Early clinical exposure as a highly interesting educational program for undergraduate medical students: an interventional study

BACKGROUND

Training professional medical experts is so much dependent on the efficacy of the medical curriculum. Bearing this in mind, we aimed to evaluate the attitude of the undergraduate medical students toward the Early clinical exposure (ECE) program as a facilitator transition to the clinical phase.

METHODS

This quasi-experimental study was conducted on undergraduate medical students at the Mashhad University of Medical Sciences, Mashhad, Iran who were transferring from the pre-clinical course to the externship course from 2021 to 2022 by census method (i.e. all eligible students were included and no sampling was performed). An eight-session ECE intervention was performed on the participants by two professors of the Internal medicine department of Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. The participants' attitude toward the program and the program quality was assessed with the valid and reliable scale developed by Mirzazadeh et al. (Cronbach's alpha = 0.72). Statistical analyses were performed by SPSS software (version.16) with a statistically significant level of less than 0.05.

RESULTS

A total of 118 undergraduate medical students were enrolled in the study. Our results revealed that this program could familiarize (n = 95,81.2%)the students with the role of basic sciences knowledge in clinical settings, and 104(88.9%) participants believed that this intervention could motivate them toward learning more. The data revealed that this program was highly interesting for international students. There was a significant differentiation between Iranian and international students in familiarity with doctoring skills in medicine(P < 0.001), familiarity with the roles and responsibilities of clinical students(P < 0.001), and utility of early clinical exposure and providing more experiences(P < 0.001). According to the students' reports, the major strengths of the program were familiarizing themselves with the clinical fields, having excellent instructors, and performing admirable training. On the other hand, the major weakness of the program was the short duration and the high population of participants in each group.

CONCLUSIONS

The ECE program had a positive impact on the students' satisfaction with medical education, and it also enhanced their understanding of the role they will play as future physicians. Therefore, we recommend that this program be implemented as a part of the medical education curriculum in medical universities.

The effect of synbiotic adjunct therapy on clinical and paraclinical outcomes in hospitalized COVID-19 patients: A randomized placebo-controlled trial

Therapeutic approaches with immune-modulatory effects such as probiotics and prebiotics adjuvant therapy may be essential to combat against COVID-19 pandemic. The present trial aimed to reveal the efficacy of synbiotic supplementation on clinical and paraclinical outcomes of hospitalized COVID-19 patients. The current randomized placebo-controlled trial enrolled 78 hospitalized patients with confirmed COVID-19 infection. Participants were randomly allocated to intervention and control groups that received synbiotic or placebo capsules twice daily for 2 weeks, respectively. The synbiotic capsule contains multi-strain probiotics such as Lactobacillus (L.) rhamnosus, L. helveticus, L. casei, Bifidobacterium (B.) lactis, L. acidophilus, B. breve, L. bulgaricus, B. longum, L. plantarum, B. bifidum, L. gasseri, and Streptococcus (S.) thermophilus (10⁹  CFU), as well as fructooligosaccharides prebiotic agent. Besides COVID-19 clinical features, levels of proinflammatory interleukin-6 (IL-6), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), liver and renal function markers, as well as hematological parameters, were assessed during follow-up. The serum level of IL-6 was significantly decreased in the intervention group compared to the placebo after 2 weeks of intervention (p = 0.002). A significant difference was found regarding the count of white blood cells (WBC) within the synbiotic group from pre to post-treatment (p = 0.004). The levels of ESR (p = 0.935) and CRP (p = 0.952) had a higher reduction trend in the synbiotic group relative to the placebo, with no significant between-group differences. Other findings had no statistical differences between groups. Our results provide the support that synbiotic adjuvant therapy for 2 weeks can be effective to modulate inflammatory responses against COVID-19 infection.

Comparison of the efficacy and safety of methotrexate alone or in combination with leflunomide in the treatment of juvenile idiopathic arthritis: a double-blind, placebo-controlled, randomized trial

Introduction

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disorder in children. Although methotrexate (MTX) is the first line disease-modifying antirheumatic drug for JIA, many patients do not respond well or cannot tolerate MTX. The aim of this study was to compare the effect of combination therapy of MTX and leflunomide (LFN) with MTX in patients who do not respond to MTX.

Material and methods

Eighteen patients (2-20 years old) with polyarticular, oligoarticular or extended oligoarticular subtypes of JIA who did not respond to conventional JIA therapy participated in this double-blind, placebo-controlled, randomized trial. The intervention group received LFN and MTX for 3 months while the control group received oral placebo and MTX at a similar dose to the intervention group. Response to treatment was assessed every 4 weeks using the American College of Rheumatology Pediatric criteria (ACRPed) scale.

Results

Clinical criteria, including number of active joints and restricted joints, physician and patient global assessment, Childhood Health Assessment Questionnaire (CHAQ38) score, and serum erythrocyte sedimentation ratelevel, did not differ significantly between groups at baseline and at the end of the 4^th and 8^th weeks of treatment. Only the CHAQ38 score was significantly higher in the intervention group at the end of the 12^th week of treatment. Analysis of the effect of treatment on study parameters revealed that only the global patient assessment score differed significantly between groups (p = 0.003).

Conclusions

The results of this study showed that combining LFN with MTX does not improve clinical outcomes of JIA and may increase side effects in patients who do not respond to MTX.

Human T-lymphotropic virus type 1 and novel coronavirus disease 2019; More complex than just a simple coinfection

The recent coronavirus disease 2019 (COVID-19) significantly affected many people worldwide, especially those with underlying diseases. While some people with underlying illnesses, including cardiovascular diseases, are more vulnerable to develop severe COVID-19, other populations, including people who have autoimmune diseases, may develop severe diseases similar to the general population. The severity and outcome of COVID-19 are reviewed in individuals with underlying viral diseases, including acquired immune deficiency syndrome and hepatitis, however, some infectious diseases, including human T-lymphotropic virus type 1 (HTLV-1) diseases, is under-reported in the literature. HTLV-1 is a sexually transmitted disease that is endemic in some parts of the world. Infected patients may develop clinical symptoms of HTLV-1 associated myelopathy / tropical spastic paraparesis (HAM/TSP) and adult T cell leukemia (ATL) or may remain asymptomatic during their life. To the best of our knowledge, no clinical studies evaluate the severity and outcomes of SARS-CoV-2 infection in HTLV-1 infected patients. We aimed to review the pathogenesis of both of these viral infections and discuss their similarities in provoking immune responses. Although HTLV-1 infected patients may have had variable degrees of inflammation and immune system dysregulation, the available data is limited to conclude that HTLV-1 infected patients may be more vulnerable to developing severe COVID-19 in contrast to the general population.

Comparison of Propofol-Fentanyl with Midazolam-Ketamine Combination in Pediatric Patients Undergoing Kidney Biopsy

INTRODUCTION

Kidney biopsy is a procedure of choice for the diagnosis of many kidney diseases. In children it is performed with the use of sedatives. The aim of this study was to compare the combination of propofol/fentanyl with midazolam/ketamine for sedation in pediatric patients undergoing kidney biopsy.

METHODS

In this double-blinded clinical trial, seventeen children, candidate of kidney biopsy were included and randomized into two groups. One group received Midazolam/Ketamine with doses of 30 to 50 μg/kg and 0.25 to 1 mg/kg, and the other group were sedated with propofol/fentanyl combination in doses of 0.5 to 1 mg/kg and 0.5 to 1 mg/kg, respectively. Administration time, medication doses, total procedure time, need for analgesic use after the procedure, and patient relaxation, with no agitation during and after the biopsy were recorded.

RESULTS

Nine patients received midazolam/ketamine and eight received propofol/fentanyl. None of them experienced vomiting or itching after sedation. There were no meaningful differences in qualitative variables of the need for pain relief between two groups. Regarding the distribution of pain at the time of sedation, and 1, 3, 6, and 24 hours after sedation, there was no significant statistical difference between the two groups. There was also no significant statistical difference between the two groups, regarding patients' relaxation during, and 1, 3, 6, and 24 hours after biopsy.

CONCLUSION

There was no statistically significant difference between the degree of sedation and the analgesic effect of the two regimens in the two groups.  DOI: 10.52547/ijkd.6982.

Clinical characteristics of 200 COVID-19 patients in Mashhad, Iran, February and March 2020

Introduction:

Coronavirus disease 2019 (COVID-19) is a pulmonary involvement which was reported for the first time in December 2019 in the city of Wuhan, Hubei province, China. The aim of the study was to describe the demographic, clinical, laboratory, and radiological characteristics of 204 definitive laboratory-confirmed COVID-19 patients hospitalized in Mashhad, Khorasan Razavi province, Iran.

Patients and Methods:

This study was performed on 204 laboratory-confirmed COVID-19 patients. A set of laboratory tests combined with various patient information and results from lung high-resolution computed tomography (HRCT) were gathered in a checklist and analyzed to give us a better view of patients who are hospitalized due to the complications caused by this disease.

Results:

The average age of our patients was 58.83 ± 15.93 years. There were 122 (59.8%) male and 82 (40.2%) female patients, and almost all of our patients had at least one underlying disease. Nine (4.4%) of our patients reported having gone for a trip to COVID-19-epidemic areas in the last 2 weeks. The most common signs shared among all our patients were cough, fever, and decreased O₂ saturation; the average respiratory rate was 25.50 ± 6.74/min, average axillary body temperature was 37.69°C ± 0.69°C, and average O₂ saturation was 88.34% ± 7.34%.

Conclusion:

Based on our results, the most common signs of this disease are fever, cough, and shortness of breath, similar to seasonal influenza. Our data on disease severity showed that 33 (16.2%) patients had moderate disease, 139 (68.1%) had severe disease, and 28 (13.7%) were critical; 22 (10.8%) of our hospitalized patients died due to the complications of this disease.

Analgesia for Pediatric Arteriovenous Fistula Cannulation in Hemodialytic Patients: A Comparison of Lidocaine Gel, Lidocaine Spray, and Needle Plate

Background

Children undergoing hemodialysis (HD) via arteriovenous fistula (AVF) experience approximately 300 painful punctures per year which may lead to non-compliance with HD. This study was conducted to show the effect of local anesthetics on pain perception in AVF cannulation.

Methods

This randomized clinical trial included 20 children under HD via AVF in Sheikh Children's Hospital Hemodialysis Center in February 2014. The first intervention was conducted as the baseline pain assessment (control), then every patient randomly received all three other interventions: Lidocaine gel, lidocaine spray, and needle plate, before venipuncture. Pain perception was expressed and recorded by patients using the visual analogue scale (VAS). VAS scores were compared, and a P value of <0.05 was considered significant.

Results

The VAS mean in lidocaine spray state, lidocaine gel state, and needle plate state was respectively 47.87, 51.31, and 49.43, which were significantly less than the control state with the VAS mean of 60.06 (lidocaine spray vs. control P value = 0.001, lidocaine gel vs. control P value = 0.001, and needle plate vs. control P value = 0.003).

Conclusion

Our study showed that the use of needle plate, lidocaine spray, and lidocaine gel are all equally effective ways in controlling the degree of pain in AVF needling in children undergoing HD.

A Survey on Sleep Disorders and Related Hormones in Patients with Newly Diagnosed Systemic Lupus Erythematosus

Background and Objectives

Systemic lupus erythematosus (SLE) is reportedly associated with sleep disorders. Thus, the present study aimed to investigate sleep disorders in newly diagnosed SLE patients.

Materials and Methods

This study was conducted on patients with newly diagnosed SLE (ie, case group) and a control group. The case and control groups were matched in terms of gender, age, socioeconomic status, and educational level. Venous blood samples were obtained from the participants to measure prolactin and melatonin levels. Furthermore, they were subjected to polysomnography. The data were analysed by SPSS (version 16) at a significance level of 0.05.

Results

A total of 28 women were enrolled in this study (ie, 14 individuals in each group). The frequencies of sleep disorder in the case and control groups were obtained as 64.3% and 50%, respectively (P=0.4). These two groups had the mean sleep onset times of 10.76±10.64 and 8.67±7.12 min (P=0.5) and the respiratory disturbance indices of 9.20±10.23 and 8.44±9.27, respectively (P=0.8). The frequency of sleep apnoea was obtained at 50% for both case and control groups (P=1). There was no significant difference between these groups in terms of the mean serum prolactin and melatonin levels (P=0.3 and P=0.2, respectively). Serum melatonin level showed a direct correlation with sleep latency to N1 (i.e., the first part of non-rapid eye movement in sleep) and spontaneous arousal index in the case group (P=0.02, r=0.602 and P=0.04, r=0.544, respectively).

Conclusion

According to the findings, there was no significant difference in the frequency of sleep disorders between the healthy subjects and patients at the onset of lupus. Additionally, melatonin and prolactin levels showed no significant difference between the groups. Our results are inconsistent with previous studies, due to the difference in disease duration probably. It seems that the chronicity and complications of the disease, as well as the adoption of glucocorticoid therapy for the chronic disease affect sleep quality in SLE patients more than disease duration.

Clinical features and disease severity in an Iranian population of inpatients with COVID-19

Coronavirus disease 2019 (COVID-19) can present with a variety of symptoms. Severity of the disease may be associated with several factors. Here, we review clinical features of COVID-19 inpatients with different severities. This cross-sectional study was performed in Imam Reza hospital, Mashhad, Iran, during February-April 2020. COVID-19 patients with typical computed tomography (CT) patterns and/or positive reverse-transcriptase polymerase chain reaction (RT-PCR) were included. The patients were classified into three groups of moderate, severe, and critical based on disease severity. Demographic, clinical, laboratory, and radiologic findings were collected and compared. P < 0.05 was considered statistically significant. Overall, 200 patients with mean age of 69.75 ± 6.39 years, of whom 82 (41%) were female were studied. Disease was severe/critical in the majority of patients (167, 83.5%). Disease severity was significantly associated with age, malignant comorbidities, dyspnea, nausea/vomiting, confusion, respiratory rate, pulse rate, O2 saturation, extent of CT involvement, serum C-reactive protein (CRP), pH, pO2, and aspartate transaminase (P < 0.05). Moreover, complications including shock, coagulopathy, acidosis, sepsis, acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admission, and intubation were significantly higher in patients with higher severities (P < 0.05). O2 saturation, nausea/vomiting, and extent of lung CT involvement were independent predictors of severe/critical COVID-19 (OR 0.342, 45.93, and 25.48, respectively; P < 0.05). Our results indicate O2 saturation, nausea/vomiting, and extent of lung CT involvement as independent predictors of severe COVID-19 conditions. Serum CRP levels and pO2 were also considerably higher patients with higher severity and can be used along with other factors to predict severe disease in COVID-19 patients.

Investigation of hematological parameters related to the severity of COVID-19 disease in Mashhad, Iran

Introduction:Human coronavirus disease 2019 (COVID-19) is an emerging respiratory disease that has become pandemic worldwide. The patients have a range of mild to severe symptoms, such as pneumonia, acute respiratory distress syndrome, arrhythmia, shock, and other organs involvement. Clinical and hematological evidence can serve as a prognostic factor to detect severe cases of COVID-19. Objectives: The present study aimed to evaluate hematological parameters related to the severity of the disease in COVID-19 patients in Mashhad, Eastern Iran. Patients and Methods: All the individuals with positive real-time reverse transcription-polymerase chain reaction test results and the patients with clinical symptoms whose computed tomography scan results were matched with the diagnosis of viral pneumonia were included in the study. The hematological examinations and complete blood count of the patients were performed by the healthcare personnel through collecting blood samples at the time of admission and discharge from the hospital. Results: In total, 189 COVID-19 patients were included in the study, 47.6% and 58.73% of whom were over 60 years old and male, respectively. Investigation of the hematological parameters revealed that the number of white blood cells, mean value of corpuscular volume, number of platelets, and lymph count had significantly increased at the time of discharge (P<0.01). On the other hand, red blood cells, hemoglobin, hematocrit, mean corpuscular hemoglobin, mean corpuscular hemoglobin, and red cell distribution width values were significantly higher at the time of admission in comparison to discharge (P<0.01). Furthermore, it was found that male gender had a significant relationship with the development of lymphopenia in the patients (P=0.021). Conclusion: It can be concluded that hematological parameters and inflammatory biomarkers in COVID-19 patients could potentially act as the independent factors and affect the prognosis of the disease.

A Systematic Review of Efficacy and Safety of Ofatumumab Therapy in Children With Difficult-to-treat Nephrotic Syndrome

Context: Different studies have been done so far on drug safety and efficacy in children with refractory nephrotic syndrome (NS). Ofatumumab might be an effective drug for this syndrome; however, the long-term effects and cost-effectiveness of ofatumumab treatment have not been comprehensively assessed.  Objectives: This study aims to perform a systematic review of the efficacy and safety of ofatumumab in children with difficult-to-treat NS. Study Selection: An electronic literature search was conducted to identify appropriate studies. The search key terms were as follows: (“nephrotic syndrome” OR “minimal change disease” OR “focal segmental glomerulosclerosis” OR “membranous”) AND (“Ofatumumab” or “CD20” or “Arzerra” or “HuMax-CD20”).  Data Extraction: Data were extracted from the articles according to the selection criteria by two independent reviewers. Results: A total of 83 potentially relevant articles were identified. Thirty-two articles were removed due to duplication. Then 26 more articles were excluded because they were book sections and review papers and therefore not relevant. Another 14 items were removed after reviewing the full text of selected papers because the topics did not fit our study subject. Finally, 11 studies were selected in our systematic review. The benchmark considered to assess the efficacy of ofatumumab in children with nephrotic syndrome in most of the studies was a complete remission rate. Conclusions: In conclusion, our systematic review showed that ofatumumab may be an effective drug in refractory NS treatment in children and could bring down the use of steroids and immunosuppressants. However, further large randomized trials are suggested.

The Spectrum of Glomerular Diseases in Mashhad According to Kidney Biopsy Records

INTRODUCTION

Knowing the national statistics of glomerular diseases will help in the management and minimizing their burden in the community. The aim of this study was to assess the overall distribution of subtypes of glomerulonephritis (GN) and the prevalence of renal diseases in a subgroup of diabetic and hypertensive patients.

METHODS

This cross-sectional study was conducted on 860 patients with different subtypes of GN diagnosed by percutaneous renal biopsy and histological examination.

RESULTS

The most common subtype of GN was membranous GN (30.1%) followed by minimal change disease (20.1%), IgA nephropathy (9.5%) and Lupus nephritis (8.8%), as well as membranoproliferative GN (6.4%), focal segmental GN (5.6%), crescent GN (43, 5%), and DM nephropathy (36, 4.2%). IgA nephropathy and focal segmental GN were mostly common among maleswhile the most female dominant GN was Lupus nephritis. Lupus nephritis was the most common GN diagnosis among subjects who were younger than 29 years old (50%), while the diabetic nephropathy was the most common GN diagnosis among subjects who were older than 53 years old (44.4%). The most common GN among hypertensive subgroups was focal segmental GN (41.7%) followed by diabetic nephropathy (33.3%) whereas the most common subtypes of GN among diabetics was diabetic nephropathy.

CONCLUSION

The most common type of GN among Iranian population in Mashhadwas membranous GN and minimal change disease. The distribution of each subtype of glomerular disease depend on the baseline determinants including age, gender and hypertensive state.

A Comparison Between Tacrolimus and Cyclosporine As Immunosuppression after Renal Transplantation in Children, A Meta-Analysis and Systematic Review

INTRODUCTION

There are some randomized trials which have already evaluated different calcineurin inhibitors (CNIs), especially comparing Tacrolimus and Cyclosporine, as immunosuppressant agents in children. However, their findings have been occasionally conflicting and thus debatable. Therefore, the evidence on safety and efficacy of immunosuppressive therapy after kidney transplantation in children has been inconclusive and argued to date. This study was aimed to compare the benefits and disadvantages of tacrolimus versus cyclosporine as the primary immunosuppression after renal transplantation in children.

METHODS

A systematic review and meta-analysis was done. An electronic literature review was conducted to identify appropriate studies. The outcomes were presented as relative risk, with 95% confidence intervals.

RESULTS

Five qualified randomized controlled trials were included in this systematic review. Tacrolimus was insignificantly superior to cyclosporine considering the total effect size of graft loss (RR = 0.67, 95% CI: 0.40 - 1.11; P > .05) and acute rejection (RR = 0.79, 95% CI: 0.59 - 1.05; P > .05). On the contrary, cyclosporine seemed to be insignificantly superior to tacrolimus regarding mortality rate (RR = 1.06, 95% CI: 0.59 - 1.90; P > .05).

CONCLUSION

Admitting the study limitations mainly because of the nature and case study size of the included trials, it can be concluded from our systematic review results that Tacrolimus seems insignificantly superior to Cyclosporine respecting graft loss and acute rejection. However, Cyclosporine was shown to be insignificantly superior regarding mortality rate. However additional studies with a larger sample size are highly recommended.

Effect of Low Dose Imipramine in Patients with Nocturnal Enuresis, A Randomized Clinical Trial

INTRODUCTION

Nocturnal enuresis is a condition, which can affectthe quality of life in children. The present study was designed toinvestigate the efficacy of low-dose imipramine combined withdesmopressin on treatment of patients with primary nocturnalenuresis who were defined as desmopressin non-responders.

METHODS

A randomized clinical trial was carried out on patientswith primary nocturnal enuresis. Forty children with enuresisranging from 5 to 12 years old were randomly divided into theintervention (n = 20) and control groups (n = 20). The subjects inthe intervention group were treated with desmopressin combinedwith 5 mg imipramine at bedtime, and those in the control groupwere given desmopressin alone. The patients were followed upweekly for one month. The number of wet nights was recorded.

RESULTS

Two individuals in the intervention and three individualsin the control group were excluded from the study. Our findingsindicated that the age and gender showed no significant difference.Furthermore, a significant better recovery in the enuresis wasobserved in 18 of 20 patients who were treated with combinationtherapy after 1 month (P < .05). In addition, the frequency ofrecovery was significantly higher (83.3%) in the intervention group,compared with the control group (29.4%).

CONCLUSION

The analysis showed that low-dose imipramine is welltolerated in clinical practice and may represent a good short-termtreatment option in combination therapy where desmopressinalone is not efficient enough.

Decreased expression of lncRNA loc285194 as an independent prognostic marker in cancer: A systematic review and meta-analysis

BACKGROUND

Several studies have indicated that lncRNA loc285194 is aberrantly expressed in many types of cancer. This meta-analysis was performed to elucidate the potential role of lncRNA loc285194 as a prognostic marker in malignant tumors.

METHODS

An electronic search of PubMed, Medline, Embase, and Web of Science was performed to identify all eligible papers related to the prognostic impact of lncRNA loc285194 expression in cancer. Hazard ratios (HR) and 95% confidence intervals (CI) were extracted from the included studies to explore the association between lncRNA loc285194 expression and patient overall and disease-free survival (OS & DFS). The odds ratios (ORs) were also calculated to assess the association between lncRNA loc285194 expression and clinicopathological parameters.

RESULTS

A total of 14 eligible articles with 1215 patients were included in this meta-analysis. Meta-results revealed that low expression of lncRNA loc285194 was significantly correlated with poorer overall survival (OS; HR = 2.34; 95% CI, 1.78-3.06; P < 0.001) and disease-free survival (DFS; HR = 2.66; 95% CI, 1.95-3.64; P = 0.001) rates in cancer patients. Low lncRNA loc285194 expression was also found to be significantly associated with lymph node metastasis (LNM; OR = 2.17; 95% CI, 1.23-3.83; P = 0.007), and distant metastasis (DM; OR = 2.49; 95% CI, 1.26-4.91; P = 0.009).

CONCLUSIONS

This study demonstrated that decreased level of lncRNA loc285194 was associated with poor clinical outcomes for patients with different types of cancer, supporting a promising potential biomarker for prognosis and metastasis in human cancers.

A systematic review on the efficacy and safety of eculizumab for atypical hemolytic uremic syndrome

Context: To date, several studies have been done regarding the treatment of atypical hemolytic uremic syndrome (aHUS) which discussed eculizumab as a potential treatment for this syndrome. However, the safety and efficacy of eculizumab were not fully assessed. This study aims to do a systematic review about the efficacy and safety of eculizumab in treatment of aHUS. Evidence Acquisitions: An electronic literature search was conducted to identify appropriate studies. We included all randomized trials and observational studies about using eculizumab in aHUS. Two independent reviewers extracted data from the articles according to the selection criteria. Results: Eligible studies were included in this systematic review. The literature search and reference mining yielded 571 potential relevant articles. We removed 173 articles because of duplication. We also excluded 245 articles after reviewing the titles and abstracts, and removed 61 studies because the topics were not relevant to the subject. Finally, five studies were included in the systematic review. Conclusions: Acknowledging the limitations of the study due to the size and nature of the included studies, our systematic review shows that eculizumab was effective in the treatment of aHUS. However, further large randomized trials are suggested.

A Systematic Review and Meta-analysis of Using Acupuncture and Acupressure for Uremic Pruritus

INTRODUCTION

Uremic pruritus is characterized by an uncomfortable and unlimited sensation which leads to scratch, which strongly reduces the quality of life. Pruritus is a common symptom in patients with end-stage renal disease. Various clinical trial studies have examined the effects of acupuncture and acupressure on treatment of uremic pruritus. This systematic review meta-analysis aimed to evaluate the effectiveness based on published studies.

MATERIALS AND METHODS

An electronic literature search was conducted to identify appropriate trial studies. The results for continuous outcomes were presented as weighted mean difference, with 95% confidence intervals.

RESULTS

A total of 5 articles, including 6 trials, were enrolled in this systematic review. Only 3 of the six trial studies used a visual analogue scale score for assessing pruritus and acupressure for intervention regime, which were considered for meta-analysis. The combined results showed that acupuncture or acupressure was effective in treatment of uremic pruritus (pooled mean difference, -1.994; 95% confidence interval, -2.544 to -1.445).

CONCLUSIONS

This study confirms that using acupuncture and acupressure is effective in treatment of uremic pruritus. However, further vigorous studies are needed to verify these findings.

Clinical Course of Children and Adolescents with Primary Vesicoureteral Reflux: A retrospective study of 958 patients

Introduction. Vesicoureteral reflux (VUR) is the most common pediatric urologic abnormality and since it can predispose to urinary tract infection and resultant kidney scar it is an important issue in pediatric nephrourology. Methods. A retrospective chart review and follow-up of 958 patients with primary VUR was performed in the Children’s Medical Center, Tehran, Iran. Children with primary vesicoureteral reflux were included in the study and these parameters were studied: age, sex, clinical presentation, VUR grade, sonographic findings, DMSA changes, treatment modality (medical, surgical or endoscopic) and response to treatment, hypertension (presence/absence), urinary tract infection recurrence and development of new kidney scars in patients under medical treatment. Results. VUR was more prevalent in girls. Sonography was unable to detect VUR in many cases. Presence of renal scars was strongly associated with degree of reflux. Medical management was effective in a substantial percentage of patients and they experienced full resolution of reflux. This was especially true for lower degrees of VUR. 17.6% of patients developed new kidney scars on followup which was associated with higher degrees of VUR. Hypertension and breakthrough urinary tract infection was an uncommon finding in our patients. Conclusion. Medical management, which means using prophylactic antibiotics for prevention of urinary tract infection, is effective in many cases of VUR especially in cases with lower degrees of VUR. Surgical and endoscopic procedures must be reserved for patients with higher degrees of VUR unresponsive to conservative management or in whom new scars may develop.

Challenges of OSCE national board exam in Iran from participants' perspective

Background

The national board exam for residents in Iran is held in two parts: Multiple-choice and Objective Structured Clinical Examination (OSCE). The OSCE is a suitable method for evaluation of residents’ clinical qualifications. However, it requires experienced human resources, accurate planning, facilities and reliable evaluation tools.

Objective

To determine the challenges of the OSCE National Board Exam in Iran.

Methods

This cross-sectional study was conducted on all the final-year pediatrics and gynecology residents of Mashhad University of Medical Science, who participated in the board exam in September 2014. A questionnaire was designed to evaluate the residents’ opinion on challenges of the OSCE. Data was analyzed with SPSS16. We used U Mann–Whitney test independent t-test, and Pearson correlation coefficient.

Results

Fourteen pediatrics and eleven gynecology residents participated. In the gynecology group, there was no significant statistical correlation between the individual marks and questionnaire scores. However, in the pediatrics group, there was a significant correlation (p=0.046, r=−0.763). Based on pediatrics residents’ perspective, the main challenge of the OSCE part of the exam was the imbalance and disproportion between the allowed time and the task load in each exam stage. In other words, they believed that the tasks could not be fulfilled in the given time. In the gynecology group, the main challenge reported was the delay in announcing the exam results. In the pediatrics group, the main complaint was the disproportion of the allowed time and the task load in the exam stages.

Conclusion

Some of the challenges of the board exam were associated with the examiners and the exam environment, and some of them were related to the home university where the candidates had studied. To solve the problems, both aspects should be considered.

Continued root formation of a pulpless permanent incisor following root canal treatment: a case report

AIM

To present a case of a pulpless permanent incisor that continued root formation following root canal treatment.

SUMMARY

A healthy 8-year-old girl with a history of dental trauma resulting in a coronal fracture involving enamel, dentine and pulp was referred by her general dental practitioner for treatment and evaluation of tooth 21. The tooth had a necrotic pulp and periapical rarefaction was evident radiographically. The canal was prepared, dressed with Ca(OH)2 and then filled with a rolled gutta percha cone and Roth's root canal sealer. A radiograph exposed eight years post-treatment, showed evidence of continued apical formation.

KEY LEARNING POINTS

*Teeth with necrotic pulps and periapical rarefaction may show evidence of continued apical formation after root canal treatment. *Hertwig's epithelial root sheath may be more resistant than expected to trauma and infection.

Coronal dye penetration of the apical filling materials after post space preparation

Forty canals of palatal and distal roots of molars were cleaned and shaped with the use of a step-back technique. Thirty canals were obturated, 10 each with lateral, vertical, and thermafil techniques. Five root canals were obturated without a root canal sealer and served as positive controls. Another five root canals were obturated, and their coronal half was sealed with sticky wax and served as negative controls. The apical 5 to 6 mm of the filling materials were exposed to india ink for 48 hours. The depth of dye penetration was measured in all groups and statistically analyzed. The apical plugs in the thermafil group had the highest degree of coronal leakage. The ANOVA test showed a significant statistical difference between coronal dye leakage between this group and those found in canals filled by lateral or vertical condensation techniques. The results indicate that the apical filling materials obtained by lateral or vertical condensation leak less than those obtained by thermafil.

A comparison of copper-loading disease in Bedlington terriers and Wilson's disease in humans

Eleven Bedlington terriers were found to have a mean hepatic copper concentration of 6,321 micrograms/g dry wt (normal, 200 micrograms/g dry wt) and renal copper concentration that was three or four times normal. Brain copper levels were normal in younger dogs, were elevated in two older dogs, and were 100 times normal in one dog that died of the disease. Increased concentrations of copper in the liver, kidney, and brain also characterize Wilson's disease. Erythrocyte survival was normal in three affected dogs, but serum glutamic-pyruvic transaminase levels were usually elevated. Unlike the hypoceruloplasminemia of patients with Wilson's disease, plasma ceruloplasmin activity was not only normal but was also slightly elevated in the terriers. Despite their normal or excessive ceruloplasmin, the Bedlington terriers could convert ionic 64Cu to radioceruloplasmin but did so only very slowly. These dogs accumulated significantly more 64Cu in their livers than normal, much like patients with Wilson's disease do before symptoms develop.