linear model and stepwise linear regression were used in analysis. The mean age (±SD) of participants was 27.6±5.3 years. Vitamin C group had statistically significant better normal motility (20.8 vs. 12.6, P=0.041) and morphology (23.2 vs. 10.5, P<0.001) than placebo group. Considering the values prior to surgery as covariate, vitamin C was not effective on sperm count (P=0.091); but it improved sperm motility (P=0.016) and morphology (P<0.001) even after excluding the confounding effect of age (P=0.044 and P=0.001, respectively). Vitamin C was also an independent factor in predicting motility and normal morphology after surgery. Ascorbic acid can play a role as adjuvant treatment after varicocelectomy in infertile men.

Impact of metabolic syndrome on response to medical treatment of benign prostatic hyperplasia.

PURPOSE: To investigate the effect of metabolic syndrome (MetS) on the response to medical therapy of benign prostatic hyperplasia (BPH) after a 3-month period of treatment. MATERIALS AND METHODS: This was a cohort study of 100 patients, 47 with MetS and 53 without MetS, referred to either the primary care unit or referral hospital with BPH who had moderate lower urinary tract symptoms of prostate involvement and were candidates for medical treatment. Our main outcome was response to medical treatment with prazosin 1 mg twice a day and finasteride 5 mg daily in patients with BPH on the basis of International Prostate Symptom Score (IPSS). Multivariate analysis of covariance was used to compare BPH treatment response in patients with and without MetS before and after receiving treatment. RESULTS: The mean volume of the prostate was significantly higher in MetS patients than in patients without MetS (57 ± 32.65 mL compared with 46.00 ± 20.19 mL, p=0.036). The control group demonstrated an 11-unit reduction in IPSS, whereas those with MetS showed a reduction in the symptom score of only 6 units (p<0.001). Regarding the components of MetS separately, triglyceride (p<0.001), fasting blood sugar (p=0.001), and waist circumference (p=0.028) significantly affected the clinical progression of BPH. The observational nature of this study may be a limitation in comparison with an interventional study. CONCLUSIONS: The results of the present study showed that MetS can negatively affect the response to medical treatment of BPH. Therefore, it is necessary to consider MetS in selecting patients with BPH for drug therapy.

Model determination of delayed causes of analgesics prescription in the emergency ward in arak, iran.

BACKGROUND: According to the reports of the World Health Organization 20% of world population suffer from pain and 33% of them suffer to some extent that they cannot live independently. METHODS: This is a cross-sectional study which was conducted in the emergency department (ED) of Valiasr Hospital of Arak, Iran, in order to determine the causes of delay in prescription of analgesics and to construct a model for prediction of circumstances that aggravate oligoanalgesia. Data were collected during a period of 7 days. RESULTS: Totally, 952 patients participated in this study. In order to reduce their pain intensity, 392 patients (42%) were treated. Physicians and nurses recorded the intensity of pain for 66.3% and 41.37% of patients, respectively. The mean (SD) of pain intensity according to visual analogue scale (VAS) was 8.7 (1.5) which reached to 4.4 (2.3) thirty minutes after analgesics prescription. Median and mean (SD) of delay time in injection of analgesics after the physician's order were 60.0 and 45.6 (63.35) minutes, respectively. The linear regression model suggested that when the attending physician was male or intern and patient was from rural areas the delay was longer. CONCLUSIONS: We propose further studies about analgesics administration based on medical guidelines in the shortest possible time and also to train physicians and nurses about pain assessment methods and analgesic prescription.

Comparison of the accuracy and reproducibility of focused abdominal sonography for trauma performed by emergency medicine and radiology residents.

We compared the diagnostic accuracy of emergency medicine residents (EMRs) and radiology residents (RRs) in performing focused abdominal sonography for trauma (FAST). The cohort in this prospective study comprised 200 unstable patients (163 males and 37 females; mean ± standard deviation of age, 34.3 ± 16.4 y) who presented with trauma. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. Patients with positive FAST results underwent further diagnostic procedures such as computed tomography, diagnostic peritoneal lavage and laparotomy. Those with negative FAST results underwent clinical follow-up for 72 h until their condition deteriorated or they were discharged. Sensitivity, specificity, positive and negative predictive values and accuracy in evaluating free intraperitoneal fluid were 80%, 95%, 57%, 98% and 94% when FAST was performed by EMRs and 86%, 95%, 59%, 98% and 94% when FAST was performed by RRs. The level of agreement between EMRs and RRs was moderate (κ = 0.525). FAST is a useful screening tool for initial assessment of free abdominal fluid in patients with trauma. Our results indicate that EMRs can perform sonography on trauma patients as successfully as RRs.

A scientometric analysis of 20 years of research on breast reconstruction surgery: a guide for research design and journal selection.

BACKGROUND: Breast reconstruction refers to the rebuilding of a woman's breast using autologous tissue or prosthetic material to form a natural-looking breast. It is increasingly offered to women undergoing mastectomy for breast cancer. However, there is no systematic analysis available for the expanding area of research on breast reconstruction. METHODS: A bibliometric method was used to obtain a view of the scientific production about breast reconstruction by data extracted from the Institute for Scientific Information (ISI). Specific parameters were retrieved from the ISI. Articles about breast reconstruction were analyzed to obtain a view of the topic's structure, history, and document relationships using HistCite software. Trends in the most influential publications and authors were analyzed. RESULTS: The number of articles was constantly increasing. Most highly cited articles described the methods of flap construction in the surgery. Other highly cited articles discussed the psychological or emotional aspects of breast reconstruction, skin sparing mastectomy, and breast reconstruction in the irradiated breast. CONCLUSIONS: This was the first breast reconstruction scientometric analysis, representing the characteristics of papers and the trends of scientific production. A constant increase in the number of breast reconstruction papers and also the increasing number of citations shows that there is an increasing interest in this area of medical science. It seems that most of the research in this field is focused on the technical aspects of surgery.

Comparison of diagnostic value of conventional ultrasonography by emergency physicians with Doppler ultrasonography by radiology physicians for diagnosis of deep vein thrombosis.

OBJECTIVES: To determine sensitivity, specificity and other operating characteristics of bedside three-point compression ultrasonography performed in emergency department by emergency physicians in comparison with duplex ultrasonography. METHODS: The cross-sectional study at Rasoul-e-Akram Hospital in Tehran, Iran, prospectively evaluated 81 suspected patients of lower extremity deep vein thrombosis between March 2006 and March 2007. A trained second-year resident and one attending physician of emergency medicine evaluated the veins of all the patients with through compression ultrasonography. Then, a second-year resident of radiology assessed the patients with duplex ultrasonography. Finally, data were compared and quantitative and categorical variables were worked out along with other statistical analysis through SPSS version 16. RESULTS: The mean age of the patients was 47.2 +/- 18.6 years. When cases who lost the compressibility of at least one of their femoral or popliteal veins were considered to be positive, there were 80.2% diagnosed by compression ultrasonography and 79% by the duplex variety. Sensitivity, specificity and accuracy of the former in comparison with the latter were 85.9%, 41.2% and 84.6% respectively. CONCLUSION: Compression ultrasonography has relatively an acceptable sensitivity and accuracy level, but has low specificity in the diagnosis of deep vein thrombosis in the hands of Iranian emergency physicians. It is better to implement duplex ultrasonography whenever accessible. Otherwise, compression ultrasonography results should be compared with the results of duplex ultrasonography as soon as possible.

Clinical audit of emergency unit before and after establishment of the emergency medicine department.

OBJECTIVE: To assess the deficiencies and potential areas through a medical audit of the emergency departments, in six general hospitals affiliated to Shahid Beheshti University of Medical Sciences at Tehran, Iran, after preparing specific wards-based international standards. METHODS: A checklist was completed for all hospitals which met our eligibility criteria mainly observation and interviews with head nurses and managers of the emergency medicine unit of the hospitals before (2003) and after (2008) the establishment of emergency departments there. Domains studied included staffing, education and continuing professional development (CPD), facility (design), equipment, ancillary services, medical records, manuals and references, research, administration, pre-hospital care, information systems, disaster planning, bench-marking and hospital accreditation. RESULTS: Education and CPD (p = 0.042), design and facility (p = 0.027), equipment (p = 0.028), and disaster (p = 0.026) had significantly improved after the establishment of emergency departments. Nearly all domains showed a positive change though it was non-significant in a few. In terms of observation, better improvement was seen in disaster, security, design, and research. According to the score for each domain compared to what it was in the earlier phase, better improvement was observed in hospital accreditation, information systems, security, disaster planning, and research. CONCLUSION: Security, disaster planning, research, design and facility had improved in hospitals that wave studied, while equipment, records, ancillary services, administration and bench-marking had the lowest improvement even after the establishment of emergency department, and, hence, needed specific attention.

Impact of cardiac rehabilitation on metabolic syndrome in Iranian patients with coronary heart disease: the role of obesity.

BACKGROUND: Due to high prevalence of metabolic syndrome (MetS) and coronary heart disease (CHD) in Iran, and their mutual relationship, we evaluated how comprehensive cardiac rehabilitation (CR) can affect MetS in patients with CHD. METHOD: In this study (1998-2003), we evaluated 547 patients with CHD undergoing comprehensive CR. RESULTS: Cases with MetS decreased from 42.8% to 33.3% after CR program (p < .001). Decrease in high fasting plasma glucose, triglyceridemia, systolic and diastolic blood pressures, and increase in HDL cholesterol, functional capacity, and left ventricular ejection fraction was more prominent in the "MetS but not obese" group. However, total cholesterol, low-density lipoprotein, weight, body mass index, and waist circumference showed a greater decrease in groups with obesity. CONCLUSION: Cardiac rehabilitation is an effective treatment of MetS, particularly in the absence of obesity. This represents an additional argument for the prevention of obesity and the linked insulin resistance.

Perforated peptic ulcer disease: mid-term outcome among Iranian population.

BACKGROUND/AIMS: The aim of this study was to evaluate midterm outcome of patients with perforated peptic ulcer disease and to determine the main predictors of mid-term mortality. METHODS: Demographic and clinical characteristics of 56 patients with the diagnosis of perforated peptic ulcer who were hospitalized in Taleghani Hospital over a 10-year period (19962005) were retrospectively collected, and in-hospital mortality and morbidity were determined. Patients were also followed for one month, one year and five years after the operation. RESULTS: Among these patients, 85.5% were treated with omental patch closure, 7.1% underwent vagotomy pyloroplasty, 5.3% underwent concurrent vagotomy and gastrojejunostomy, and 1.8% underwent antrectomy. In-hospital mortality and morbidity were 5.3% and 48.2%, respectively. Survival rates at one month, one year and five years after the operation were 92.9%, 89.3% and 78.6%, respectively. Advanced age (p=0.001), preoperative shock (p=0.003), history of malignancy before surgery (p=0.001), treatment delay (p=0.028), intensive care unit admission (p=0.032), and size of ulcer >5 cm (p=0.043) were the main predictors of five-year mortality in the followed patients. CONCLUSIONS: Mid-term mortality of treated perforated peptic ulcer disease among our population was notable, and the main predictors of mortality included advanced age, history of malignancy, treatment delay, intensive care unit admission, and ulcer size.

Impact of cardiovascular risk factors on the outcome of renal transplantation.

Cardiovascular diseases are common in renal transplant recipients and renal insufficiency has been shown to be a risk factor for cardiovascular disease. Some studies have reported that cardiovascular risk factors may contribute to the outcome of renal transplantation. This study was performed to determine the impact of cardiovascular risk factors on the outcome of renal transplantation in Iranian subjects. This is a retrospective, observational study including patients of 20-85 years of age who had undergone renal transplantation. Parameters documented and analyzed included demographics, cardiovascular risk factors, past medical history, date of last transplantation, the outcome of transplant, last measured serum creatinine, cause of graft failure, rejection, and death. A total of 192 patients were analyzed including 152 in the case group (with identifiable cardiovascular risk factors) and 40 controls (transplant recipients without identifiable risk factors). The mean serum creatinine in the case and control groups were 1.33 +/- 0.13 and 1.29 +/- 0.36 mg/dL respectively (P = 0.493). Response to transplantation was categorized based on a report from the World Health Organization. Complete response to grafting occurred in the control group more than the case group (P = 0.009), while frequency of partial response to grafting was higher in the case group (0.008). A history of chronic obstructive pulmonary diseases (COPD) could significantly predict the outcome of grafting (P = 0.008) as could the occurrence of renal failure (P = 0.022). Results were consistently reproduced using multivariate cumulative log it model. Our study indicates that the measured cardiovascular risk factors do not significantly influence the outcome of renal transplantation.

Knowledge, attitudes and practice of Iranian medical specialists regarding hepatitis B and C.

BACKGROUND AND AIMS: Health care workers (HCWs) are at risk of contracting and spreading hepatitis B virus (HBV) and hepatitis C virus (HCV) to others. The aim of this study was to evaluate knowledge, attitudes and behavior of physicians concerning HBV and HCV. METHODS: A 29-item questionnaire (reliability coefficient = 0.7) was distributed at two national/regional congresses and two university hospitals in Iran. Five medical groups (dentists, general practitioners, paraclinicians, surgeons and internists) received 450 questionnaires in 2009, of which 369 questionnaires (82%) were filled out. RESULTS: Knowledge about routes of transmission of HBV and HCV, prevalence rate and seroconversion rates secondary to a needlestick injury was moderate to low. Concern about being infected with HBV and HCV was 69.4±2.1 and 76.3±2 (out of 100), respectively. Complete HBV vaccination was done on 88.1% of the participants. Sixty percent had checked their hepatitis B surface antibody (anti-HBs), and 83.8% were positive. Only 24% of the surgeons often used double gloves and 28% had reported a needlestick. There was no significant correlation between the different specialties and: concern about HBV and HCV; the underreporting of needlestick injuries; and correct knowledge of post-needlestick HBV infection. CONCLUSIONS: Although our participants were afraid of acquiring HBV and HCV, knowledge about routes of transmission, prevalence, protection and post-exposure seroconversion rates was unsatisfactory. By making physicians aware of possible post-exposure prophylaxis, the underreporting of needlestick injuries could be eliminated. Continuous training about HBV and HCV transmission routes, seroconversion rates, protection, as well as hepatitis B vaccination and checking the anti-HBs level, is a matter of necessity.