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Background:  Rotator cuff injuries are one of the most common causes of shoulder pain.
There are different therapeutic approaches in this disease. The evidence of the positive effect of exercise therapy in this pathology is inconclusive. This study aimed to investigate the effect of a complete exercise protocol on improvement of the patients with rotator cuff injuries.
Methods: The patients with shoulder pain received the 12-week exercise protocol in 4 phases if they had confirmed rotator cuff injuries in clinical examination and shoulder MRI. 
Pain was measured by visual analog scale (VAS) and function was measured by two questionnaires; disabilities of the arm, shoulder and hand (DASH) and western Ontario rotator cuff index (WORC). Range of shoulder joint motion (ROM) was measured in five directions by goniometry. All of the outcomes were evaluated before intervention and in 6, 12, 24 weeks after starting the intervention.
Ethic: This study was registered in Iranian Registry of Clinical Trials (IRCT20100718004409N13). A written consent was taken from All participants before the study. 
Results: In this study Twenty-four patients with rotator cuff tendinopathy and tear were analyzed finally in terms of effectiveness of exercise therapy. The average of their age was 51.7 years old. 14 patients (53.8%) with Supraspinatus tendinopathy, 6 patients (23%) with Supraspinatus tear, 3 patients (12.5%) with Supraspinatus plus biceps tendinopathy, and one patient (4.16%) with Subscapularis plus Biceps tendinopathy were assessed. The pain score (Visual Analog Scale) decreased at all fallow-ups specially after 24 weeks (3±0.1) versus before intervention (8±0.1) (P value < 0.001). Shoulder range of motions by goniometer and also the patients function based on WORC and DASH Questionnaires were improved after 24 weeks versus before intervention that was significant statistically and clinically (P value < 0.001). 
Conclusion: A 12- week exercise protocol including strengthening, stretching, PNF and dynamic stabilizer exercises was effective on pain reduction and improvement of function and shoulder joint range of motion improvement in the patients with shoulder rotator cuff tendinopathy and partial tear. The improvement of the variables lasted 6 months.
 

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Background and Aim: Different implant angulation, which is unavoidable in clinical situations, can affect the accuracy of impression. The aim of this study was to investigate the effect of fixture position on the accuracy of connecting impression coping to implants with internal hex.
Materials and Methods: A gypsum model with 4 implants with internal hex connection was prepared. The implants were installed in different mesiodistal angles of 0, 15, 25 and 35 degrees to the longitudinal axis in the gypsum model. To simulate the gums, a gingival mask was injected around the implants to a height of 2 mm. After a training session for senior dental students on how to close the impression coping, forty students were asked to close the impression copings on four implants. The correctness of the impression coping was evaluated by an expert prosthodontist. Data were statistically analyzed using Cochran Q test. Significance level was considered 0.05.
Ethical Considerations: this article is approved by ethics committee of Arak University of Medical Sciences.
Findings: The correct performance of students in connecting the impression coping to the implant at angles of 0, 15, 25 and 35 degrees was equal to 85%, 72%, 52%, 35%, respectively. With the exception of 0 and 15 degree groups, a statistically significant difference was observed between different study groups.
Conclusion: The fixture position has a significant effect on the accuracy of connecting impression coping to the implants with the internal hex and by increasing the implant angulation, the accurate connection the impression coping to the implant decreases. 

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Background and Aim This study aimed to investigate the clinical and laboratory characteristics of hydatid cyst disease in patients admitted to Imam Reza, Imam Hossein, and Bisotoon hospitals in Kermanshah City, Iran, from 2014 to 2018. 
Methods & Materials In this descriptive study, we studied and analyzed the medical records of 350 patients with hydatid cysts who were hospitalized and underwent surgical treatment in Kermanshah hospitals from 2014 to 2018. Also, the demographic characteristics of patients, including gender, age, occupation, place of residence, and affected organs, were extracted and recorded.
Ethical Considerations The Ethics Committee of Kermanshah University of Medical Sciences approved this study (Code: IR.KUMS.REC.1398.366).
Results In total, 350 patients with a Mean±SD age of 43.2±19.7 in women and 43.3±20.7 in men were admitted with a diagnosis of hydatid cyst. The highest and lowest prevalence of hydatid cysts were in the age groups of 41-50 (16.5%) years and 1-10 (4.8%) years, respectively. The prevalence was 181 (51.7%) in women and 169 (48.2%) in men. The organs mostly infected with hydatid cysts were the liver, lung, and brain, with 241 cases (68.8%), 55 (15.7%), and 24 (6.8%), respectively. 
Conclusion This study shows that hydatid cyst disease is an important disease, especially in rural areas of Kermanshah Province, Iran.

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In global healthcare systems, nurses are recognized as the main pillars of care, but their voices, despite their vital role, are often lost amidst a cacophony of loud silences. This silence does not signify tranquility, but rather reflects hidden pressures, unexpressed fears, and an imposed passivity in the face of structures that limit the freedom of expression.
"Organizational silence," a concept recognized for years in the fields of management and organizational psychology, has become a global crisis in nursing. According to a qualitative meta-synthesis, over 91% of nurses have experienced organizational silence at least once in their professional careers [1].
The causes of silence among nurses are multifaceted. Part of it stems from defensive silence, meaning a nurse refrains from speaking up before superiors or in hierarchical structures for fear of negative consequences. At other times, we encounter acquiescent silence, where the nurse believes that speaking out is futile and will not bring about any change. Previous experiences of having concerns ignored or autocratic leadership styles reinforce this feeling [1,2]. Furthermore, in some cultures, such as Japan or Egypt, prioritizing group harmony over individual expression leads to the normalization of silence [3].
Silence is not just an individual reaction but a response to an inefficient work environment. Nurses who feel their voices are not heard eventually experience job burnout, decreased motivation, and ultimately, leave the profession [2,3,4]. In a study from Spain, half of the nurses surveyed had considered leaving the profession [3,5]. Job burnout not only harms the nurse's mental health but also reduces the quality of patient care. Fatigue, reduced concentration, and impaired communication with patients increase the risk of clinical errors [1,6].
This vicious cycle of silence and its consequences creates a downward spiral in healthcare organizations:
Silence on staff or resource shortages → Increased stress and workload → Job burnout → Decreased quality of care → Intensified dissatisfaction → More silence.
If nurses feel that their concerns are ignored even when expressed, silence becomes an adaptive strategy [4].
Meanwhile, the financial impact of nurse turnover is also significant. According to estimates, the turnover cost for a single nurse in the United States is over $44,000, and hospitals lose an average of $3.6 to $6.1 million annually due to nurse turnover [7]. This substantial figure provides an economic incentive for systemic interventions to reduce silence and retain human resources.
Solving this problem is not possible through individual training or psychological resilience alone. Although strengthening skills like professional assertiveness can be effective, it will not be sustainable without structural and cultural support [4]. Creating psychological safety in the workplace—where nurses can freely express their concerns without fear of punishment—is a vital starting point for change [6].
Leaders of healthcare organizations play a key role in shaping or dismantling a culture of silence. When managers interact with nurses with empathy, a listening ear, and responsiveness, trust is built, and the space for expression becomes safer. A transformational leadership style, participation in decision-making, and the creation of professional growth paths are among the most important factors in retaining nurses and reducing silence [8].
There is also a need for macro-level policymaking at national and international levels. Programs like the "Global Nursing Workforce," which focuses on supporting the sustainability of the profession, can be effective in addressing the root causes of the problem [7]. Moreover, new guidelines from bodies such as The Joint Commission on preventing workplace violence (effective July 2024), which define requirements for reporting and accountability, can serve as models for combating silence on other issues as well [8].
Ultimately, organizational silence in nursing is not just a communication issue; it is an alarming indicator of the ethical, psychological, and systemic health of healthcare institutions. This phenomenon should be considered an "organizational vital sign." The healthcare system has a duty not only to listen but to act. The voices of nurses must lead to decisions, policies, and structural reforms, so that their silence is no longer loud, but is transformed into an effective cry on the path to improvement.
 

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Nurses, as one of the main pillars of the healthcare system, have always been at the forefront of delivering medical services. However, recent studies reveal that this professional group is facing serious challenges in terms of mental health and job satisfaction, largely due to structural and systemic failures in the workplace (1). Data from the COVID-19 pandemic underscore the severity of this issue, revealing high rates of burnout among nurses. 34.1% experienced emotional exhaustion, and 12.6% reported a loss of professional identity. These figures reflect not only a transient crisis but also chronic deficiencies within the healthcare system (2).
Key factors exacerbating nurse burnout include workforce shortages, inadequate resources, and workplace violence
(3, 4). The global shortage of nurses is estimated at around 5.9 million, placing excessive pressure on the remaining staff. Additionally, lack of resources and specialized training, particularly during crises, significantly contribute to burnout risk. Workplace violence, particularly in emergency departments and psychiatric units, is on the rise, and many reports suggest that the actual number of incidents is much higher than what is officially recorded (2, 5).
The consequences of these conditions extend beyond individual nurse wellbeing, directly compromising patient care quality and safety. Meta-analyses have shown significant associations between nurse burnout and reduced patient safety, increased hospital-acquired infections, and medication errors (5). Furthermore, only 50% of nurses in 2021 felt that their organizations prioritized their health and safety (1).
The mental health crisis among nurses is also alarming. Rates of anxiety, depression, post-traumatic stress disorder (PTSD), and insomnia are considerably higher in this group compared to other professions. Predictive factors include understaffing, excessive workload, workplace violence, and lack of organizational support. In addition, the stigma surrounding mental health services acts as a major barrier for nurses seeking professional help (6).
Effective solutions include adjusting nurse-to-patient ratios, banning mandatory overtime, enforcing zero-tolerance policies against workplace violence, and strengthening managerial support. For example, California’s implementation of minimum nurse-to-patient ratio laws has led to increased direct care time, better patient outcomes, and higher nurse retention. Emphasis must shift from merely increasing nurse numbers to retaining the current workforce—a crucial step in healthcare reform.
In conclusion, considering the critical importance of nurse wellbeing and its direct impact on patient care, structural and supportive reforms must be prioritized by health policymakers and administrators.