Patient with refractory seizure may undergo awake craniotomy when the area to be resected is immediately adjacent to eloquent cortex. An awake craniotomy in a 30-year-old man was conducted using a scalp block, dexmedetomidine, and remifentanil infusion without any airway device throughout the procedure. Dexmedetomidine administered at a loading dose of 1 μg/kg and maintenance dose of 0.2–0.7 μg/kg/h. Remifentanil dose was 0.02 μg/kg/min. The patient remained comfortable and hemodynamically stable throughout the procedure. Cortical electrical stimulation revealed motor cortex overlapped with seizure focus. So that surgical procedure was limited to subpial resection of the epileptic focus. Dexmedetomidine with concurrent scalp block appears to be an useful sedation for awake craniotomy when sophisticated neurological test is required.

Langerhans cell histiocytosis (LCH) is characterized by idiopathic monoclonal infiltration of Langerhans cells in different organs such as the skeleton, skin, pituitary gland, liver, spleen, lungs, and the hematopoietic system. Skin lesions are common in LCH and affect about 40% of cases. It is reported that skin lesions are usually the first manifestation of LCH in 80% of patients. Usually, cutaneous presentations of LCH in adults are generalized or seborrhea-like lesions and it is often the first manifestation of disease. Here, we describe a 45-year old female who was known case of hypothyroidism, systemic lupus erythematosus, and diabetes insipidus. In our patient, cutaneous involvement was unusual. It was single and presented in unusual site (ankle) and before developing such lesion, she had diabetes insipidus for several years due to the involvement of pituitary gland.

Background: Infertility, as one of the most common gynecological disorders, affects many people worldwide. To choose the clinical treatment, correct assessment of tubal patency can provide an important clue; therefore, it is considered as one of the major steps in workup examinations of infertile women. In this study, we aimed to compare the results of transvaginal ultrasonography (TVS) after hysteroscopy (HSC) with laparoscopy, as a gold standard, for assessing the fallopian tubal patency in infertile women. Materials and Methods: This is a cross-sectional study which included 49 infertile women referred to Shahid Beheshti Hospital affiliated with Isfahan University of Medical Sciences during the years 2015 and 2016. At first, patients who met the inclusion criteria were examined through HSC in by a specialist in gynecology and obstetrics in operating room because laparoscopy was performed after TVS with HSC, but HSC was performed without anesthesia. TVS was performed before and after of HSC to observe fluid in the pouch of Douglas. The findings of TVS with HSC and laparoscopy were compared. Results: There was a strong agreement between TVS after HSC and laparoscopy (kappa coefficient = 0.935, 95% confidence interval [CI]: 0.81, 1.00). The sensitivity of TVS after HSC was 100% (95% CI: 66.37, 100) and specificity was 97.50% (95% CI: 86.84, 99.94) with a positive predictive value of 90% (95% CI: 55.50, 99.75) and negative predictive value of 100% (95% CI: 90.97, 100). Conclusion: TVS after HSC is an accurate diagnostic tool for examination of fallopian tubal patency in infertile women.

Background: This study was aimed to evaluate the influence of oral N-acetylcysteine (NAC) application as an adjuvant to letrozole on induced ovulation outcomes in patients with polycystic ovary syndrome (PCOS). Materials and Methods: This was a placebo-controlled double-blind randomized clinical trial with 130 PCOS patients who were infertile. First, patients were randomly divided into two groups. Patients in Group 1 were administered letrozole 5 mg/d plus NAC 1.2 g/d and patients in Group 2 were administered letrozole plus placebo for 5 days starting at the 3^rd day of the menstruation period. On the 12^th day of the cycle, ultrasound evaluation was performed, and in whom at least one follicle with an 18–20 mm diameter was found, 10,000 unit human chorionic gonadotropin (hCG) was prescribed, and 36 h after hCG injection, timed intercourse was advised. On the 16^th day, after hCG injection, serum β-hCG level was evaluated. Results: The number of follicles >18 mm was significantly higher in the letrozole + NAC group (P = 0.007). The ovulation and pregnancy rates were also significantly higher in the letrozole + NAC group (P = 0.045). No adverse side effects and no cases of ovarian hyperstimulation syndrome were observed in NAC group. Conclusion: NAC is demonstrated to be a safe and well-tolerated adjuvant to letrozole and can increase the pregnancy rates in PCOS patients.

Background: The aim of this study was radiobiological evaluation of different radiotherapy (RT) techniques, namely, combined photon-electron, two tangential photon beams, and electron therapy which are commonly used for treatment of mastectomy patients. Materials and Methods: The mentioned techniques were planned on the computed tomography (CT) images of a chest phantom, using TiGRT treatment planning system (TPS). The TPS dose calculations were verified using Thermo Luminescence dosimeters (TLD) measurements. Dose-volume histogram (DVH) of the plans was generated in the TPS, and also tumor control probability (TCP) and normal tissue complication probability (NTCP) values were calculated using DVH data for each technique. For TCP and NTCP modeling, Poisson Linear-Quadatric (PLQ) and Lyman-Kutcher-Burman (LKB) models were used, respectively. Results: The TCPs for the chest wall, internal mammary nodes, supraclavicular nodes, and axilla for the combined photon-electron was 90%, 90%, 90%, and 65%, respectively, which was higher compared to tangential beams (up to 11%, 11%, 5%, and 5%, respectively) and the electron therapy (up to 11%, 11%, 33%, and 23%, respectively) Whereas the NTCPs of the tangential beams for ipsilateral and contralateral lungs, heart, and chest wall–lung interface was 4%, 1%, 3%, and 5.6%, respectively. These NTCP values were considerably lower than electron therapy (up to 42%, 66%, and 40% and 30%, respectively) and combined photon-electron (up to 55%, 75%, 50%, and 20%, respectively) methods. Conclusion: Tangential beam is suggested for treating mastectomy patients, due to sufficient value of TCP, and also lower NTCP compared to the other techniques such as electron therapy and combined photon-electron.

Background: The type 2 diabetes is one of the most common autoimmune diseases. Due to a key role in the metabolism of unsaturated fatty acids such as arachidonic acid, one of the most important precursors of immunity mediators, fatty acid desaturase (FADS) genes could have an important impact in the development of type 2 diabetes. Materials and Methods: This study aimed to determine the relationship between polymorphisms rs174537 in FADS1 gene and rs174575 in FADS2 gene with type 2 diabetes in Iranian population. After extracting genomic DNA, the locations of mutations and allele types were identified with high-resolution melting (HRM)-polymerase chain reaction method. Then, association between these mutations with metabolic syndrome, dyslipidemia, and type 2 diabetes was investigated using χ² correlation coefficients for variables and logistic regression. Results: The results showed that among 50 diabetic participants, 68% of patients have the mutant allele for rs174537 in FADS1 gene. This rate is 26% for rs174575 in FADS2 gene. Based on the results, it seems that participants having rs174537 mutant allele are more prone to become diabetic but it has a beneficial effect on total and low-density lipoprotein cholesterol and participants having rs174575 mutant are less prone to become diabetic, and also, it leads to higher triglycerides and body mass index (obesity). Conclusions: Detecting FADS1 and FADS2, gene polymorphisms using HRM can be an anticipating tool for making decision on initiating lifestyle modifications to prevent type 2 diabetes.

Background: Hemodynamic monitoring is an essential part in the treatment of critically ill patients. Establishment of intravascular volume and creation of a normal systemic perfusion are the most important part to reduce the risk of organ failure and mortality. This study aimed to determine the correlation between the inferior vena cava (IVC) sonographic indices and the central venous pressure (CVP) to provide a useful guide for noninvasive intravascular volume status assessment in children. Materials and Methods: Target sample of children who were admitted to the pediatric critical care unit and required CVP monitoring were enrolled in this study. The collapsibility index (CI) and IVC/aorta (AO) ratio, from bedside ultrasonography measurement of the IVC, were calculated. Results: Of the 70 participants, 22 patients (31.4%) revealed a CVP of 8 mm/Hg or less and 48 patients (68.6%) revealed a CVP >8 mm/Hg. Fifty-six patients (80%) had an IVC-CI of 0.5 or greater and 17 patients (24.3%) had an IVC/AO of 0.8 or less. IVC-CI index is 45.5% sensitive and 91.7% specific with positive predictive value of 71.4 and negative predictive value of 78.6 to predict CVP <8, and the IVC/AO index is 50.8% sensitive and 87.5% specific with a positive predictive value of 64.7 and a negative predictive value of 79.2 to predict CVP <8. Conclusion: Based on the present finding, the IVC sonographic indices provide a useful guide for noninvasive intravascular volume status assessment in children.

Background: Sulfonylureas are important drugs of choice for treatment of type 2 diabetes mellitus (T2DM). It is suggested that differential response to sulfonylureas from T2DM patients is under influence of single nucleotide polymorphisms in some of the target genes. In spite of favorable therapeutic effects, sulfonylureas are associated with some adverse side effects such as microvascular complications and stroke, especially in older patients. Therefore, for T2DM patients who are getting less benefit, sulfonylureas should be avoided. Cyclin-dependent kinase 5 regulatory subunit-associated protein 1-like (CDKAL1) gene variation is reported to be associated with sulfonylureas effectiveness. Due to the inconsistency of available data regarding association of rs7754840 in CDKAL1 gene with sulfonylureas response in T2DM patients, the present study is conducted. Materials and Methods: Fifty-one diabetic patients sensitive to sulfonylureas and 51 patients resistant to sulfonylureas treatment were recruited to this study. After extraction of DNA from patients' peripheral blood samples, rs7754840 single-nucleotide polymorphism was genotyped by polymerase chain reaction-restriction fragment length polymorphism assay using MaeII (Tail) restriction enzyme. Results: Frequency of G allele in resistant group was more than sensitive group (71, 6% vs. 57, 8%). Regression analysis was shown significant association between GG genotype and higher risk of resistance to sulfonylureas treatment (odds ratio = 2.250 [95% confidential intervals: 1.010–5.012]; P = 0.046). Conclusion: Our data confirmed that genotypes of rs7754840 are significantly associated with sulfonylureas treatment response. rs7754840 in CDKAL1 gene in combination with other clinicopathological findings would help to move towards personalized therapy of T2DM patients.

Background: A secure airway and effective ventilation are key components of advanced life support, and misplacement of endotracheal tube (ETT) can lead to morbidity in multiple trauma patients. The purpose of this study was to investigate the accuracy of ultrasound in diagnosis of direction for tracheal intubation. Materials and Methods: This descriptive-analytical study was conducted on 100 traumatic patients requiring intubation in 2016 in the Emergency Department of Al-Zahra and Kashani Medical Education Centers in Isfahan. Surface probe was placed transversally in the front of the neck at the top of the suprasternal notch, and the position of trachea was specified by front of comet-tail artifact which is the contour between hyperechoic air–mucosa (A–M) and a posterior reverberation artifact. Intubation accuracy by capnography was investigated, and the results were recorded in each patient's profile. Tracheal sonography was done during placement, or as soon as, the ETT has been embedded. The scanning time was minimized and it was carried out in total time of 10 s. Results: The diagnosis of intubation accuracy indicated that it was successful in 94 individuals (94%) and unsuccessful in 6 ones (6%). Intubation accuracy in 93 people (93%) was confirmed, and inaccuracy of intubation in 7 people (7%) was diagnosed. Ultrasound sensitivity in diagnosis of intubation accuracy was 97.9% (92.94) with 83.3% (5.6%) specificity. The positive and negative predictive values were 98.9% (92.93) and 71.4% (5.7%) respectively. Conclusion: Ultrasound method has high sensitivity and specificity to determine the correct placement of the tracheal tube, and it can be implemented as a reliable method given the acceptable positive and negative predictive values.

Background: Irritable bowel syndrome (IBS) is one of the most common disorders among young adults. Various studies have demonstrated that the use of probiotics can reduce the overall symptom of IBS, and thus, our aim was to evaluate the efficacy of probiotic products in the reduction of IBS syndrome after colonoscopy. Materials and Methods: Our patients were divided among three groups, including immediate probiotic users, start use of probiotics 1 month after colonoscopy, and placebo group. All the patients were interviewed for having common IBS symptoms (stool consistency and frequency, gas, abdominal pain, and flatulence) at baseline, 3^rd month of follow-up, and 6^th month of follow-up. Results: The mean reduction in abdominal pain was 3.05 ± 1.21, 3.86 ± 0.94, and 3.82 ± 0.63 in the control group, immediate probiotic users, and 1 month after colonoscopy, respectively (P < 0.001). The symptoms of the disease, such as stool consistency, the frequency of defecation, and flatulence (except gas) in the first quarter, in the two treatment groups were significantly improved more than in the control group (P < 0.05). In contrast, the frequency of defecation was not significantly different in the treatment group receiving the probiotics month after colonoscopy compared to the placebo users (P > 0.05). Conclusion: According to our results, the use of probiotics had the beneficial effect on IBS symptoms. Furthermore, it can be said that reductions in symptoms and pain in the two treatment groups were not significantly different, but after 6 months of treatment, the effect of probiotics in patients who immediately use it after colonoscopy was more visible and more stable.

Background: The aim of this study was to evaluate the effect of dydrogesterone in the outcome of idiopathic intrauterine growth restriction (IUGR). Materials and Methods: It is a double-blind randomized control clinical trial study that was done in Shahid Beheshti hospital of Isfahan during 2015–2016. In this study, 89 pregnant women with idiopathic IUGR fetus were selected and randomly divided into two intervention and control groups. Intervention group was treated with dydrogesterone 10 mg every 12 h for 2 weeks, while the control group received conventional management and treatment of IUGR, which also has been performed in the intervention group. Results: After 2 weeks of intervention, fetal weight was significantly increased in dydrogesterone group as compared to control group (2053.15 vs. 1736.36 g, P = 0.001); furthermore, we observed significant differences in the term of fetal abdominal circumference between the groups (27.25 vs. 25.92 cm, P = 0.006). Middle cerebral artery resistance index (0.67 vs. 0.83, P < 0.001) and uterine artery (UA) resistance index (0.68 vs. 0.81, P < 0.001) were significantly decreased in dydrogesterone group as compared to control group. Conclusions: Our results showed that dydrogesterone reduces resistance index of uterine artery and middle cerebral and increased fetal weight, while no sign of toxicity was observed. Dydrogesterone supplementation would have the potentiality to become a simple and economic means to prevent IUGR.