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Introduction: Deep sternal wound infection is a rare but serious complication after cardiac surgery that can increase mortality and morbidity. The aim of this study was to investigate the incidence and causative germs of deep sternal wound infection following cardiac surgery.

 

Methods: Data were collected retrospectively from patients who underwent different cardiac surgeries including coronary artery bypass grafting and valvular heart surgeries between July 2010 and October 2012 at a teaching hospital in the north east of Iran. Patients with a deep sternal wound infection (DSWI) were defined based on clinical findings and culture results of the wound. The patients were tracked for the development of DSWI and causative germs and sensitivity were identified according to the microbiological studies.

 

Results: 4621 patients underwent different cardiac surgeries during the study period. There were 82 cases (1.77%) of DSWI with mean age of 53.93 years and male to female ratio of 47:35 with mortality rate of 10.9%. The most common germs in order of decreasing frequency included Klebsiella, Pseudomonas, Staphylococus Coagulase Negative, Acinetobacter, Staphylocciaureus, Escherichia coli, methicillin resistant Staphylocciaureus, Providenciarettgeri, and Obligatory anaerobe Streptococus.

 

Conclusions: We conclude that DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival with gram negative rods as the most common pathogens. 

 

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Torsion of the gallbladder is a relatively rare surgical disease which mimics acute cholecystitis' symptoms that usually would not be respondable to medical therapies. The torsion would mostly be diagnosed intra-operatively. Cholecystectomy is the treatment of choice. In general in our centre, General Surgery department, Imam Reza hospital, Mashhad, Iran, since 1986 over 14000 cholecystectomies have been performed and 3 cases with an underlying cause of gallbladder torsion are documented. The relative literatures reviewed so then the presentation, paraclinical findings, and the treatment of gallbladder volvulus are discussed. Gallbladder volvulus: Review of the literature and report of three cases.

 

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ntroduction: Electrocautery device is one of the most widely used electronic devices in operating rooms despite its advantages in operations, production risks such as the halo of smoke above the operating position. The smoke with hazardous substances,cause to transmitting HIV, HPV and hepatitis and complications such as respiratory distress, nausea and vomiting, eye irritation, headache, and so on The purpose of the present study was to determine Surgical Team' Knowledge of electrocautery smoke complications in the Educational hospitals in Birjand, 2011. Methods: In this descriptive and cross-sectional study Surgical Team in Birjand Educational hospitals who were available were selected. After ensuring that they were content with and cooperate in the study, a researcher designed questionnaire was filled. The questionnaire included demographic questions (4 items) and knowledge questions (21 items) of electrocautery smoke complications. The obtained data was analyzed by SPSS software (V: 16), using Kruskal-Wallis and Mann-Whitney at the significant level P<0.05. Results: Mean score Surgical Team ' knowledge of electrocautery smoke complications were 9.0±4.88 (of the total 21 points) that is, 57% of them had low knowledge of electrocautery smoke complications. Conclusions: Given the low level of knowledge about electrocautery smoke complications in Surgical Team, planning to enhance their knowledge through workshops and continuing education programs and training is essential.

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Introduction: A growing number of children around the world are being born by surgical delivery, or cesarean section. Concerns about the steep increase in cesarean deliveries have been raised because of the possibility that surgical delivery is associated with greater maternal and infant mortality and morbidity than vaginal delivery. The purpose of the present study was to determine Prevalence of cesarean section and related causes of in women referring to Vali-e-Asr and tamin -e-ejtemaee hospitals in Birjand, 2010.
Methods: In this descriptive study, which cross-sectionally was carried out, 293 pregnant women referring to Vali-e-Asr and tamin -e-ejtemaee hospitals were studied. A questionnaire in 2 portions was filled out at mothers’ bed, in delivery room, operation room, and women's ward. The obtained data was analyzed by SPSS software, using chi square test at the significant level P<0/05.
Results: From 293 pregnant women in this study 147 (50.2%) had a normal delivery and 146 (49.8%) by Cesarean. The most common causes for caesarean were cephalopelvic disproportion (22.4%), malpresentation (21.7%) and Failure to progress (16.8%).
Conclusions: In this study, the prevalence of caesarean section is more than the WHO standard. In order decrease the number of unnecessary cesarean, teaching the young pregnant mothers about the disadvantages of cesarean is necessary.

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 Introduction: Causes of death vary globally, and they depend regionally on lifestyle and socio-cultural factors. The purpose of this study was to determine accident-related mortality in Southern Khorasan Province, Iran, in the year 2010. 

Methods: This descriptive-analytical study involved all the death cases in the year 2010 in Southern Khorasan. The data were collected from the death registration system, and were classified and analyzed according to the codes of the 10th revision of the International Classification of Deaths (ICD). 

Results: From among the 3,792 deaths in 2010, n=633 (16.7%) were accident-related. Of accident-related deaths, 73.6% (n=450) of the deceased persons were male. The highest rate of mortality belonged to Summer (July 23 to Aug 22) (n=203 32.1%). The median age in accident-related deaths was 36.6±21.9 years with the minimum age of 5 days and maximum age of 92 years. The leading cause of mortality was traffic accidents (52.1%) and violence (18%). The median age of the deceased women in accidents was significantly higher than men (P<0.048) and in rural persons more than urban people (P=0.02), with Surgical complications as the least frequent cause of death.

Conclusions: Since road traffic accidents rank first in accident-related mortality, it is recommended to have measures to improve road safety as well as quality and safety of vehicles, and to establish strict rules for those who disobey traffic rules. 

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  Introduction: As a key member of the healthcare workforce, nurses play an important role in patient care. N ursing care performance, especially sterilization, is of significant importance in provision of health and prevention of complications such as hospital infections. This study aimed to investigate nurses’ performance concerning sterilization while performing nursing techniques in ICU wards of educational hospitals affiliated to Birjand University of Medical Sciences.

  Methods: In this descriptive-analytic study, 36 nurses working in the ICU ward were selected by census method. A researcher-made observational checklist with three choices for each item was designed to check the sterilization techniques used by nurses in terms of obtaining intravenous (IV) access (10 items), suctioning of the endotracheal tube (7 items), and dressing (8 items).For each technique, a total score of≥75% was considered as good, between 50-75% as moderate, and <50% as poor performance. Content validity was used to confirm the validity of the checklist, and Cronbach’s alpha was calculated 0.67 to confirm its reliability. Data were analyzed in SPSS (version 16) using independent t-test at the significant level of P<0.05.

  Results: Mean score in the suction technique (out of 21) was 15.3±0.88 for which 8.3% of participants had good and 91.7% had moderate performance. As for the dressing technique, the mean score (out of 24) was 18.1±0.68 for which 46.4% of participants had good and 53.6% had moderate performance. Mean score in the obtaining IV access (out of 30) was 18.64±1.03 for which 100% of participants had moderate performance. No poor technical performance was observed, nor was there a Significant differences between the participants’ demographics and their performance.

  Conclusions: Nurses’ performance concerning sterilization techniques used in the ICU wards was moderate. Considering the results, periodic re-education programs are suggested to improve nurses’ performance.

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Introduction: Anxiety and depression are among major problems encountered by most patients after cardiac surgery. They can have serious consequences for patients’ quality of life, physical and psychological morbidity, and follow-up treatments. Accordingly, the present study was conducted to determine the status of depression and the associated factors in coronary artery bypass grafting (CABG) patients hospitalized in cardiac surgery ward of Imam Reza Hospital of Mashhad in 2013.

Methods: The current investigation is a descriptive, cross-sectional study for which all patients undergoing CABG surgery were selected using the census method. The subjects included inpatients hospitalized in Imam Reza (AS) Hospital of Mashhad from April 2013 to March 2014. The data was collected using the demographic characteristics form as well as Beck Depression Inventory (BDI-II). Analysis of data was conducted with SPSS (version 16) using paired t-test, independent t-test, ANOVA and Pearson correlation coefficient. The significance level was set at P<0.05.

Results: The mean score of depression after cardiac surgery was 31.5±10.60 and 29.3±10.55 for male and female patients, respectively. From among the patients, 64.4% suffered from severe depression after surgery, while 32.1% had moderate depression. No statistically significant relationship was found between age, sex, marital status, employment status, and education level on the one hand and post-operative depression score on the other hand.

Conclusions: As regards the high rates of pre-surgical and post-surgical depression in patients undergoing CABG, effective communication with patients and patient training are recommended as critical components of nursing care to reduce depression.

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Aortic coarctation is a rare but dangerous condition. Presence of aortic dissection in addition to coarctation is significantly rarer and more life-threatening. Here, we present a case of acute inferior MI due to aortic dissection complicating a native aortic coarctation. A 17-year-old boy was admitted to our emergency department due to severe chest pain and loss of consciousness. His electrocardiogram showed ST elevations in Inferior leads proposing an inferior MI. Further evaluations revealed that the patient had been suffering from an underling aortic coarctation complicated by an acute aortic dissection. For every young person with symptoms of acute coronary syndrome, aortic dissection should be considered as a potentially fatal differential diagnosis. Coexistence of aortic coarctation, as an underling and exacerbating factor, should be assessed using appropriate imaging modalities whenever suspected.

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Introduction: The use of e-learning and computer-aided methods is rapidly on the rise in medical and nursing education. Therefore, given the conflicting findings and lack of systematic clinical trials on comparison of the effects of e-learning and traditional methods in nursing education, this study aimed to assess the effects of offline e-Learning on cognitive learning (levels of knowledge, comprehension, and application) in the Fluid and Electrolyte Imbalances course among nursing students. Methods: This is a quasi-experimental study with a two-group, post-test-only design. A total of 52 third-semester nursing students were selected by convenience sampling method. Course contents were presented during 6 weeks by lecture and question and answer (Q & A) in the traditional learning group and by offline e-Learning in the second group. Afterwards, the students’ cognitive learning (knowledge, comprehension, and application) was assessed using a 23-item questionnaire on Fluid and Electrolyte Imbalances course. The obtained data were analyzed in SPSS (version 16) using Mann-Whitney, t-test, Chi-square, Fisher's Exact Test, and analysis of two-way variance. The significant level was considered as P < 0.05. Results: The mean score of cognitive learning was significantly higher in the traditional learning group (14.1±1.9) than in the e-learning group (12.4±2.2) (P=0.006). The difference was also significant in the domain of knowledge (P<0.001), but insignificant in comprehension (P=0.097) and application (P=0.892) domains. Conclusions: According to the results, the method of teaching e-learning, alongside traditional teaching method is recommended.

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Introduction: Opium addiction is a social and health problem in many parts of the world, including Iran. The exact effects of this substance on the cardiovascular system and postoperative complications are not clear And the results of studies in this regard are also contradictory, Therefore, the present study aims to compare short-term mortality After coronary artery bypass surgery In two groups Opium consumer And non-consumer was done.
Methods: This cross-sectional study was performed on 194 patients who were hospitalized during September 2013 to September 2015 In Valiasr Hospital of Birjand, they were under CABG operations conducted. In this study, short-term mortality)Hospital and a month After discharge) Through existing records And phone calls were reviewed. All data were analyzed by SPSS 22 software and analyzed using descriptive and inferential statistics.
Results: Of the 194 patients who had undergone surgery twenty-three patients (12.2%) used opioid Among them, In the form of Inhaler, 13 patients (56.5%) orally And 3 patients (13%) was a combination of orally and inhaled. In general, there is a case of mortality during surgery And 7 cases (77.77%) of mortality occurred in the Hospital ward. During the one month follow up, There was a death case. Among the non-addicted patients164 case were alive and 7 died And among addicted patients as well 22 cases were alive And there was a death case. Finally, the results showed, No statistically significant difference between the mortality after surgery, Blood lipids, and diabetes, In two groups Opium consumer And non-consume(p>0/05). But hypertension in the non-addicted group was significantly higher (p <0.05).
Conclusions: Based on the results of this study, there was no significant relationship between opioid dependence and short-term mortality in patients after CABG surgery. Due to low sample size and cross-sectional study, The design of cognitive studies with higher sample sizes seems to be necessary in order to discover causal relationships.

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Introduction: The health system development plan is currently one of the most fundamental changes in Iran. The purpose of this study was to determine the amount of attention to the components of change in health Development plan from the Viewpoint of staff in Al-Zahra hospital in Isfahan and Afzalipour hospital in Kerman in 2015.
Methods: In this quasi-experimental study , the staff of Al-Zahra hospital in Isfahan and Afzalipour hospital in Kerman were selected by convenience sampling method. Data were collected using a researcher-made questionnaire and its validity and reliability were taken into account. Data were analyzed by SPSS version 21 and two-way multivariate analysis of covariance was used as appropriate at a significant level of p <0.05.
Results: The average rate of attention to the components of change in three factors namely "support and planning", "training and counseling", and efficiency" Were respectively 3.93±0.63, 2.91±0.86 and 2.3±0.69. The overall mean of attention to change components was 2.83±2.52.
Conclusions: The mean of the total score showed that less attention has been paid to the components of change in the Health Development Plan. We suggest conducting a national survey to identify faulty components and elements in order to take corrective measures.

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Introduction: The incidence rate of trauma in pregnancy is about 5 to 7 percent. More than 50% of the trauma during pregnancy is caused by motor vehicle accidents, and about 80% of fetal deaths occur during these automobile accidents. A traumatic pregnant woman should be visited and evaluated typically because placental abruption can have sudden consequences for the fetus with or without signs. Management strategies of maternal trauma should be reliant on accurate assessment of the mother. In order to accurately assess the patient's trauma, it is essential to provide a medical image of the patient. Radiography and CT scan are the first, fastest and most accessible imaging techniques in most health centers. Imaging techniques based on ionizing radiation present hazards and harmful effects to living organisms. The risk of ionizing radiation during pregnancy is highly dependent on the absorption dose and the age of the fetus. Absorbed doses for different radiographic examinations are different. The aim of this study was to evaluate the received radiation dose by the pregnant traumatic patient, and secondly assess the received dose by the fetus. 
Methods: In this narrative review, we concentrated on literature in three fields relating to firstly traumatic pregnant patients, secondly ionizing radiation dose from different medical imaging and finally, fetal dose and risk.
Results: Depending on the type of radiography, the dosage of the embryo is also different. For example, examinations in which the embryo is placed on the pathway of the primary beam increases the received dose. Considering the harmful effects of ionizing radiation in imaging traumatic patients with a large number of images, the examinations that include the abdominal and pelvic region should be justified in detail. And, as far as possible, use non-ionizing imaging techniques instead of ionizing methods. One of the most reliable methods for reducing fetal doses is the development and promotion of non-ionizing imaging methods in traumatic pregnant women, such as ultrasound and MRI.
Conclusions: All efforts should be made on the pregnant women in such a way that the embryo dose is as low as possible. It is strongly recommended that physician and medical team staff have a good knowledge and attitudes towards the radiation protection principles and in practice use standard of radiation protection safety principles.

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Dear Editor,

• Vitamin D deficiency or insufficiency affects about 30% of children and 60% of adults across the world (1). This condition also occurs in about 70% of critically ill patients (2). Although vitamin D is typically known as a fat-soluble vitamin in bone metabolism, it is a steroid hormone with pleiotropic effects (3). Vitamin D deficiency can lead to cardiovascular, neurological, and autoimmune diseases and different types of cancers, including the breast, prostate, lung, colon, and renal cancers. Accordingly, this deficiency has a direct correlation with mortality (4-6).
• Many critically ill patients enter the Intensive Care Unit (ICU) with a deficient level of vitamin D. Disrupted metabolism of vitamin D in some critically ill patients results in a fast decrease in vitamin D levels after ICU admission (7). It has been well documented that vitamin D deficiency is associated with increased morbidity, mortality, and ICU length of stay (8, 9). The randomized clinical trials having been performed in recent years are indicative of no significant improvement in the clinical outcome of critically ill patients supplemented with vitamin D (10).
• The ICU admission can be predicted in several conditions, such as some elective surgeries and intensive chemotherapies (7). Furthermore, one of the problems of the studies performed till now is that they have not exclusively investigated the​patients with vitamin D deficiency. However, the exclusive inclusion of patients with vitamin D deficiency can lower the sample size for a clinical trial.
• It is required to perform randomized clinical trials with a reasonable sample size to investigate the effect of vitamin D supplementation among vitamin D deficient patients who are in a critical medical state. These studies will be useful for the better conceptualization of treatment with vitamin D in critically ill patients.

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• Traumatic brain injury (TBI) is the leading cause of morbidity and mortality worldwide. The initial injury is followed by a series of secondary processes that can further harm the injured brain and worsen the outcome. The endocannabinoid system (ECS) consists of ligands, such as anandamide and 2-arachidonoyl-glycerol (2-AG), receptors (e.g., Cannabinoid receptor type 1 and Cannabinoid receptor type 2), as well as transporters, and enzymes. Dexanabinol (HU-211) is a synthetic cannabinoid with cerebroprotective effects devoid of cannabimimetic effects, which exhibits the
• pharmacological properties of N-Methyl-D-aspartate receptor antagonist. The increase in the brain levels of endocannabinoids in the pathogenic events of brain injury suggests that this system plays a role in compensatory repair mechanisms. In recent year, the therapeutic effects of cannabinoid manipulative drugs have been numerously studied through the manipulation of the ECS in TBI. Therefore, the literature review was performed to assess the therapeutic effects of ECS manipulation, cannabinoid-derived drugs, and HU-211 in traumatic brain injury pathology. The ECS possesses promising effects in the treatment of diverse TBI pathologies through releasing endogenous ligands and changes in cannabinoid receptors activity or both. Preclinical studies suggest that the ECS has many targets for therapeutic agents that might help decrease TBI pathologic effects and should be considered for developing novel drugs. Furthermore, more clinical trials with larger populations and more  extended follow-up periods should be performed for a better understanding of the effects of ECS manipulative drugs. 

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• The emergency department (ED) is one of the challenging educational environments in medical education. Clinical teaching at ED requires balancing the provision of patient care services, clinical teaching, and clinical experiences for learners at different levels of learning. Accordingly, using effective teaching strategies at teachable moments and getting feedback from learners provide a balance between patient care and education. This narrative review aimed to review strategies for improving clinical teaching in the ED. Searching the literature was done in ProQuest, PubMed, ISI Web of Science, as well as Science Direct databases, and Google Scholar search engine with the keywords, including "teaching model", "learning", "educational strategy", "training", "emergency department", "emergency medicine", "clinical teaching", "resident", and "medical student", in English language with no time limit for searching. Finally, after reviewing 53 abstracts, 19 articles were included in the present study. In this review, effective training in the ED and important determinants of adequate educational encounters were provided with suggestions on how to implement them in clinical settings. The eight main themes related to the study were extracted, including professional reflection, obvious expectations, interprofessional training, strategies for clinical teaching with limited time, strategies for effective bedside teaching, selecting a teaching strategy for ENGAGE multilevel learner, and applying the principles of adult learning and faculty development. Accordingly, to maximize learning opportunities in the ED, the faculty members' development is recommended for fulfilling accountability in the community.
   

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• ​Introduction: Cholecystitis is one of the most common diagnoses among patients referred to surgical emergencies with acute or recurrent abdominal pain. The mainstay of treatment for this disease is cholecystectomy, and the gold standard procedure is laparoscopic cholecystectomy. Pain which is the most common complication after laparoscopic cholecystectomy gives priority to the administration of the best pain relief medicine. This study aimed to compare the efficacy of diclofenac suppository with intravenous Meperidine for pain relief in opioid-dependent and independent patients undergoing laparoscopic cholecystectomy.
• Methods: A total of 120 opioid-dependent and independent patients (60 each) participated in this single-blinded study. Each group was randomly divided into two equal subgroups and 100 mg diclofenac suppository and 25 mg Meperidine via intravenous injection were administered to the participants in each group. Pain intensity was measured by the Verbal Rating Scale (VRS) pain scale 24 hours after recovery. The data were analyzed in SPSS software (version16.0). A P-value of less than 0.05 was considered statistically significant.
• Results: Based on the results of the study, Meperidine for pain relief after laparoscopic cholecystectomy was reported to be more effective in opioid-dependent patients and diclofenac in opioid-independent patients. Moreover, the use of diclofenac in 90% of opioid-independent patients resulted in favorable responses and ease of pain (Fisher=61.01; P=0.001), and the rate of opioid-dependent patients treated with Meperidine with excellent responses was measured at 83.3% (Fisher=56.98, P=0.001).
• Conclusions: Meperidine can be the mainstay of treatment for pain relief after laparoscopic cholecystectomy used in opioid-dependent patients; however, the selected drug for pain relief after laparoscopic cholecystectomy in opioid-independent patients is diclofenac.

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