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Aim Systemic sclerosis (SSc) is a rare autoimmune disorder characterized by vascular and fibrosing involvement of the skin and internal organs. In this study, we determined the prevalence and characteristics of radiological hands and feet involvements in Iranian SSc patients to identify the associations between clinical features and radiologic findings. Methods 43 SSc patients (41 women and 2 men), with a median age of 44.8 years (ranges 26–70 years) and a mean disease duration of 11.8 years (ranges 2–28 years) were studied in this cross-sectional study. Results 42 patients had radiological changes both in their hands and feet. Only one patient had alteration just in hand. The most frequent changes that we found in hand were Juxta-articular Osteoporosis (93%), Acro-osteolysis (58.2%), and Joint Space Narrowing (55.8%). The prevalence of joint space narrowing or acro-osteolysis was higher in subjects with active skin involvement [modified Rodnan skin score (mRSS) > 14] [16/21 vs. 4/16 for patients with inactive skin involvement (mRSS p = 0.002]. The most frequent changes that we found in the foot were Juxta-articular Osteoporosis (93%), Acro-osteolysis (46.5%), Joint Space Narrowing (58.1%), and subluxation (44.2%). The presence of anti-ccp antibody was detected in 4 (9.3%), while positive rheumatoid factor was found in 13 (30.2%) of SSc patients. Conclusion This study corroborates that arthropathy is common in SSc patients. The introduction of the specific radiological involvements of SSc needs to be confirmed by further studies, in order to define the appropriate prognosis and treatment of patients.

Background: Computerized Tomographic (CT) scan is a rapid, non-invasive, and common diagnostic modality in radiology. More and faster growth of cells, as well as longer lifespan of a child, may lead to a cumulative effect of radiation and a greater chance of mutation, especially in children who are more vulnerable. Objectives: This study was designed to evaluate the current trend in the use of this modality. Methods: In this descriptive study, all cases of children admitted to Taleghani Hospital who were studied by CT scan during the years 2018 - 2019, entered in survey. Demographic information, anatomical location of the scan, findings from the CT scan report, initial and final diagnosis, number of scans, patient’s complaint that led to his hospitalization and total amount of radiation received by the patient were analyzed. The data were analyzed by SPSS software version 23 with descriptive statistics (frequency, frequency percentage, and mean and standard deviation). Results: In this study, 344 scans of 280 patients were reviewed. Out of 280 patients, 222 patients underwent scan of one, 55 patients of two and four patients of three different anatomical locations. There were 146 male patients (52.1%) with a mean age of 57.7 months and 134 female patients (47.9%) with a mean age of 54.7 months. Out of all scans, the brain constituted 43.6%, chest 30.52%, and other areas 25%. The CT scan was performed at the request of the physician in charge. Pneumonia (19%) followed by convulsion (17%) and febrile seizures (12%) were the most common final diagnoses. The number of completely normal CT scans was 151 (44.2%), with brain scans having the highest frequency of normal scans with 74.19%. Brain scans with an average of 358.66 milliGray.centimeter (mGy.cm) and a maximum of 995.30 mGy.cm had the highest average absorbed dose. Conclusions: In this study, the rate of normal CT scans was relatively high and the range of radiation exposure available for each modality was significantly wide. Effective interventions must be made in this regard.

Bilobed testis is an uncommon congenital malformation with only eight cases reported up to now. It seems that bilobed testicle is a form of polyorchidism which is not yet thoroughly divided. This report could provide information about diagnosing minor lobulation on ultrasound and MRI for the first time.In this report, a 13-year-old boy presented with extreme Epididymo-orchitis on the right testis, without any history, which showed itself on ultrasound as type A3 polyorchidism or bilobed testis.Recent studies have not shown an apparent association between bilobed testis with testicular torsion and malignancy. In our case, because the minor lobulation is small, it probably has no association with torsion. The bilobed testis seems benign, so there is no requirement to check tumor markers. An inflamed testicular appendix and epididymitis can appear similar to a major lobulation which must be accurately found and evaluated on ultrasound as separate entities.Inflamed minor lobulation of the testicle can demonstrate itself as polyorchidism or bilobed testicles; thus, Ultrasound and MRI can assist in diagnosing minor lobulation. Serial examination and imaging are recommended for managing minor lobulation.

Coronavirus disease 2019 (Covid-19) is highly contagious with limited treatment options. Early and accurate diagnosis of Covid-19 is crucial in reducing the spread of the disease and its accompanied mortality. Currently, detection by reverse transcriptase-polymerase chain reaction (RT-PCR) is the gold standard of outpatient and inpatient detection of Covid-19. RT-PCR is a rapid method; however, its accuracy in detection is only ~70–75%. Another approved strategy is computed tomography (CT) imaging. CT imaging has a much higher sensitivity of ~80–98%, but similar accuracy of 70%. To enhance the accuracy of CT imaging detection, we developed an open-source framework, CovidCTNet, composed of a set of deep learning algorithms that accurately differentiates Covid-19 from community-acquired pneumonia (CAP) and other lung diseases. CovidCTNet increases the accuracy of CT imaging detection to 95% compared to radiologists (70%). CovidCTNet is designed to work with heterogeneous and small sample sizes independent of the CT imaging hardware. To facilitate the detection of Covid-19 globally and assist radiologists and physicians in the screening process, we are releasing all algorithms and model parameter details as open-source. Open-source sharing of CovidCTNet enables developers to rapidly improve and optimize services while preserving user privacy and data ownership.

The COVID-19 disease usually leads to mild infectious disease in children, but some develop serious complications. Here, we describe the characteristics of children with COVID-19 in northern Iran, the Golestan province. Ninety-one confirmed cases were enrolled in the study, aged 0–18 years. Demographic, clinical, comorbidity, laboratory, and radiological data were compared based on the disease severity (admitted to intensive care unit (ICU) or not) and disease outcome (recovered or deceased). Sixteen (17.5%) cases were hospitalized in ICU, and 8/91 (8.8%) deceased. Fever and cough were the most common clinical symptoms. Among all symptoms notified there were no significant differences between severe and milder cases, or between those who deceased and recovered. Failure to thrive (FTT), malignant disease and neurological disease were significantly more prevalent in severe cases as was frequently reported comorbidities. Laterality, ground-glass opacity, and lung consolidation were the most common findings in chest computed tomography. The data confirms that the COVID-19 disease has various presentations in children, and clinical, laboratory, and radiological findings may help predict the development of severe forms of COVID-19 among children.

PURPOSE: Early diagnosis and management of diabetic nephropathy (DN) might prevent or delay its progression to end-stage renal disease. The purpose of this study was to investigate whether changes in the duplex Doppler resistivity index (RI) are useful for the early identification of renal involvement in children and adolescents with insulin-dependent diabetes mellitus and associated conditions. MATERIALS AND METHODS: A total of 49 diabetic patients (two groups: 21 with DN and 28 without DN) were included in this study. DN was defined as 30–300 mg/l of albumin excretion in a random urine sample. The RI of the main renal arteries and their intrarenal branches (arcuate, interlobar) were evaluated with duplex Doppler ultrasound and correlated with age, renal length, duration of diabetes, and laboratory examinations. RESULTS: The mean age did not significantly differ between the two groups. The patients with DN had a significantly longer duration of type 1 diabetes (p = 0.02). The majority of patients (90.5%) had mild renal involvement with microalbuminuria and normal renal function. The mean RI was normal in both groups of patients, with no significant difference between the two groups. CONCLUSION: The RI did not increase in the early clinical stage of DN and was not a reliable marker for the screening of DN in patients with type 1 diabetes mellitus.

Objectives There is little information about Coronavirus Disease 2019 (COVID-19) management for critically ill patients. Most of these patients develop acute respiratory distress syndrome (ARDS) due to excessive inflammatory response and the ensuing cytokine storm. Anti-inflammatory drugs including corticosteroids can be used to effectively reduce the effect of this cytokine storm and lung damage. However, corticosteroids can have side effects, so simultaneous administration of immunoglobulin (IV-IG) and interferon-beta can help manage treatment using corticosteroids. Therefore, we designed a trial to test our hypothesis that early administration of dexamethasone in combination with IV-IG and interferon-beta can reduce the effect of the cytokine storm in critically ill patients COVID-19. Trial design A phase two multi-center randomized controlled trial (RCT) with three parallel arms (1:1:1 ratio). Participants They will be hospitalized patients with severe COVID-19 who have positive RT-PCR test and have blood oxygen saturation levels (SpO2) less than 90% and respiratory rate higher than 24 per minute or have involvement of more than 50% of their lung when viewed using computed tomography (CT)-scan. The age range of patients will be 18-70 years old. Exclusion criteria: the need for intubation; allergy, intolerance, or contraindication to any study drug including dexamethasone, IV-IG, and interferon-beta; pregnancy or lactation; known HIV positive or active hepatitis B or C. The study will be conducted in several hospitals of the Golestan province, Iran. Intervention and comparator The study subjects will be randomly allocated to three treatment arms: two experimental groups (two arms: Intervention 1 and Intervention 2) and one Control Group, which will be matched for age and sex using frequency matching method. Each eligible patient in the control arm will receive the standard treatment for COVID-19 based on WHO guidelines and the Ministry of the Health and Medical Education (MOHME) of Iran. Each patient in the Intervention Group 1 will receive the standard treatment for COVID-19 and dexamethasone, at the first 24 hours’ time of admission. The intervention begins with the administration of dexamethasone based on the SpO2 levels. If the level of SpO2 does not improve after 24 hours, IV-IG (400 mg/kg once daily for 5 days) and interferon-beta (7 doses every other day) will be prescribed along with dexamethasone administration. In Intervention Group 2, the administration of dexamethasone will be started within the first 24 hours’ time of admission and will be continued for 48-72 hours and then the SpO2 level will be checked. Then, if the level of SpO2 has not improved after that time, IV-IG and interferon-beta will be prescribed as the same dosage as Group 1. If the percentages of the SpO2 level are between 85 and 90/ 80 and 85/ 75 and 80/ less than 75, the dosages will be 4 mg every 12 hours/ 4 mg every 8 hours/ 8 mg every 12 hours/ 8 mg every 8 hours, respectively. According to the WHO recommendation, all participants will have the best available supportive care with full monitoring. Main outcomes Primary: An increase in the SpO2 level to reach more than 90% in each case, which will be assessed by the oximeter. Secondary: The duration of hospital stays; intubation status and the percentage of patients who are free of mechanical ventilation; the mortality rates during hospitalization and one month after the admission time. Randomisation Participants will be allocated into either control or intervention groups with a 1:1:1 allocation ratio using a computer random number generator to generate a table of random numbers for simple randomization. Blinding (masking) The project's principal investigator (PI) is unblinded. However, the PI will not analyse the data and interpret the results. An unblinded researcher (a pharmacist) will cover the drug’s bottles with aluminium foil and prepare them interventions and control drugs in a syringe with a code so that patients are blinded. This person will have no patients contact. The staff and nurses, caring for the patients, will be unblinded for each study group due to the nature of this study. The staff that take outcome measurements will be blinded. The laboratory technicians will also be blinded as well as the statistical team. These study statisticians will have access to coded data and will analyse the data labelled as group X, group Y, and group Z. Numbers to be randomised (sample size) The target sample size will be 105 critically ill COVID-19 patients, who will be allocated randomly to the three trial arms with 35 patients in each group. Trial status Recruitment is ongoing. The study began on April 18 2020 and will be completed June 19 2020. This summary describes protocol version 1; April 2 2020. Trial registration https://www.irct.ir/. Identifier: IRCT20120225009124N4 version 1; Registration date: April 2 2020. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting the dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The full protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.

Background: Since December 2019, the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged the world. In this descriptive study, we aim to share the clinical information of 427 Iranian COVID-19 patients. Methods: The different information on COVID-19 patients who were hospitalized from 24 February 2020 to 1 April 2020 was analyzed using R software. The patients were categorized into two groups as non-severe or severe and survivor or non-survivor cases. Outcomes of the cases were followed up until one month after the time of admission. Findings: Overall, the median age of the patients was 53 with a difference of ten years between two categories in each group. Among patients, 50·8% were males who had worse outcomes than female patients. Cough (72·8%), fever (69·3%), and dyspnea (64·0%) were the most common symptoms. There were more underlying comorbidities in the group of severe (73·5%) and non-survivor (77·5%) cases compared to the non-severe (53·6%) and survivor (44·1%) groups. Changes in the pattern of the parameters of complete blood counts including lymphopenia (227/333; 68·2%) were the most prominent findings. Factors associated with the liver and kidney damage were significantly increased in patients, especially in non-survivor cases. Around 90% of the COVID-19 patients had at least one abnormality in the chest CT scans including simultaneously both crazy paving and consolidation patterns (27·1%), followed by the ground-glass opacity (24·7%). Interpretation: According to the results, the patients' age, underlying comorbidities, percentage of SpO2, and blood laboratory findings at the time of admission may indicate the progression of the disease in the coming days. Funding Statement: The Golestan University of Medical of Sciences, Iran. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The ethics committee of Golestan University of Medical Sciences approved the study (IR.GOUMS.REC.1398.383).

Background: Systemic sclerosis (SSc) is a connective tissue disease with heterogeneous symptoms and a non-predictable process. The most involved organ after the skin is the gastrointestinal tract (GI tract) and any part of it can be affected. The calprotectin level is increased in plasma, urine, sputum and feces when an inflammatory process is occurring with the presence of neutrophils which is measurable. Objectives: So we decided to examine fecal calprotectin as a simple method to diagnose GI disorders and disease activity in SSc. Methods: Totally 46 patients with SSc were invited by telephone, who have been referred to sayyad shirazi Hospital and the rheumatologists’ offices in Gorgan and their information has been registered there. Seven patients did not enter our study because of having the items in exclusion criteria like Diabetes, a history of GI operation and having other connective tissue diseases at the same time.for the other 39 patients who was remained, a questionnaire about GI symptoms (UCLA SCTS 2.0) was filled in and then their skin was examined and the skin score was determined (the score more than 14 was considered as positive). Blood sample was taken from all patients to do tests as ESR,CRP, Magnesium, albumin, Ferritin, Folic acid, Vitamin B12 and Zinc and use them as a scale for malnutrition. Then the stool samples were collected to measure the calprotectin level. At last to determine GI disorders in a non-aggressive way, Barium Swallow (Esophagus malfunction) and CT Enterography (intestinal disorders) was done. The patients in our study according to the median of age which was 42, was divided in to two groups: young and middle aged. Due to the fact that FC level wasn’t less than 50µgr/gr in any of our cases, the patients was divided in to two groups: the one with FC level less than 200 µgr/gr and the one with FC level as 200 µgr/gr or more than 200 µgr/gr and the latter was considered as positive. Results: As we didn’t have any male patients, the correlation between FC level and sex was not verifiable. Increased levels of FC didn’t have any correlation with age (P Value=0.79), disease type (P Value=0.59), small intestine wall thickening (P Value=0.10), esophageal dilatation (P Value=0.18), skin score (P Value=0.25), final GI score (P Value=0.30) and none of serum tests. One of the most important reasons, was low sample size.In our study just 5 cases had evidence of wall thickening in CT Enterography and all that 5 cases had increased levels of calprotectin so we see that if we have a lrager sample size we may ensure the connection between these two variables. Also as most of our patients take vitamin and mineral supplements, we couldn’t find any signs of micronutrient deficiencies and any correlation with FC level as well. Conclusion: Although there was no statistical correlation between FC level and variables, the results are in favor of FC’s specificity for assessing intestinal wall thickening. References [1] -Marie I, Leroi aM, Menard JF, Levesque H, Quillard M, Ducrotte P. Fecal calprotectin in systemic sclerosis and review of the literature. Autoimmunity reviews. 2015;14(6):547-54. [2] - andreasson K, Scheja a, Saxne T, Ohlsson B, Hesselstrand R. Faecal calprotectin: a biomarker of gastrointestinal disease in systemic sclerosis. J intern Med. 2011;270(1):50-7. [3] - affandi aJ, Radstake TR, Marut W. Update on biomarkers in systemic sclerosis: tools for diagnosis and treatment. Seminars in immunopathology. 2015;37(5):475-87. Disclosure of interests: None declared

Introduction: Atherosclerosis progression in the patients suffering from end-stage renal disease (ESRD) is more than normal population. Magnesium levels are also associated with an increase in atherosclerosis in the common carotid artery. Intima-media carotid calcification is either directly or indirectly related to cardiovascular disease and a higher rate of death among patients with chronic renal failure. Objectives: The purpose of the present study was to evaluate the protective role of serum magnesium levels in vascular calcification and the improvement of the carotid intima-media thickness (CIMT). Patients and Methods: In this cross-sectional research, the participants were selected from all patients with ESRD in Five Azar Medical Center of Gorgan, Iran. Blood samples collected from research units were tested for serum magnesium level in three times. Patients were referred to a radiologist to measure CIMT. Data collected in all patients were evaluated based on Spearman’s correlation test. Results: The correlation between serum magnesium level and CIMT was not statistically significant (P = 0.66 r= 0.04), however a positive correlation between CIMT and the dialysis adequacy (KT/V) was detected (r = 0.306, P = 0.006). Conclusion: This study demonstrated no correlation between the serum magnesium level and the CIMT in hemodialysis patients.

Introduction: Understanding the variation in the size and shape of the paranasal sinuses in detail is a clinically relevant matter for sinusitis patients. This study was performed to determine the right and left maxillary sinus dimensions by computed tomographic (CT) scan based on gender in the Turkmen ethnic groups in Gorgan, northern Iran. Material and Methods: In this descriptive-analytical study, 100 Turkmen subjects (50 males and 50 females) aged 18–45 were measured with 2 mm and 3 mm slices in the coronal and Axial Planes by the CT scanner SOMATOM Emotion of the multi-slice from the SIEMENS model and using the “Syngo software Siemens.” Results: Maximum width, height, and volume of right and left maxillary sinuses in the Turkmen ethnic group were more in males than females (P

Background: Rapid Ultrasound in Shock (RUSH) is a recently reported emergency ultrasound protocol designed to help clinicians better recognize distinctive shock etiologies in a short time. We tried to evaluate the accuracy of early RUSH protocol performed by emergency physicians to predict the shock type in critically ill patients. Materials and Methods: Our prospective study was approved by the ethics committee of trauma research center, Baqiyatallah University of Medical Science, Iran. We enrolled 52 patients with shock state in the emergency department from April 2013 to October 2013. We performed early bed-side sonographic examination for participants based on RUSH protocol. Patients received all needed standard therapeutic and diagnostic interventions without delay and were followed to document their final diagnosis. Agreement (Kappa index) of initial impression provided by RUSH with final diagnosis, and also sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RUSH for diagnosis of each shock type were calculated. Results: Fifty-two patients were enrolled in our study. Kappa index was 0.7 (P value = 0.000), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic and obstructive shocks, the protocol had sensitivity of 100% but had lower PPV. For shocks with distributive or mixed etiology, RUSH showed PPV of 100% but had low sensitivity. For cardiogenic shocks, all reliability indices were above 90%. Conclusion: We highlight the role of RUSH examination in the hands of an emergency physician in making a rapid diagnosis of shock etiology, especially in ruling out obstructive, cardiogenic, and hypovolemic types.

Meningeal melanocytoma is a primary melanocytic neoplasm with certain MR and immunohistochemical characteristics worthy to note. In a 38-year-old man with a complaint of headache for a couple of years and recently added nausea, vomiting, diplopia, progressive visual blurring and hearing loss, magnetic resonance imaging (MRI) was remarkable for T1 shortening of leptomeninges and certain nodules in precontrast study. Subsequent contrast-enhanced MR imaging of the brain and spine revealed enhancement in the basal cisterns extending throughout the spinal canal. Contrast-enhanced MRI revealed diffuse enhancement in the basal cisterns extending throughout the spinal canal. Immunohistochemical analysis on one of the intraspinal nodules proposed leptomeningeal melanocytoma. The characteristic shortening of T1 and T2 relaxation times in MRI as a result of the paramagnetic stable free radicals that exist within melanin, often suggests a diagnosis of a melanocytic leptomeningeal process. Moreover, there are unique immunohistochemical characteristics for these varied lesions. In appropriate clinical settings, certain radiologic findings, especially both T1 and T2 shortening in nodular CNS lesions should propose meningeal melanocytoma.

Background: Erection is a dynamic multi-stage neurovascular phenomenon consisting of 4 phases. Conventional protocol of color Doppler study can easily overlook these ongoing dynamic events. Objectives: Here, we tried to designate patterns for these dynamic spectral waveform changes of cavernosal arteries in patients with erectile dysfunction and subsequently better describe the extent of their underlying problem. Patients and Methods: We evaluated 59 men who were referred for post-intracavernosal injection (ICI) color Doppler investigation of suspected erectile dysfunction (ED). The demographic data and medical history were recorded. Afterwards, first scan injection was done. Then scanning of cavernosal arteries was started about one minute after the injection and was continued thereafter. For better description of temporal changes in the waveform of cavernosal arteries, new patterns were defined and used. Patients were also classified based on previously known etiologic categories (i.e. arterial insufficiency, venous leak, mixed type, and normal response). Results: The mean age was 45.6 ± 13.1 (24 to 74 ) years. Twenty-two were normal responders [considered as non-organic causes (37.3% of all patients)], 27 were classified as venous leakage, eight had arterial insufficiency and two were mixed type. Maximum PSV occurred before the fifth minute in 47 patients (92.2%). Eight patients completed all phases of erection in the first 5 minutes. We defined 8 patterns for the temporal changes in cavernosal arterial waveform. Pattern 5 was the most common pattern of venous leak; while, patterns 3 and 4 were considered as the uncommon group. Six patients demonstrated the uncommon patterns of venous leak (22.2%). Hypertension was more prevalent in the uncommon pattern of venous leak. Conclusions: We highlight the considerable role of continuous evaluation starting one minute after intra cavernosal with ICI injection of the vasoactive agent for better description of the underlying pathologies of ED especially in patients with venous leak etiology.

Background: Rapid ultrasound in shock (RUSH) is the most recent emergency ultrasound protocol, designed to help clinicians better recognize distinctive shock etiologies in a shorter time frame. Objectives: In this study, we evaluated the accuracy of the RUSH protocol, performed by an emergency physician or radiologist, in predicting the type of shock in critical patients. Patients and Methods: An emergency physician or radiologist performed the RUSH protocol for all patients with shock status at the emergency department. All patients were closely followed to determine their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of RUSH for diagnosis of each case. Results: We performed RUSH on 77 patients. Kappa index was 0.71 (P Value = 0.000), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97% yet it had a lower PPV. For shock with distributive or mixed etiology, RUSH showed a PPV of 100% but it had low sensitivity. Subgroup analysis showed a similar Kappa index for the emergency physician and radiologist (0.70 and 0.73, respectively) in performing rush. Conclusions: This study highlights the role of the RUSH exam performed by an emergency physician, to make a rapid and reliable diagnosis of shock etiology, especially in order to rule out obstructive, cardiogenic and hypovolemic shock types in initial exam of shock patients.