[Improving patient flow management process in emergency department using simulation and PROMETHEE method]

Introduction: This article proposes a method which could improve the performance of an Emergency Department [ED] in a large hospital in Tehran, where the long waiting times cause patients' and ED staff 's dissatisfaction. ED is considered as a bottleneck in hospitals. To reduce long waiting time and improve patient satisfaction, application of system improvement methods is required

Methods: Using discrete- event simulation, it first models patient flow and identifies bottlenecks. In simulation model, patient arrival is assumed to be non-homogenous and operations of medical tests are detailed and consequently patient queues and virtual specimen queues can be considered separately. The analytic hierarchy process [AHP] was used to specify weights for each criterion and PROMETHEE to rank scenarios

Results: Based on simulation results and important criteria, what-if scenarios were designed to evaluate system reactions. Using this method, 10 scenarios were designed. Implementing the best scenario would reduce waiting time by approximately 6%

Conclusion: Considering ED overcrowding, simulation is used to reflect current situation. Based on the simulation reports, what-if scenarios were used to design scenarios which could improve ED performance. Multi criteria decision making method was used to find the best scenario based on criteria like waiting time, utilization, leave with own responsibility [LWOR] and cost

Ecological characteristics of sand flies in Golestan province, Iran [2011]

Leishmaniasis is one of the main Zoonotic Vector-Born disease which is transmitted by sand flies to human and animals. This study was carried out to determine the ecological characteristics of sand flies in Golestan province, North of Iran. In this descriptive study, 3 villages in Aliabad Katul district in north of Iran were selected according to rural geography distribution and positive detected samples of human infection during 2010-02. Sand flies were collected by sticky traps. Three places were sampled in each village and in indoor and outdoor places 10 traps were installed. Sand flies were collected and their species was determined. Totally 299 sand flies [160 from indoors and 139 from outdoors] were collected and consequently, 7 species of sandflies were identified including 4 species of phlebotomus genus and 3 species of Sergentomiya genus Ph.papatasi [55%] and S.sintoni [51%] were predominant species in indoor resting places and outdoor places, respectively. Sand flies seasonal activity extended from mid May through early October. Sand flies had one peak of activity in early August. Among the detected species, S.hodgsoni reported for first time from Golestan province. Ph.papatasi was recognized as predominant species in Aliabad Katul district, Golestan provincein northern Iran

Effect of 3,4 Methylendioxy Meth Amphetamine on hepatocyte and liver enzymes Wistar Rats

Ecstasy [3,4 Methylendioxy Meth Amphetamine [MDMA]] exerts destructive effects on body organs particularly on the nervous system. The current study was carried out to measure the adverse effects of MDMA on hepatocyte and liver-specific enzymes. In this experimental study, 50 male Wistar rats were randomly divided in equal numbers into 5 groups: control, sham, experimental 1, 2, and 3. Animals in the experimental groups were received, intraperitoneally 2, 4 and 8 mg/kg of MDMA, respectively. The sham group were received normal saline but the control group was not subjected to any injection. Serum samples were collected and levels of three enzymes under study: alanine aminotransferase [ALT], aspartate aminotransferase [AST] and alkaline phosphatase [ALP] were measured. The sections from the liver tissue were prepared counting the hepatocytes. Data were analyzed using SPSS-16 and One-way ANOVA and Tukey's HSD tests. Data indicated the levels of all three enzymes had been elevated in the animal groups that received MDMA and that the increase was statistically significant compared to sham and control groups [P<0.05]. Also, in experimental groups the number of hepatocyte were reduced in comparison with controls [P<0.05]. This study showed that the MDMA significantly increased ALT, AST, ALP and reduced the number of hepatocytes and these effects are dose depended

Factors influencing range of motion after total knee arthroplasty

The range of motion after a total knee arthroplasty is an important clinical outcome affecting the life of the patient. The aim of this study was to determine the most important factors influencing the postoperative knee flexion in Tehran, Iran. Between July 2007 and January 2009, on 95 cases of total knee joint replacement [89 patients], who were followed for 1 year postoperatively, the risk factors were assessed. Patient demographics [sex, age, body mass index, previous surgery, preoperative Knee Society System score, and preoperative range of motion] as well as radiographic measurement for preoperative tibiofemoral angle were statistically analyzed and the probable predictors entered into a linear regression model. Univariate analysis showed that age, preoperative flexion angle, preoperative flexion arc and preoperative tibiofemoral angle had significant correlation with the postoperative flexion angle. The linear regression model on the other hand revealed that preoperative flexion angle and preoperative tibiofemoral angle were the true predictors of the postoperative flexion angle with coefficients of 0.64 and -0.21, respectively. Better range of motion before the surgery with a lower tibiofemoral varus/valgus angle were more likely to result in a better range of motion after the surgery, suggesting that an appropriate timing for the surgery when the knee joint is still in a better function can lead to a better outcome

[Management of a complex strabismus secondary to complicated endoscopic dacryocystorhinostomy]

To report a patient with exotropia due to medial rectus muscle entrapment as a complication of endoscopic dacryocystorhinostomy [EDCR]. A 34-year-old female was referred with left exotropia 18 days after EDCR for treatment of primary nasolacrimal duct obstruction. She had a large angle left exotropia in primary position as well as complete limitation of adduction and partial limitation of abduction in the left eye. Forced duction test was positive in adduction and abduction, and force generation test revealed total paralysis of the left medial rectus. CT scan showed a large fracture of the medial orbital wall in which the medial rectus muscle was entrapped. She underwent the first operation through a medial canthal incision for releasing the entrapped muscle as well as repair of the medial orbital wall defect. After two additional surgeries including medial transposition of vertical rectus muscles and left lateral rectus muscle disinsertion she had 10 PD exotropia and her diplopia disappeared in primary position. In addition the patient had developed optic atrophy and superior arcuate visual field defect in her left eye probably because of intraoperative trauma to the optic nerve after EDCR. To the best of our knowledge, this is the first report of medial rectus entrapment following EDCR. This complication should be kept in mind in the approach to a patient with strabismus following endoscopic sinus and nasal surgeries in order to select appropriate diagnostic and therapeutic measures

[Effective factors for choosing the delivery method among the pregnant women in Kashan]

Considering the increasing number of cesarean cases and to identify the effective factors in choosing such surgery, this study was performed to evaluate the attitudes of medical specialists and gynecological assistants toward the type of delivery and the reasons for increasing rates of cesarean. Data were gathered through a semi-structured interview and analyzed using a content-analysis method. Finally, 11 physicians and assistants were participated in the study. The participants were selected through purposeful sampling. The first two participants were selected through accessible sampling, while the others by previous participants to consider the variety of physicians' experiences and attitudes. Data were analyzed using the Cheevakumjon method. After reviewing the data, key sentences and concepts were derived and finally categorized. Fear of the delivery pain was one of the most important reasons that made women to select the cesarean, while having a good delivery experience was one of the most important reasons for choosing the vaginal delivery. Four categories of factors, some facilitators for choosing the cesarean and the others for vaginal delivery, affecting the choice of delivery were related to patient, culture, delivery conditions and also the outcomes. Several factors should be considered in choosing a delivery method. Furthermore, preparing a woman for a painless and pleasant delivery and also changing the attitudes toward the type of delivery are very important

[Assessment of the efficiency of electro-Fenton process in degradation of formaldehyde from a highly concentrated aqueous solution by aluminum and iron electrodes]

Due to its high reactivity, colorlessness, stability, purity in different commercial forms and low price, formaldehyde is increasingly used in industries. According to the CERCLA list, formaldehyde is toxic and dangerous to the humans and environment. The aim of this study was to investigate the efficiency of electro-Fenton process for pretreatment of industrial wastewater containing high concentrations of formaldehyde. This was an experimental laboratory study. First of all a reactor was designed and built. Then optimal reaction time was determined and kept constant to determine optimal pH. Finding optimal pH and reaction time, the influence of initial hydrogen peroxide concentration and arrangement of iron and aluminum electrodes as anode and cathode material in constant density, with 1 L/min aeration was investigated for treatment of synthetic wastewater containing initial concentration of 7500 mg/L of formaldehyde. MS Excel 2010 and relative standard deviation were used for data analysis and interpretation. Our findings demonstrated that the increase of pH and initial hydrogen peroxide concentration resulted in an increase of formaldehyde removal by Electro-Fenton Process. Increasing the reaction time up to 10 min resulted in an increase in formaldehyde removal, but increase of the reaction time more than 10 min led to a decrease in formaldehyde removal by the above mentioned process. Use of iron as anode and cathode electrodes led to more removal of formaldehyde in comparison to other possible arrangements between iron and aluminum. The results indicated that the maximum formaldehyde removal was 71.54 percent which was achieved at operational conditions of pH=10, current intensity of 8.5 mA/cm2, primary H2O2 concentration of 50 mM/L after 10 minutes by using iron for anode and cathode electrodes

[Study of relation between physical activity and preterm birth]

Preterm birth is the main cause of neonatal mortality and morbidity and the importance of knowing its causes is clear. Since the effect of physical activity on preterm birth is unknown and its prevention is the priority in health care, we decided to do this study with the aim of determining the relation between physical activity and preterm birth. In this case-control study, 300 pregnant women delivering in Izadi Hospital in Qom, Iran in the second half of 2008, selected through simple sampling. The data were collected using standard pregnancy physical activity questionnaire that categorizes the physical activity into 4 groups: work activities, home activities, transport activities and fun/exercise activities. The physical activity severity was calculated as MET [Metabolic Equivalence Test]. Finally, the data were analyzed using descriptive and analytic [x[2] and t test] statistics. A p<0.05 was considered as significant. The findings didn't show any significant relation between physical activity and preterm birth. In addition, in view of activity type, fun/exercise and work activities [respectively] and in view of activity severity, sedentary and moderate activities [respectively] were associated with higher, but insignificant rate of preterm birth. Among demographic factors, only gravidity of women was significantly associated with preterm birth. Although, in this study the significant relation between physical activity and preterm delivery wasn't observed, the same research with further sample is recommended

[Evaluation of refractive state in patients with unilateral congenital nasolacrimal duct obstruction]

To evaluate refractive state in patients with unilateral congenital nasolacrimal duct obstruction. In this descriptive prospective study, patients with unilateral congenital nasolacrimal duct obstruction scheduled for surgery were enrolled over a period of two years [2007-2009]. Cycloplegic refractive error in both eyes was measured under anesthesia before surgery [probing, silicon intubation or dacryocystorhinostomy]. When more than one procedure was required, only the first refraction was considered for analysis. Anisometropia greater than 0.5 diopter was defined as clinically significant. Ninety-four patients with mean age of 25.4 +/- 20.4 months [range: 6 month to 10 years] entered the study. In older ages the prevalence of clinical signs secondary to nasolacrimal obstruction such as discharge and epiphora increased, however, this was not statistically significant [r=0.115 and P=0.270]. Spherical equivalent refractive error in 78 [83%], 8 [8.5%] and 8 [8.5%] affected eyes was hyperopic, myopic and emmetropic, respectively. Corresponding figures in unaffected eyes were 67 [71.3%], 22 [23.4%] and 5 [5.3%], respectively. The prevalence of anisometropia greater than 0.5 D was 25% and that of less than 0.5 D was 43%. Anisometripia was not present in 32% of patients. Each month increase in patient's age was associated with 0.007 D higher difference in spherical refractive error between two eyes [P=0.019]. For cylindrical refractive error, this change was negative and non-significant [P=0.291] and for spherical equivalent it was positive but non-significant [P=0.137]. In older ages, more surgeries were needed [r=0.297, P=0.004]. Anisometropia increase with age and more time is necessary to relieve the obstruction during surgery. Anisometropia specially anisohyperopia in older subjects becomes more common and also difficult to treat. Early refraction and intervention help to prevent amblyopia and may reverse the anisometropia

[ case of tuberous sclerosis presenting with eyelid lesions]

To report the clinical, paraclinical and histopathologic features of eyelid mass lesions in a patient with tuberous sclerosis. A 14 year old boy with a slowly progressive right upper lid mass and history of seizures, mental retardation and multiple skin lesions on the face and body was referred to Labbafinejad Medical Center. Cortical tubers and subepandimal nodules were reported in neuroimaging and fibroadenoma with sebaceous hyperplasia were observed on histopathologic assessment. A diagnosis of tuberous sclerosis was made based on multiple major signs and the patient was referred to other subspecialities for comprehensive medical care. The ophthalmologist may be the first specialist to diagnose tuberous sclerosis because of associated ocular signs. Attention to systemic signs is necessary to establish a diagnosis

[Epidemiology of orbital and preseptal cellulitis over a 10-year period at labbafinejed medical center, Tehran, Iran and a review of literature]

To evaluate the epidemiology of orbital and preseptal cellulitis in patients admitted to Labbafinejed Medical Center from 1997 to 2007. Hospital records of patients were reviewed. Personal and clinical characteristics of the patients together with results of treatment and complications of the disease were evaluated. During the study period, 93 patients including 54 cases of preseptal cellulits were admitted. Male to female ratio was 2 for orbital cellulitis and 1 for preseptal cellulitis. Mean age was 27.4 +/- 23.9 years [range, 6 months to 98 years] in patients with orbital cellulitis and 19.1 +/- 23.3 years [range, 1 month to 82 years] in patients with preseptal cellulitis. Most of the cases [97.8%] were unilateral. Mean time from onset to referral was 4 days. Mean duration of hospitalization was 6 days for orbital cellulitis and 4.5 days for preseptal cellulitis. Most cases occurred during spring. The most common underlying disease was sinusitis which was present in 53.8% of cases of orbital sinusitis and 24.1% of cases of preseptal cellulitis with the ethmoid sinus being the most common involved sinus. An overage of 2 antibiotics were used for treatment. Surgical intervention was required in 48.7% of orbital and 14.8% of preseptal cellulitis cases. Extraocular muscle palsy occurred in one case as the only complication leading to surgical management. Orbital and preseptal cellulitis are seen most frequently in young patients in spring and sinusitis is the most common underlying disease. Timely treatment of sinusitis may prevent orbital and preseptal cellulitis

[Pyogenic granuloma of the lacrimal sac]

To report a case of free floating pyogenic granuloma within the lacrimal sac. A 13 month old infant with unresolving dacryocystitis and history of two times failed probing and once failed turbinate fracture was scheduled for dacryocystorhinostomy [DCR]. A free floating red mass was removed from the sac. Histopathologic examination confirmed a diagnosis of pyogenic granuloma. Eight months after the operation the patient was asymptomatic. When probing of the lacrimal duct fails to improve its obstruction, in addition to nasal lesions, lacrimal sac masses including pyogenic granuloma must be considered

[Eyelid sarcoidosis; a case report]

To describe a patient with eyelid sarcoidosis. A 54 year-old patient was referred for an eyelid mass from 6 months ago.Excisional biopsy showed inflammatory granuloma with tuton gaint cells. Chest radiograph demonstrated bilateral hilar adenopathy, increased absorption on gallium scan was noted and bronchoalveolar lavage confirmed a diagnosis of sarcoidosis. Treatment with prednisolone was started leading to clinical improvement. Sarcoidosis is a multisystemic disorder and may have uncommon manifestations such as skin lesions before pulmonary signs develop

[Comparison of therapeutic effcets of dorsal wrist splint with cockup splint in carpal tunnel syndrome based on median sensory nerve conduction measurements]

Carpal tunnel syndrome [CTS] is one of the most common disease among the entrapment neuropathies. The purposes of this study was to compare the efficacy of a new dorsal wrist splinting versus common palmar splinting for CTS based on sensory nerve conduction measurements. This single blind randomized control trial study was carried out on 22 idiopathic CTS patients. Subjects were randomly divided in two groups: Dorsal splint group [n=12] and palmar splint group [n=10]. Both groups used splints for 4 weeks. Sensory conduction study of median nerve were done initially for having baseline and after 4 weeks follow up. SPSS-16 and Kolmogorov-Smirnov, independent T, and paired T tests were used for analysis of Data. After four weeks median nerve sensory distal latency and conduction velocity improved significantly in both groups [P<0.05]. There was significant difference between both groups due to electro-diagnostic improvement. This study showed that based on electro-diagnostic method, dorsal wrist splint is more effective than cockup splint in carpal tunnel syndrome

[Frequency of colorectal tumors among patients who underwent colonoscopy in Imam Khomeini hospital, Ardabil, Iran from November 2008 to September 2010]

Colorectal cancer is the most common cancer and the second leading cause of cancer deaths. Annually it is the cause of more than 500000 deaths worldwide. Therefore, detection and treatment of these tumors could potentially enhance recovery and improve prognosis. This study determines the frequency of colorectal tumors among patients who underwent colonoscopies in Imam Khomeini Hospital, Ardabil, Iran. This retrospective cross-sectional study was performed on 853 patients who underwent colonoscopies in Imam Khomeini Hospital from November 2008 to September 2010. All patients were evaluated for demographic variables, location and size of tumors by a checklist. The collected data were statistically analyzed by tables, graphs and student's t-test with SPSS v. 16 software. Among 853 patients who were studied, 432 [50.87%] were females and 419 [49.13[y0] were males. Of these, 45.4% were less than 50 years of age. The most common cause for patient visits were rectal bleeding [34.5%] and abdominal pain [20.2%]. The most common complaint among patients with colorectal lesions seen in colonoscopies were rectal bleeding [54.2%], abdominal pain [18.75%], anemia [10.4%], diarrhea [8.3%], and constipation [8.3%]. Of all colonoscopies performed, 37.2% were normal. Lesions of the right colon were seen in 27.08% and 72.9% were in the left colon. According to results of this study and the frequency in detecting colorectal tumors, the performance of retrospective studies based on disease risk factors could be effective in decreasing future disease cases

[Ptosis surgery in patients with weak levator function using orbicularis oculi and frontalis muscles]

To evaluate the outcomes of ptosis surgery in patients with weak levator function using orbicularis oculi and frontalis muscles. This prospective interventional case series study was conducted over 3 years on patients with ptosis and weak levator function [less than 4mm]. In all cases, orbicularis oculi and frontalis muscles were used directly to correct the ptosis. Success was defined as upper lid margin to central corneal reflex distance [MRD1] equal or higher than 3 mm in bilateral cases and less than 1 mm difference between the two eyes in unilateral types. The study included 26 eyes of 22 patients with mean age of 15.4 +/- 9.4 years; 12 patients [54.5%] had a history of previous unsuccessful ptosis surgery. Mean follow up was 13.5 +/- 8.4 months. The most common cause of ptosis was congenital which was present in 15 patients [68.2%]. The operation was successful in 19 patients [86.4%]. Age and history of previous surgery was not correlated with success rate but the amount of levator function was directly correlated with success [P=0.02]. Direct use of orbicularis and frontalis muscles to correct ptosis in patients with weak levator function can be a good substitute for other methods of surgery

[ case of traumatic carotid cavernous fistula]

To describe a complicated case of traumatic carotid-cavernous fistula [CCF] and our management strategy. A 13-year-old patient was referred one month following a car accident and facial trauma with severe proptosis, chemosis and limitation of ocular movement. Presence of murmur and an enlarged superior ophthalmic vein on orbital imaging suggested an arteriovenous fistula. The patient underwent transarterial fistula ballooning which resulted in alleviation of the fistula and improvement of signs and symptoms. Orbital signs and symptoms following trauma may indicate an arteriovenous fistula

[Effectiveness of psycho-social support intervention in Qazvin earthquake survivors]

Psycho-social consequences and effects of natural disasters are important issues, but it has been paid little attention in our country. This research aims to study the effectiveness of psycho-social support intervention in Qazvin earthquake survivors in 2003. In this research, about 389 of participated in meetings such as children and adults were assessed in order to determine the effectiveness of psycho-social support services for the injured before intervention and a year after providing services by 10 clinical psychologists. The control group was selected from unaffected areas in Qazvin province. The research was done by using different questionnaires such as 28 questions of public health; Rutter behavioral disorder; and questionnaire of stress disorder symptoms of Watson and Yule after disaster. After receiving services, psycho-pathological disorders among people at age 15 or over were 33/5% [45% before intervention] in the experimental group and it was 23/1% [34/1% before intervention] in children [under the age of 15]. Psychological support services could relieve significantly stress disorder symptoms after disasters in two groups. Psycho-social support services to the injured can greatly minimize stress disorder symptoms after stressful disasters and psycho-pathological mental disorders among survivors and also prevent the prevalence of social problems in them

[Outcomes of treatment for sixth nerve palsy]

To report the outcomes of surgical and non-surgical treatment for sixth nerve palsy and paresis in our center. Hospital records of 33 patients [35 eyes] with sixth nerve dysfunction who were referred to Labbafinejad Medical Center from September 1996 to September 2006 and underwent surgical procedures or botulinum toxin injection were reviewed. Patients were divided into three groups: Group A had muscle surgery without transposition; group B had transposition procedures and group C had botulinum toxin injection. The deviation improved from 50.3 +/- 16.8 to 6 +/- 9.8 prism diopter [PD] after the first operation and to 2.5 +/- 5 PD after the second operation in group A; from 56.9 +/- 24.3 to 5.5 +/- 16 PD after the first operation and to almost zero following the second operation in group B; and from 44.3 +/- 10.5 to 15 +/- 20 PD 6 months following botulinum toxin injection. Head posture and limitations of motility also improved significantly in all three groups. The overall reoperation rate was 18.2%. Various procedures are effective for sixth nerve dysfunction; all improve ocular deviation, head turn and abductive capacity of the eye. The rate of reoperation is not high if treatment is selected appropriately according to the patient's condition

[Isolated eyelid involvement as a rare presentation of orbital pseudotumor]

To report a case of isolated eyelid pseudotumor. A 40-year-old man presented with swelling and erythema of the right upper eyelid of 4 months duration. Multiple topical and systemic antibiotics had been administrated without any response. Incisional biopsy and evaluation of the lesion disclosed a diagnosis of eyelid pseudotumor. Oral prednisolone was initiated and then tapered slowly on the basis of clinical response. After six months, the eyelid lesion disappeared totally. Isolated eyelid involvement is a rare presentation of inflammatory pseudotumor of the orbit and should be considered in the differential diagnosis of eyelid lesions