National treatment outcome and predictors of death and treatment failure in multidrug-resistant tuberculosis in Ethiopia: a 10-year retrospective cohort study

OBJECTIVES

Treatment success rate in patients treated for multidrug-resistant tuberculosis (MDR-TB) is low, but predictors of treatment failure and death have been under-reported. Thus, we aimed to determine the national proportion of treatment success rate in the past 10 years and factors that predict treatment failure and death in patients with MDR-TB in Ethiopia.

SETTING

A retrospective cohort study with a 10-years follow-up period was conducted in 42 MDR-TB treatment-initiating centres in Ethiopia.

PARTICIPANTS

A total of 3395 adult patients with MDR-TB who had final treatment outcome and who were treated under national TB programme were included. Data were collected from clinical charts, registration books and laboratory reports. Competing risk survival analysis model with robust standard errors (SE) was used to determine the predictors of treatment failure and death.

PRIMARY AND SECONDARY OUTCOMES

Treatment outcome was a primary outcome whereas predictors of treatment failure and death were a secondary outcome.

RESULTS

The proportion of treatment success was 75.7%, death rate was 12.8%, treatment failure was 1.7% and lost to follow-up was 9.7%. The significant predictors of death were older age (adjusted hazard ratio (AHR)=1.03; 95% CI 1.03 to 1.05; p<0.001), HIV infection (AHR=2.0; 95% CI 1.6 to 2.4; p<0.001) and presence of any grade of anaemia (AHR=1.7; 95% CI 1.4 to 2.0; p<0.001). Unlike the predictors of death, all variables included into multivariable model were not significantly associated with treatment failure.

CONCLUSION

In the past 10 years, although MDR-TB treatment success in Ethiopia has been consistently favourable, the proportion of patients who died is still considerable. Death could be attributed to advanced age, HIV infection and anaemia. Prospective cohort studies are necessary to further explore the potentially modifiable predictors of treatment failure.

Effect of maternal mental health during pregnancy on infant growth at six months of age in Suburban communities in South of Iran

Background: Due to the controversial effects of mental health disorders during pregnancy on infant health, the present study aimed to evaluate the effect of gestational depression, stress, and anxiety on the growth of offspring at six months of age in disadvantaged communities in South of Iran.

Methods: The sample comprised of 470 pregnant women (response rate=98%) who are participated in the Bandar Abbas Pregnancy Cohort study. Maternal mental health was measured by the DASS-21 questionnaire during pregnancy. Data on infant growth was collected based on infant`s growth chart at six months of age. The relative risk of suboptimal infant growth was calculated by Modified Poisson regression models at 5% significant level.

Results: The prevalence of depression, anxiety, and stress was 19.0%, 26.1% and 6.5%, respectively. At six months of age, the mean (SD) of infant`s weight (gram), height (cm) and head circumference (cm) were 7287.30 (1019.85), 63.23 (5.62) and 41.39 (2.70), respectively. Compared to normal mothers, the risk of suboptimal weight at six months of age significantly increased by 71% in mothers who were classified as having depression (Adjusted RR: 1.71, 95% CI: 1.07, 2.09). The presence of anxiety significantly increased the risk of suboptimal height at six months of age by 43% (ARR: 1.43, 95% CI: 1.07, 1.92). There were no statistically significant effects of either depression anxiety or stress on the suboptimal head circumference at six months of age.

Conclusion: Our results showed that mental health disorders of pregnant women might adversely influence the weight and height growth of offspring within the first six months of age. Screening protocols to early diagnose of mental health disorders during pregnancy, and to strict follow up of diagnosed cases postpartum are proposed.

Factors associated with quality of life among joint and nuclear families: a population-based study

Background

Advantages and disadvantages associated with joint and nuclear family systems can affect quality of life (QOL). However, there is scarcity of literature about QOL among joint and nuclear family systems. This study aimed to assess the factors associated with QOL in joint and nuclear family systems.

Methods

We conducted a population based cross sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select participants from both nuclear and joint family houses. The validated Urdu version of World Health Organization Quality of Life Questionnaire-Brief Version (WHOQOL-BREF) was used to assess quality of life among participants. Univariate and multivariate analyses were performed to explore the associations of different socio demographic variables with QOL among both family systems. Also a multilevel linear regression using backward analysis to obtain final model for each domain was performed to find out the variables that are associated with QOL score in each of family systems.

Results

A total of 2063 participants were included in this study (51.0% joint family, 49.0% nuclear family) with the response rate of 97.4%. In multiple linear regression analysis of each domain for joint and nuclear family systems, rural residence compared to urban (p < 0.001), being female (p < 0.001), older age (p < 0.001), having comorbidity (p < 0.001) and lower socioeconomic status (p < 0.001) were found to be a strong predictor of poorer QOL. Furthermore, social capital (p < 0.001) had a positive effect on joint and nuclear family QOL scores.

Conclusion

This study was the first of its kind which determined the factors of QOL in joint and nuclear families using the validated Urdu version of WHOQOL-BREF in Pakistan. Male gender, urban residence, younger age, higher socioeconomic status and social capital were positive predictors of QOL score while older age and presence of illness were associated with lower QOL scores among both family systems.

The comparative performance of wavelet-based outbreak detector, exponential weighted moving average, and Poisson regression-based methods in detection of pertussis outbreaks in Iranian infants: A simulation-based study

BACKGROUND

Early detection of outbreaks of transmissible diseases is essential for public health. This study aimed to determine the performance of the wavelet-based outbreak detection method (WOD) in detecting outbreaks and to compare its performance with the Poisson regression-based model and exponentially weighted moving average (EWMA) using data of simulated pertussis outbreaks in Iran.

METHOD

The data on suspected cases of pertussis from 25th February 2012 to 23rd March 2018 in Iran was used. The performance of the WOD (Daubechies 10 [db10] and Haar wavelets), Poisson regression-based method, and EWMA Compared in terms of timeliness and detection of outbreak days using the simulation of different outbreaks. In the current study, two simulations were used, one based on retrospectively collected data (literature-based) on pertussis cases and another one on a synthetic dataset created by the researchers. The sensitivity, specificity, false alarm, and false-negative rate, positive and negative likelihood ratios, under receiver operating characteristics areas, and median timeliness were used to assess the performance of the methods.

RESULTS

In a literature-based outbreak simulation, the highest and lowest sensitivity, false negative in the detection of injected outbreaks were seen in db10, with sensitivity 0.59 (0.56-0.62), and Haar wavelets with 0.57 (0.54-0.60). In the researcher simulated data, the EWMA (K = 0.5) with sensitivity 0.92 (0.90-0.94) had the best performance. About timeliness, the WOD methods showed the best performance in the early warning of the outbreak in both simulation approaches.

CONCLUSION

Performance of the WOD in the early alarming outbreaks was appropriate. However, this method would be best used along with other methods of public health surveillance.

Alarm Thresholds for Pertussis Outbreaks in Iran: National Data Analysis

Objectives

The purpose of the current study was to determine the upper threshold number of cases for which pertussis infection would reach an outbreak level nationally in Iran.

Methods

Data on suspected cases of pertussis from the 25^th February 2012 to the 23^rd March 2018 from the Center for Disease Control and Prevention in Iran was used. The national upper threshold level was estimated using the exponentially weighted moving average (EWMA) method and the Poisson regression method.

Results

In total, 2,577 (33.6%) and 1,714 (22.3%) cases were reported in the Spring and Summer respectively. There were 1,417 (18.5%) and 1,971 (25.6%) cases reported in the Autumn and Winter, respectively. The overall upper threshold using the EWMA and the Poisson regression methods, was estimated as a daily occurrence of 8 (7.55) and 7.50 (4.48–11.06) suspected cases per 10,000,000 people, respectively. The daily seasonal thresholds estimated by the EWMA and the Poisson regression methods were 10, 7, 6, 8 cases and 10, 7, 7, 9 cases for the Spring, Summer, Autumn, and Winter, respectively.

Conclusion

The overall and seasonal estimated thresholds by the 2 methods were similar. Therefore, the estimated thresholds of 6–10 cases in a day, per 10,000,000 people could be used to detect pertussis outbreaks and epidemics by health policymakers.

Effect of Social Distancing on COVID-19 Incidence and Mortality in Iran Since February 20 to May 13, 2020: An Interrupted Time Series Analysis

BACKGROUND AND OBJECTIVE

Numerous actions have been taken to control the COVID-19 pandemic and reduce their morbidity and mortality. One of the most important measures in this regard is social distancing. However, there is limited evidence on the effectiveness of social distancing on COVID-19 incidence and mortality. Thus, the current study aimed to assess the effectiveness of social distancing measures on the COVID-19 incidence and mortality in Iran.

MATERIALS AND METHODS

In the current quasi-experimental study, we evaluated the daily incidence cases and the number of deaths of COVID-19 in Iran before and after the implementation of social distancing measures. The segmented regression model was used to analyze the data. We also performed the interrupted time series (ITS) analysis using Newey ordinary least squares (OLS) regression-based methods.

RESULTS

After the implementation of social distancing, the trend of both daily new cases and deaths due to COVID-19 was decreasing [(ß = -1.70 (95% CI = [-2.30 - -1.10; P < 0.001])) and (ß = -0.07 (95% CI = [-0.10 - -0.05; P < 0.001], respectively))].

CONCLUSION

Social distancing along with other public health interventions could reduce the morbidity and mortality of COVID-19 to some degrees, and it seems to be crucial to control the pandemic.

Exploring spatial dependencies in the prevalence of childhood diarrhea in Mozambique using global and local measures of spatial autocorrelation

Background: Diarrhea in children under 5 years is generally considered as an important public health problem and the major cause of childhood morbidity and mortality in Sub-Saharan Africa. The purpose of this study was to present exploratory spatial data analyses to identify spatial clusters and outliers in the prevalence of childhood diarrhea in Mozambique. Methods: Using data from 2011 Mozambique Demographic and Health Survey, we calculated the prevalence of childhood diarrhea on the district level. Two exploratory spatial data analyses methods were applied, namely, global and local Moran's I statistics, providing spatial autocorrelation and spatial clusters/outlier in the prevalence of childhood diarrhea, respectively. Results: Choropleth mapping and global Moran's I statistics showed that the prevalence of childhood diarrhea has clustered distribution across the study area. A local Moran's I index revealed spatial clusters within the province of Tete, Gaza, Cabo Delgado, and Zambezia. However, spatial outliers were confined within Sofala province. Conclusion: The exploratory spatial data analyses showed various spatial clustering and outliers present in the prevalence of childhood diarrhea, indicating interventions needed in targeted regions.

Prevalence of tuberculosis treatment non-adherence in Ethiopia: a systematic review and meta-analysis

<sec> <title>SETTING</title> Non-adherence to treatment is one of the challenges facing global tuberculosis (TB) control. In Ethiopia, an extremely variable and high magnitude of TB treatment non-adherence have been reported from different parts of the country. However, there has been no attempt to estimate the pooled prevalence of non-adherence from this heterogeneous data. </sec> <sec> <title>OBJECTIVE</title> To review the available literature and estimate the overall prevalence of treatment non-adherence among patients with TB on first-line treatment in Ethiopia. </sec> <sec> <title>DESIGN</title> A systematic review and meta-analysis of published articles on TB treatment non-adherence. </sec> <sec> <title>RESULTS</title> We included 26 studies, which contained data on 37 381 patients with TB. The crude prevalence of non-adherence reported by the studies included was extremely variable (range 0.2-35%). The overall pooled estimate of non-adherence prevalence was 10.0% (95%CI 8.0-11.0). The pooled prevalence of patients lost to follow-up alone was 5.0% (95%CI 4.0-6.0), while the pooled prevalence of intermittent non-adherence was 20.0% (95%CI 15.0-25.0). </sec> <sec> <title>CONCLUSION</title> The rate of TB treatment non-adherence in Ethiopia remains too high to achieve target treatment success rates and prevent drug resistance. Implementing an effective patient retention scheme, along with the DOTS strategy, is critical to improving treatment adherence and preventing drug resistance. </sec>.

Spatio-temporal analysis of Pertussis using geographic information system among Iranian population during 2012-2018

Background: In spite of existing vaccination programs in many countries, outbreaks of pertussis are still reported. In Iran, the suspected and confirmed cases of pertussis are reported annually. Due to the lack of similar studies, the purpose of the current study was to determine the Spatio-temporal distribution of Pertussis using Geographic Information System (GIS) to identify high-risk areas in Iran during 2012-2018.

Methods: In the current cross-sectional study, registered data in the department of vaccine-preventable diseases in the Iranian ministry of health were used. To assess the temporal trend, the Cochran–Armitage test was used. To show the spatial distribution and to identify hotspot areas, Choropleth map and Getis-Ord Gi statistics were used. All analyses performed by Arc.map10.5, Stata 15 and Excel 2010.

Results: The incidence of suspect pertussis cases had an increasing trend but did not have a linear trend (p=0.06). Most of the cases happened in under 1 year infants (62.66%). The incidence of reported cases in northern areas was higher than in the Southern areas. The Zanjan had the most reported cases during the understudied period with a median of 7.63 reported cases per 100,000. The clustering of infection and hotspots were identified in northern areas of Iran including Qazvin, Qom, Markazi, and Hamadan.

Conclusion: Our results showed that the cumulative incidence of reported cases is increasing. The northern provinces had the highest incidence of Pertussis. Therefore, the causes of this spatio-temporal pattern of pertussis should be determined. Also, supervision on vaccination programs in high-risk areas is recommended.

Low enrollment and high treatment success in children with drug-resistant tuberculosis in Ethiopia: A ten years national retrospective cohort study

Background

Limited evidence exists on the treatment outcome and factors that are associated with the duration from the initiation of treatment to death or treatment failure in children with drug resistant tuberculosis (DR-TB). Thus, we aimed to determine the proportion of treatment enrollment, status of treatment outcome and determine factors that are associated with the duration from treatment initiation to death or treatment failure in children treated for DR-TB in Ethiopia.

Methods

We conducted a retrospective cohort study in children younger than 15 years old who were treated for DR-TB from February 2009 to February 2019 in Ethiopia. We collected data on socio-demographic and clinical characteristics from clinical charts, registration books and laboratory result reports on 155 children. Proportion of enrollment to the treatment was calculated by dividing the total number of children who were receiving the treatment by the total number of DR-TB patients treated during the specified years. We used Cox proportional hazard models to determine factors that were associated with the duration from the beginning of the treatment to death or treatment failure. Data was analyzed using STATA version 14.

Results

Of the 3,478 DR-TB patients enrolled into the treatment and fulfilling our inclusion criteria during the past ten years, 155 (4.5%) were children. Of the 155 children, 75 (48.4%) completed the treatment and 51 (32.9%) were cured. Furthermore, 18 (11.6%) children were died, seven (4.5%) lost to follow up and treatment of four (2.6%) children was failed. The overall treatment success was 126 (81.3%). Age younger than 5 years old [Adjusted Hazard Ratio (AHR) = 3.2, 95%CI (1.2–8.3)], HIV sero-reactivity [AHR = 5.3, 95%CI (1.8–14.9)] and being anemic [AHR = 4.3, 95%CI (1.8–10.3)] were significantly associated with the duration from the enrollment into the treatment to death or treatment failure.

Conclusion

In this study, the proportion of children enrolled into DR-TB treatment was lower than the proportion of adults enrolled to the treatment (4.5% in children versus 95.5% in adults) in last ten years. Our findings also suggest that children with DR-TB can be successfully treated with standardized long term regimen. Further prospective cohort study is required to investigate factors contributing to death or treatment failure.

The relationship between maternal mental health during pregnancy and type of delivery in the suburbs of Bandar Abbas during 2017-2018

Background: The effect of maternal mental health during pregnancy on Cesarean section through implications of pre- and postnatal birth have narrowly been investigated. The aim of the present study was to investigate the effect of maternal mental health during pregnancy on the type of delivery in the suburbs of Bandar Abbas. Methods: This study used data of 200 mothers registered in a prospective cohort study on pregnant women in the suburbs of Bandar Abbas, South of Iran, during 2016-18. The presence of depression, anxiety, or stress in expecting mothers were measured by DASS-21 questionnaire and the outcome defined as having Cesarean section (Cesarean section) was measured at postpartum. The relative risk (95% CI) was calculated using Cox regression models. All analyses were performed using STATA statistical package, with a significance level of 5%. Results: Information of 196 mothers were collected (98% response rate); the mean age of the participants was 27.28 (±5.62) years. The prevalence of depression, anxiety, and stress was 13.8% (27), 40.4% (40), and 7.6% (15), respectively. Nearly 40% of mothers went through Cesarean section. Compared to mothers with good mental health, the risk of Cesarean section was 96% higher in depressed mothers (RR=2, 95% CI: 1.43-2.74) (p=0.001), 81% higher in anxious mothers (RR=1.81, 95% CI: 1.29-2.53) (p=0.003), and 75% higher in stressed mothers (RR=1.75, 95% CI: 0.86-3.56) (p=0.121). Conclusion: The findings of this study showed that poor mental health, especially anxiety and depression, during pregnancy could increase the risk of Cesarean section. Accordingly, screening protocols for mental health status and prenatal counseling sessions are suggested for pregnant mothers to increase their informed decision on types of delivery.

Level of satisfaction and its predictors among joint and nuclear family systems in District Abbottabad, Pakistan

Background: Family system has been found to affect the satisfaction level among the family members. The objective of our study was to determine the satisfaction level and its predictors among joint and nuclear family systems in District Abbottabad, Pakistan. Methods: We conducted a population-based cross-sectional study in all 52 Union Councils (UCs) of District Abbottabad, Khyber Pakhtunkhwa province, Pakistan from March 2015 to August 2015. Multistage cluster sampling technique was used to select 2063 participants from both nuclear and joint family houses. Proportionate sampling was done for selecting mohalla from each UCs, and then subsequently households from respective mohalla's. Simple random sampling was done for selecting the 18 years and above-aged participant for the study. A structured demographic questionnaire was used to collect information from study participants. Univariate and multivariate logistic regression analysis was done to find out the predictors of satisfaction level among joint and nuclear family systems using SPSS version 20 A p-value of <0.05 was considered as significant. Results: Level of satisfaction was found to be higher among people living in the joint family system i.e., 87.5 % v/s 81 % (<0.001) compared to the nuclear family system. Multivariate regression analysis of nuclear family system showed that people having higher education level and higher socioeconomic status (SES) were more satisfied as compared to no education & low SES respectively. While, in the joint family system, only high SES was a significant predictor of satisfaction in the joint family system as compared to low SES. Conclusion: Our study reported a high level of satisfaction among joint and nuclear family systems in Pakistan. High education level and high SES were identified as important predictors of satisfaction among both systems.

Is hypothyroidism rare in multidrug resistance tuberculosis patients on treatment? A systematic review and meta-analysis

BACKGROUND

Hypothyroidism is one of the adverse drug reactions that associated with Multidrug Resistant Tuberculosis (MDR-TB) medications. Extremely variable magnitude of hypothyroidism in MDR-TB patients has been reported from different parts of the world. However, there is no evidence that tried to estimate the pooled prevalence of hypothyroidism to confirm the rareness of hypothyroidism in MDR-TB patients on treatment. Therefore, we did a systematic review and meta-analysis to estimate the prevalence of hypothyroidism in MDR-TB patients on treatment, and to summarize the demographic and clinical characteristics of the patients.

METHODS

We conducted a systematic review and meta-analysis on studies reported around the world on the prevalence of hypothyroidism in MDR-TB patients on treatment. We searched electronic databases: PubMed/Medline, EMBASE, CINAHL, Science Direct, Academic Search Complete and Google scholar for English language articles without limiting publication year. We also reviewed the bibliographies of relevant studies and conducted an electronic search for relevant conference abstracts. Eligible studies were cross-sectional and cohort studies that included at least five participants. We used a random-effects model to estimate the pooled prevalence of hypothyroidism. The registration number of this review study protocol is CRD42018109237.

RESULTS

We included 30 studies and pooled data on a total of 6,241 MDR-TB patients. The crude prevalence of hypothyroidism was extremely heterogeneous. The pooled prevalence of hypothyroidism in MDR-TB patients on treatment was 17.0% (95% CI: 13.0-20.0). Ethionamide and para-aminosalicylic acid (PAS) were the most frequently reported drugs that associated with the occurrence of hypothyroidism.

CONCLUSION

This review revealed that hypothyroidism is not a rare adverse drug reaction in MDR-TB patients on treatment. Ethionamide and PAS were the most frequently reported drugs that associated with the occurrence of hypothyroidism. Screening of hypothyroidism in MDR-TB patients on treatment is important while targeting patients on Ethionamide and PAS based treatment regimen.

Assessment of the risk factors associated with multidrug-resistant tuberculosis in Sudan: a case-control study

OBJECTIVES

The emergence of multidrug-resistant tuberculosis (MDR-TB) is a major challenge for the global control of tuberculosis (TB). The aim of this study was to determine the risk factors associated with MDR-TB in Sudan.

METHODS

This case-control study was conducted from May 2017 to February 2019. Patients newly diagnosed with MDR-TB were selected as cases, and controls were selected from TB patients who responded to first-line anti-TB drugs. A questionnaire was designed and used to collect data from study participants. Logistic regression was used to evaluate associations between risk factors and MDR-TB infection. The best multivariate model was selected based on the likelihood ratio test.

RESULTS

A total of 430 cases and 860 controls were selected for this study. A history of previous TB treatment (adjusted odds ratio [aOR], 54.85; 95% confidence interval [CI], 30.48 to 98.69) was strongly associated with MDR-TB infection. We identified interruption of TB treatment (aOR, 7.62; 95% CI, 3.16 to 18.34), contact with MDR-TB patients (aOR, 5.40; 95% CI, 2.69 to 10.74), lower body weight (aOR, 0.89; 95% CI, 0.87 to 0.91), and water pipe smoking (aOR, 3.23; 95% CI, 1.73 to 6.04) as factors associated with MDR-TB infection.

CONCLUSIONS

Previous TB treatment and interruption of TB treatment were found to be the main predictors of MDR-TB. Additionally, this study found that contact with MDR-TB patients and water pipe smoking were associated with MDR-TB infection in Sudan. More efforts are required to decrease the rate of treatment interruption, to strengthen patients’ adherence to treatment, and to reduce contact with MDR-TB patients.

Geographically Weighted Regression Analysis: A Statistical Method to Account for Spatial Heterogeneity

Ordinary linear regression (OLR) is one of the most common statistical techniques used in determining the association between the outcome variable and its related factors. This method determines the association that is assumed to be true for the whole study area - a global association. In the field of public health and social sciences, this assumption is not always true, especially when it is known that the relationship between variables varies across the study area. Therefore, in such a scenario, an OLR should be calibrated in a way to account for this spatial variability. In this paper, we demonstrate use of the geographically weighted regression (GWR) method to account for spatial heterogeneity. In GWR, local models are reported in which association varies according to the location accounting for the local variation in variables. This technique utilizes geographical weights in determining association between the outcome variable and its related factors. These geographical weights are relatively large (i.e. close to 1) for observations located near regression point than for the observations located farther from the regression point. In this paper, we demonstrated the application of GWR and its comparison with OLR using demographic and health survey (DHS) data from Tanzania. Here we have focused on determining the association between percentages of acute respiratory infection (ARI) in children with its related factors. From OLR, we found that the percentage of female with higher education had the largest significant association with ARI (P = 0.027). On the other hand, result from the GWR returned coefficients varying from -0.15 to -0.01 (P < 0.001) over the study area in contrast to the global coefficient from OLR model. We advocate that identifying significant spatially-varying association will help policymaker to recognize the local areas of interest and design targeted interventions.

Impact of Age at Menarche on Breast Cancer: The Assessment of Recall Bias

BACKGROUND

Our aim was to determine the association between age at menarche (AAM) and breast cancer adjusted for recall bias (misclassification) in AAM.

METHODS

We have used data provided from a case-control study conducted in Iran from 2005 to 2009. The cases and controls were frequency matched based on 5-year age groups and region of residence. First, logistic regression was conducted to estimate the odds ratio (OR) and second, Bayesian analysis was applied to estimate the ORs adjusted for misclassification.

RESULTS

The study was conducted on 880 cases and 998 controls. In the assumption of no correction for recall bias on self-reported AAM, the OR was 1.36 (95% Credible Interval (0.98, 1.90). Based on a sensitivity value = 71% and a specificity value = 81% (the indices about the ratio of true recall of AAM) for the case and control groups (as the first scenario), the AAM ≤ 12 years of age was associated with a lower OR for breast cancer by 1.23 (95% Credible Interval: 0.50, 3.13). In the other scenario, with consideration of 100% sensitivity and specificity of self- reported AAM in the case group, and 71% and 81% sensitivity and specificity of the item in the control group, the related OR between breast cancer and AAM was found increased to 2.96 (95% Credible Interval: 0.75, 7.66).

CONCLUSION

After adjustment for misclassification related to recall bias, this study provides evidence that the self-reported mode of AAM has a moderate impact on calculation of the OR.

Assessing the quality of life among Pakistani general population and their associated factors by using the World Health Organization's quality of life instrument (WHOQOL-BREF): a population based cross-sectional study

BACKGROUND

Measuring quality of life (QOL) in a population is important for the predictions of health and social care needs. In Pakistan, health related quality of life data exist but there are no quality of life data of general population. In this study, quality of life was assessed among the Pakistani general population and their associated factors by using the World Health Organization's quality of life instrument (WHOQOL-BREF).

METHODOLOGY

A population-based cross-sectional study was carried out in all 52 Union Councils of District Abbottabad, Khaber Pkutunkhua province, Pakistan from March 2015 to August 2015. Multi-stage cluster sampling technique was employed in this study. Quality of life was measured by using the validated WHOQOL-BREF instrument, along with socioeconomic, demographic, and World Bank social capital questions in this population- based study. The data were collected through households, utilizing face to face interviews. The association between socio-demographic variables and quality of life domains were determined by using both univariate and multivariate analysis. Descriptive statistics were derived, and a multilevel linear regression using backward analysis allowing to obtain final model for each domain was achieved to recognize the variables that affect quality of life score.

RESULTS

A total of 2063 participants were included in this study (51.2% male, 48.2% female). Mean age of participants was 37.9, SD = 13.2; ranging from 18 to 90. Mean score of quality of life domains (physical, psychological, social relationship and environmental domains) were 65.0 (SD = 15.2), 67.4 (SD = 15.0), 72.0 (SD = 16.5), 55.5 (SD = 15.0), respectively. Overall, socioeconomic status was established to be the strongest predictor of poorer quality of life for all domains as a change in SES from high to low results in reduction about (β = - 5.85, β = - 9.03, β = - 8.33, β = - 9.98, p < 0.001). Similarly, type of residency was negatively associated with physical, psychological and environmental domains while age and sex were negatively associated with physical, psychological and relationship domains in final model. Furthermore social capital (β = 0.09, β = 0.13, β =0.14, β =0.15, p < 0.001) had a positive effect on Pakistani quality of life. Overall, subjective quality of life was found to be low in our population and extremely varied by socio-demographic variables.

CONCLUSIONS

Increasing age, having average and lower socioeconomic status and living in the rural area were found to be the strong predictor of poorer quality of life in all domains, while total social capital score had a positive effect on Pakistani quality of life scores.

A network meta-analysis of the treatments for esophageal squamous cell carcinoma in terms of survival

We aimed to compare treatments for patients with esophageal squamous cell carcinoma (SCC) in terms of survival. Medline, Web of Science, Scopus, the Cochrane Library and Embase were searched. Randomized controlled trials (RCT) that had compared esophageal SCC treatments were included. The hazard ratio (HR) with 95% credible interval (CrI) was used to summarize the effect measures in the Bayesian network meta-analysis. Out of 23,256 references, 43 RCTs with 34 treatments were included. Carboplatin and paclitaxel plus radiotherapy plus surgery (carbo-pacli + RT + S) compared with surgery alone decreased risk of death (HR = 0.49; 95% CrI: 0.26, 0.90). The HRs for carbo-pacli + RT + S versus surgery plus cisplatin and fluorouracil and surgery plus cisplatin and vindesine were 0.44 (0.22, 0.86) and 0.41 (0.20, 0.83), respectively. Among all treatments in network, carbo-pacli + RT + S ranked as first treatment. It seems carbo-pacli + RT + S was a better treatment among available treatments in network in terms of survival in patients with esophageal SCC.

The effects of water-pipe smoking on birth weight: a population-based prospective cohort study in southern Iran

OBJECTIVES

Consecutive community health assessments revealed that water-pipe smoking in women and impaired growth in children were among the main health concerns in suburban communities in southern Iran. The aim of the present study was to identify the effects of water-pipe smoking during pregnancy on birth weight.

METHODS

Data from a population-based prospective cohort study of 714 singleton live pregnancies in the suburbs of Bandar Abbas in southern Iran in 2016-2018 were used in this study. Data about water-pipe smoking patterns and birth weight were collected by questionnaires during and after the pregnancy. Low birth weight (LBW) was defined as a birth weight below 2,500 g. Statistical analyses were performed using generalized linear models, and the results were presented in terms of relative risk (RR) and 95% confidence intervals (CI).

RESULTS

Fifty (8.2%) of the study subjects smoked water-pipe. The adjusted risk of LBW increased 2-fold in water-pipe smokers (adjusted RR [aRR], 2.09; 95% CI, 1.18 to 3.71), and by 2.0% for each 1-year increase in the duration of water-pipe smoking (aRR, 1.02; 95% CI, 0.99 to 1.05).

CONCLUSIONS

Our results showed that water-pipe smoking during pregnancy was an important risk factor for LBW in this population sample from southern Iran. The introduction of regulations onto prevent water-pipe smoking and the implementation of community health action plans aiming at empowering women and increasing women’s knowledge and awareness regarding the health consequences of water-pipe smoking are proposed.

Prevalence of depression in people with HIV and AIDS in Iran: A systematic review

Background: Depression is the most common mental disorder in individuals with HIV and AIDS (PLWHA), and comorbidity with depression exacerbates the disease. Several studies have estimated the prevalence of depression in HIV and AIDS patients so far, but there is no consensus about the prevalence of depression among these patients. Thus, we aimed at estimating the overall prevalence of depression among Iranian PLWHA. Methods: The international and national databases including Web of Science, Scopus, Medline, Science Direct, MagIran, Scientific Information Database (SID), IranMedex, and Medlib were searched until June 2016. The quality of included studies was assessed using Newcastle-Ottawa Scale. Results: Out of 591 references, 9 cross-sectional studies met the eligibility criteria and were included in the review. The lowest and highest reported prevalence of depression among people with HIV was 22% (95% CI: (11, 33)) and 76% (95% CI: (71, 81)), respectively. Prevalence of depression in people with HIV in the north, west, and south of Iran was 45% (95% CI: (23, 67)), 30% (95% CI: (15, 45)), and 56% (95% CI: (35, 77)), respectively. Prevalence of depression among addict and non-addict patients was 25% (95% CI: (21, 30)) and 58% (95% CI: (40, 77)), respectively. Conclusion: According to the results of this systematic review, the prevalence of depression is considerable among Iranian PLWHA. Prevalence in the southern regions of Iran is more than the western and northern regions of Iran. This evidence may be useful for Iranian health policymakers to design suitable preventive and therapeutic interventions in PLWHA to prevent and control depression among these people in Iran.

Complications of stent placement in patients with esophageal cancer: A systematic review and network meta-analysis

Background

Palliative treatments and stents are necessary for relieving dysphagia in patients with esophageal cancer. The aim of this study was to simultaneously compare available treatments in terms of complications.

Methods

Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. Statistical heterogeneity was assessed using the Chi² test and was quantified by I². The results of this study were summarized in terms of Risk Ratio (RR). The random effects model was used to report the results. The rank probability for each treatment was calculated using the p-score.

Results

Out of 17855 references, 24 RCTs reported complications including treatment related death (TRD), bleeding, stent migration, aspiration, severe pain and fistula formation. In the ranking of treatments, thermal ablative therapy (p-score = 0.82), covered Evolution® stent (p-score = 0.70), brachytherapy (p-score = 0.72) and antireflux stent (p-score = 0.74) were better treatments in the network of TRD. Thermal ablative therapy (p-score = 0.86), the conventional stent (p-score = 0.62), covered Evolution® stent (p-score = 0.96) and brachytherapy (p-score = 0.82) were better treatments in the network of bleeding complications. Covered Evolution® (p-score = 0.78), uncovered (p-score = 0.88) and irradiation stents (p-score = 0.65) were better treatments in network of stent migration complications. In the network of severe pain, Conventional self-expandable nitinol alloy covered stent (p-score = 0.73), polyflex (p-score = 0.79), latex prosthesis (p-score = 0.96) and brachytherapy (p-score = 0.65) were better treatments.

Conclusion

According to our results, thermal ablative therapy, covered Evolution® stents, brachytherapy, and antireflux stents are associated with a lower risk of TRD. Moreover, thermal ablative therapy, conventional, covered Evolution® and brachytherapy had lower risks of bleeding. Overall, fewer complications were associated with covered Evolution® stent and brachytherapy.

Risk of Coronary Heart Events Based on Rose Angina Questionnaire and ECG Besides Diabetes and Other Metabolic Risk Factors: Results of a 10-Year Follow-up in Tehran Lipid and Glucose Study

BACKGROUND

High-risk individuals for CHD could be diagnosed by some non-invasive and low-priced techniques such as Minnesota ECG coding and rose angina questionnaire (RQ).

OBJECTIVES

The present study aimed at determining the risk of incident CHD according to ECG and RQ besides diabetes and other metabolic risk factors in our population.

METHODS

Participants comprised of 5431 individuals aged ≥ 30 years within the framework of Tehran lipid and glucose study. Based on their status on history of CHD, ECG, and RQ at baseline, all participants were classified to 5 following groups: (1) History^-Rose^-ECG^- (the reference group); (2) History^-Rose⁺ECG^-; (3) History^-Rose^-ECG⁺; (4) History^-Rose⁺ECG⁺; and (5) History⁺. We used Cox regression model to find the role of ECG and RQ on CHD, independent of other risk factors.

RESULTS

Overall, 562 CHD events were detected during the median of 10.3 years follow-up. CHD incidence rates were 55.9 and 9.09 cases per 1000 person-year for participants with and without history of CHD, respectively. Hazard ratios (HRs) (95% CIs) were 4.11 (3.27 - 5.11) for History + and 2.18 (1.63 - 2.90), 1.92 (1.47 - 2.51), and 2.48 (1.46 - 4.20) for History^-Rose⁺ECG^-, History^-Rose^-ECG⁺, and History^-Rose⁺ECG⁺, respectively. RQ and ECG had the same HRs as high as those for hypertension and hypercholesterolemia; however, diabetes showed statistically and clinically more effects on CVD than RQ and ECG.

CONCLUSIONS

RQ in general and, ECG especially in asymptomatic patients, were good predictors for CHD events in both Iranian males and females; however, their predictive powers were lower than that of diabetes.

Spatial modeling of cutaneous leishmaniasis in Iran from 1983 to 2013

INTRODUCTION

Cutaneous Leshmaniasis (CL), a parasitic skin infection caused by Leishmania species, is endemic in some regions of Iran. In this study, the effect of location on the incidence and distribution of CL in Iran was studied.

METHODS

We collected datas including the number of Cutaneous Leishmaniasis cases and populations at-risk of disease in Iran's different provinces reported by the Iranian ministry of health and the National Bureau of Statistics, respectively. Spatial modeling was performed using Arc GIS software. Descriptive maps, hotspot analysis, and high/low clustering analysis were used to demonstrate distribution of the cutaneous leishmaniasis, to determine regions at risk of disease's incidence, and to reach the most appropriate method for clustering of disease.

RESULTS

The total number of cases of cutaneous leishmaniasis reported through the study period was 589,913. The annual incidence of CL was estimated to be 30.9 per 100,000 in Iranian population. We also demonstrated that Cutaneous leishmaniasis most prominently occurs in regions with dry and desert climates as well as in central parts of Iran. It affected the southwest of Iran between 1983 and 1997, and subsequently developed towards the center and the eastern between 1998 and 2013. Disease hotspots were focused in the provinces of Yazd, Khozestan and Kohgiloyeh-Boyer-Ahmad (p<0.05). No pattern of spatial clustering was observed.

CONCLUSION

Cutaneous leishmaniasis is a major health problem which could be a serious threat for inhabitants who live in high-risk provinces of Iran; much more resources need to be allocated in these areas, to warrant the prevention as well as effectively management of this disease.

Simultaneous Comparison of Efficacy and Adverse Events of Interventions for Patients with Esophageal Cancer: Protocol for a Systematic Review and Bayesian Network Meta-analysis

BACKGROUND

Esophageal cancer is one of the most serious malignancies. Due to the aggressive nature of this cancer, the prognosis is poor. A network meta-analysis with simultaneous comparison of multiple treatments can help determine better treatment options that have higher effects on overall survival of patients with lower adverse events. The aim of this review is to simultaneously compare efficacy and adverse events of treatment interventions for esophageal cancer.

MATERIALS AND METHODS

In this review, only randomized control trials (RCT) will be considered for network meta-analysis. All international electronic databases including Medline, Web of Sciences, Scopus, Cochran's library, EMBASE and Cancerlit will be searched to find randomized control trials which compared two or more treatment interventions for esophageal cancer. A network plot will be drawn for visual representation of all available treatment interventions. Bayesian approach will be used to combine the direct and indirect evidence. Treatment effects (e.g. hazard ratio for time to event outcomes, risk ratio for binary outcomes, and rate ratio for count outcomes with 95% credible interval) will be reported. Moreover, cumulative probability of the treatment ranks will be reported using the surface under the cumulative ranking (SUCRA) graphs. Consistency assumption will be assessed by the loop-specific and design-by-treatment interaction approaches.

CONCLUSIONS

The results of this study may be helpful for the patients, clinicians and health policy makers in selecting treatments that have the best effect on survival and lowest adverse events.

Reprint of "Spatial modeling of Cutaneous Leishmaniasis in Iran from 1983 to 2013"

INTRODUCTION

Cutaneous Leshmaniasis (CL), a parasitic skin infection caused by Leishmania species, is endemic in some regions of Iran. In this study, the effect of location on the incidence and distribution of CL in Iran was studied.

METHODS

We collected datas including the number of Cutaneous Leishmaniasis cases and populations at-risk of disease in Iran's different provinces reported by the Iranian ministry of health and the National Bureau of Statistics, respectively. Spatial modeling was performed using Arc GIS software. Descriptive maps, hotspot analysis, and high/low clustering analysis were used to demonstrate distribution of the cutaneous leishmaniasis, to determine regions at risk of disease's incidence, and to reach the most appropriate method for clustering of disease.

RESULTS

The total number of cases of cutaneous leishmaniasis reported through the study period was 589,913. The annual incidence of CL was estimated to be 30.9 per 100,000 in Iranian population. We also demonstrated that Cutaneous leishmaniasis most prominently occurs in regions with dry and desert climates as well as in central parts of Iran. It affected the southwest of Iran between 1983 and 1997, and subsequently developed towards the center and the eastern between 1998 and 2013. Disease hotspots were focused in the provinces of Yazd, Khozestan and Kohgiloyeh-Boyer-Ahmad (p<0.05). No pattern of spatial clustering was observed.

CONCLUSION

Cutaneous leishmaniasis is a major health problem which could be a serious threat for inhabitants who live in high-risk provinces of Iran; much more resources need to be allocated in these areas, to warrant the prevention as well as effectively management of this disease.

Estimating the Transitional Probabilities of Smoking Stages with Cross-sectional Data and 10-Year Projection for Smoking Behavior in Iranian Adolescents

BACKGROUND

Cigarette smoking is one of the most important health-related risk factors in terms of morbidity and mortality. In this study, we introduced a new method for deriving the transitional probabilities of smoking stages from a cross-sectional study and simulated a long-term smoking behavior for adolescents.

METHODS

In this study in 2010, a total of 4853 high school students were randomly selected and were completed a self-administered questionnaire about cigarette smoking. We used smoothed age- and sex-specific prevalence of smoking stages in a probabilistic discrete event system for estimating of transitional probabilities. A nonhomogenous discrete time Markov chain analysis was used to model the progression of the smoking in 10 years ahead in the same population. The mean age of the students was 15.69 ± 0.73 years (range: 14-19).

RESULTS

The smoothed prevalence proportion of current smoking varies between 3.58 and 26.14%. The age-adjusted odds of initiation in boys is 8.9 (95% confidence interval [CI]: 7.9-10.0) times of the odds of initiation of smoking in girls. Our study predicted that the prevalence proportion of current smokers increased from 7.55% in 2010 to 20.31% (95% CI: 19.44-21.37) for 2019.

CONCLUSIONS

The present study showed a moderately but concerning prevalence of current smoking in Iranian adolescents and introduced a novel method for estimation of transitional probabilities from a cross-sectional study. The increasing trend of cigarette use among adolescents indicated the necessity of paying more attention to this group.

Is the status of diabetes socioeconomic inequality changing in Kurdistan province, west of Iran? A comparison of two surveys

BACKGROUND

About 80% of deaths in 350 million cases of diabetes in the world occur in low and middle income countries. The aim of this study was to determine the status of diabetes socioeconomic inequality and the share of determinants of inequalities in Kurdistan Province, West of Iran, using two surveys in 2005 and 2009.

METHODS

Data were collected from non-communicable disease surveillance surveys in Kurdistan in 2005 and 2009. In this study, the socioeconomic status (SES) of the participants was determined based on the residential area and assets using principal component analysis statistical method. We used concentration index and logistic regression to determine inequality. Decomposition analysis was used to determine the share of each determinant of inequality.

RESULTS

The prevalence of diabetes expressed by individuals changed from 0.9% (95% CI: 0.6-1.3) in 2005 to 3.1% (95% CI: 2-4) in 2009. Diabetes Concentration Index changed from -0.163 (95% CI: -0.301- -0.024) in 2005 to 0.273 (95% CI: 0.101-0.445) in 2009. The results of decomposition analysis revealed that in 2009, 67% of the inequality was due to low socioeconomic status and 16% to area of residence; i.e., living in rural areas.

CONCLUSION

The prevalence of diabetes significantly increased, and the diabetes inequality shifted from the poor people to groups with better SES. Increased prevalence of diabetes among the high SES individuals may be due to their better responses to diabetes control and awareness programs or due to the type of services they were provided during these years.

Unnatural Deaths Among Children and Adolescents in Isfahan Province, Iran: A Forensic Epidemiology Study of Postmortem Data

INTRODUCTION

The issue of child and adolescent injury and violence is often absent from discussions and is largely invisible in public health policies. The purpose of this study was to describe the frequency and pattern of unnatural deaths during childhood and adolescence in Isfahan province in Iran.

MATERIALS AND METHODS

This retrospective, descriptive study involved unnatural deaths among individuals under the age of 20 years who died from unnatural causes as determined by a forensic autopsy at the Legal Medicine Center of Isfahan. During the study period, 8,010 unnatural deaths occurred, 1,222 of which were individuals under 20 years old.

RESULTS

All 1,222 of these unnatural deaths were identified through autopsy. Among the 1,222 cases, 895 (73.2%) were male, and 327 were female (26.8%). Accidental deaths were found to be the most frequent manner of death comprising 1,029 (83.96%) cases, followed by suicide (120, 9.82%), undetermined cause of death (39, 3.19%), and homicide (9, 2.86%) cases. Road traffic accidents were the number 1 cause of death (597, 49%), followed by burns (122, 10%) and hanging (90, 7.4%).

DISCUSSION

Injuries and violence that occur during childhood and adolescence represent a global public health problem, especially in low- and middle-income regions, and require urgent action.

Associations between diabetes self-management and microvascular complications in patients with type 2 diabetes

OBJECTIVES:

Diabetes is a major public health problem that is approaching epidemic proportions globally. Diabetes self-management can reduce complications and mortality in type 2 diabetic patients. The purpose of this study was to examine associations between diabetes self-management and microvascular complications in patients with type 2 diabetes.

METHODS:

In this cross-sectional study, 562 Iranian patients older than 30 years of age with type 2 diabetes who received treatment at the Diabetes Research Center of the Endocrinology and Metabolism Research Institute of the Tehran University of Medical Sciences were identified. The participants were enrolled and completed questionnaires between January and April 2014. Patients’ diabetes self-management was assessed as an independent variable by using the Diabetes Self-Management Questionnaire translated into Persian. The outcomes were the microvascular complications of diabetes (retinopathy, nephropathy, and neuropathy), identified from the clinical records of each patient. A multiple logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) between diabetes self-management and the microvascular complications of type 2 diabetes, adjusting for potential confounders.

RESULTS:

After adjusting for potential confounders, a significant association was found between the diabetes self-management sum scale and neuropathy (adjusted OR, 0.64; 95% CI, 0.45 to 0.92, p=0.01). Additionally, weak evidence was found of an association between the sum scale score of diabetes self-management and nephropathy (adjusted OR, 0.71; 95% CI, 0.47 to 1.05, p=0.09).

CONCLUSIONS:

Among patients with type 2 diabetes, a lower diabetes self-management score was associated with higher rates of nephropathy and neuropathy.

Risk factors for amputation in patients with diabetic foot ulcer in southwest Iran: a matched case-control study

OBJECTIVES:

Amputation is a multifactorial complication in diabetic patients. The aim of this study was to determine the risk factors associated with amputation in patients with diabetic foot ulcers.

METHODS:

This matched case-control study was conducted based on new cases of amputation from March 2012 to November 2014. We selected new cases who had undergone amputation, and the control group was chosen from the cities or areas where the cases resided. Each case was matched with two controls based on the duration of diabetes and location. Conditional logistic regression was used to evaluate the associations between potential risk factors and amputation.

RESULTS:

A total of 131 cases were compared with 262 controls. The results of the adjusted model showed that sex (odds ratio [OR], 8.66; 95% confidence interval [CI], 2.68 to 27.91), fewer than two hemoglobin A1c (HbA1c) tests per year (OR, 13.97; 95% CI, 4.97 to 39.26), unsuitable shoes (OR, 5.50; 95% CI, 2.20 to 13.77), smoking (OR, 3.44; 95% CI, 1.45 to 8.13), and body mass index (OR, 1.20; 95% CI, 1.03 to 1.41) were associated with amputation in diabetic patients.

CONCLUSIONS:

The most important factors associated with amputation were females, irregular monitoring of HbA1c levels, improper footwear, and smoking. Developing educational programs and working to ensure a higher quality of care for diabetic patients are necessary steps to address these issues.

Using drug sales data to evaluate the epidemiology of cardiometabolic risk factors and their inequality: an ecological study on atorvastatin and total cholesterol in Iran

BACKGROUND

Statins have been effective medications in lowering serum total cholesterol (TC) concentrations across populations over time. The aim of this study was to estimate national and provincial trends in atorvastatin sales in Iran, to systematically quantify its relationship with socioeconomic indicators, and changes in TC level.

METHODS

In this retrospective ecological study, conducted in Iran, we examined trends in atorvastatin sales, the wealth index (WI) as a validly-available socio-economic indicator, and TC level between 2004 and 2011. The main outcome variable was mean atorvastatin sold in defined daily dose per 100,000 people per day (DPD). We analyzed the relationship between WI and DPD and between DPD and mean TC across time and space.

RESULTS

At national level, both mean WI and mean DPD showed increasing trend over time, while we observed decreasing trend for TC. Mean WI and DPD in 2011 was nearly 5 and 50 time that of their respective figures in 2004, while the mean TC decreased for nearly 10%. Increases in both WI and DPD had happened in every province, but with different patterns. The maximum and minimum changes in DPD versus WI were seen in Gilan and North Khorasan respectively.

CONCLUSION

A striking increase occurred in the sales for atorvastatin in Iran from 2004-2012 in most provinces examined. The wealthier a province became, the more sales were seen for atorvastatin. TC optimistically decreased from 2005 to 2011 and its decrease was positively correlated with increasing sales for atorvastatin.

Evaluation of pain and its effect on quality of life and functioning in men with spinal cord injury

Background

Pain is one of the most important consequences of spinal cord injury (SCI). It may affect several aspects of life, especially the quality of life (QoL). Hence, this study was conducted to establish an understanding of pain and its correlates and effects on patients with SCI in our community.

Methods

In a cross-sectional study, 58 male veterans suffering from SCI were admitted to our center for a regular follow-up. Demographic and SCI-related descriptive information were gathered using a self-reported questionnaire. To evaluate the patients' pain quality and the effect of pain on daily life, a questionnaire in 3 parts of lumbar, cervical and shoulder pain was administered. EuroQoL questionnaire and General Health Questionnaire (GHQ) 12 were also used to assess the patients' QoL.

Results

The mean age of the participants was 45.91 ± 6.69 with mean injury time of 25.54 ± 5.91. forty-four patients (75.9%) reported pain, including lumbar pain (63%), cervical pain (39%) and shoulder pain (51%). The presence of pain was associated with lower QoL. Patients with lumbar pain reported a significant amount of pain affecting their daily life and this effect was higher in patients with lower GHQ score or anxiety/depressive disorder.

Conclusions

Musculoskeletal pain, is a common complaint in veterans with SCI and is inversely associated with functioning and general health status. Lumbar and shoulder pain affects patient's daily living more than cervical pain.

Evaluation of Sexual Function and Its Contributing Factors in Men With Spinal Cord Injury Using a Self-Administered Questionnaire

Sexual activity is an important aspect of life in patients with spinal cord injury (SCI), rated as one of the top priorities for recovery of function. This study was conducted to establish an understanding of the severity of erectile dysfunction (ED), a major component of male sexual activity, and its correlates in patients with SCI in our community. In a cross-sectional study, 37 male veterans with SCI admitted for regular follow-up at our center were recruited. Demographic and SCI-related descriptive information was gathered through a self-administered questionnaire. Sexual Health Inventory for Men was used to assess the presence and severity of ED. Euro Quality of Life questionnaire and General Health Questionnaire (GHQ-12) were also administered. The mean age of the participants was 45.7 ± 6.5 years with injury duration of 24.7 ± 6.2 years. Mean GHQ-12 score of 3.65 ± 3.38 and mean Sexual Health Inventory for Men score of 11.57 ± 5.28 were measured. All participants had ED, and 27% were suffering from severe ED. Sleep deprivation, worse GHQ-12 score, and hypertension were significantly associated with higher risk of much severe ED ( p < .05). In conclusion, ED is a common problem in veterans with SCI and is inversely associated with their general health status.

Crimean-Congo hemorrhagic fever in Iran

The presence of Crimean-Congo hemorrhagic fever virus (CCHFV) in Iran was first identified in studies of livestock sera and ticks in the 1970s, but the first human infection was not diagnosed until 1999. Since that time, the number of cases of CCHF in Iran has markedly increased. Through January 2012, articles in the published literature have reported a total of 870 confirmed cases, with 126 deaths, for a case fatality rate (CFR) of 17.6%. The disease has been seen in 26 of the country's 31 provinces, with the greatest number of cases in Sistan and Baluchestan, Isfahan, Fars, Tehran, Khorasan, and Khuzestan provinces. The increase in CCHF in Iran has paralleled that in neighboring Turkey, though the number of cases in Turkey has been much larger, with an overall CFR of around 5%. In this article, we review the features of CCHF in Iran, including its history, epidemiology, animal and tick reservoirs, current surveillance and control programs, diagnostic methods, clinical features and experience with ribavirin therapy, and consider possible explanations for the difference in the CFR of CCHF between Iran and Turkey. The emergence of CCHF in Iran calls for countermeasures at many levels to protect the population, but also provides opportunities for studying the epidemiology, diagnosis and management of the disease.

The risk of transmission of Crimean-Congo hemorrhagic fever virus from human cases to first-degree relatives

To determine the infectivity of Crimean-Congo hemorrhagic fever (CCHF) virus via routine contacts between serologically confirmed cases and their close relatives from May 2005 up to March 2006, 79 serum samples of 57 close relatives of 12 newly diagnosed serologically confirmed CCHF cases in the Sistan-va-Baluchestan province of Iran were tested for IgG and IgM antibodies against CCHF virus using the enzyme-linked immunosorbent assay technique. Nine levels of contacts were considered: percutaneous contact with the patient's blood, cutaneous contact with the patient's blood, cutaneous contact with non-sanguineous body fluids, cutaneous contact with the patient's skin, sexual contact, eating at the same table, being a roommate of the patient, being a housemate of the patient, and living with the patient in the same building. Only one out of 57 relatives was positive for anti-CCHF IgG (1.8%, 95% confidence interval 0.0 to 9.8%). Thus, the infectivity of the virus via usual routine contacts with patients appears to be low.

Knowledge and attitude toward Crimean-Congo haemorrhagic fever in occupationally at-risk Iranian healthcare workers

We assessed the knowledge and attitude (K&A) toward Crimean-Congo haemorrhagic fever (CCHF) of occupationally at-risk healthcare workers (HCWs). A cross-sectional survey was performed in three referral hospitals in the Systan-Baluchestan and Isfahan provinces of Iran where CCHF is highly endemic. In all, 191/209 eligible HCWs were enrolled (response rate: 93%). All but 11 (5.8%) had heard of CCHF. The mean K&A scores of the respondents were 50.34% and 79.25%, respectively. The correlation between K&A was significant (correlation coefficient: 0.542; P<0.001). Being a physician, working in Isfahan (versus the relatively deprived Systan-Baluchestan) and relying on academic material rather than local media were independent factors significantly associated with more knowledge; higher education and laboratory staff with better attitude were also significant factors. Although HCWs showed the best K&A for preventive measures, only 44% wore gloves and masks for contact with CCHF patients and 22% failed to observe any safety measure. Those with a history of percutaneous contact (6.3%) had significantly lower knowledge scores (P=0.047). There is a need to establish professional education campaigns in highly endemic deprived areas in order to improve physicians' attitudes, encourage nurses' use of academic materials and increase the knowledge of less-educated HCWs.

Seroprevalence of Crimean-Congo hemorrhagic fever in Sistan-va-Baluchestan province of Iran

During the years 2000 to 2004, of 248 serologically confirmed cases of Crimean-Congo hemorrhagic fever (CCHF) that occurred in several parts of Iran, 169 were reported from Sistan-va-Baluchestan province. To assess the seroprevalence of CCHF virus infection within the Zahedan and Zabol districts of the Sistan-va-Baluchestan province in Iran, 300 subjects were sampled from the general population. In addition to blood sampling, a questionnaire was completed for every subject. All but just 3 of our 300 sampled subjects participated in blood sampling, and just 7 out of the 297 serum samples were found to be IgG ELISA positive. The point estimate of the seroprevalence was 0.024 (95% confidence interval: 0.003-0.044). A history of keeping livestock in houses (even for short periods) showed an association with seropositivity (P = 0.018). It seems that even occasional contact with livestock could be effective in transmission of the virus.