Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Antianginal effects of empagliflozin in patients with type 2 diabetes and refractory angina; a randomized, double-blind placebo-controlled trial (EMPT-ANGINA Trial)

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are emerging antidiabetic agents with various potential cardiovascular benefits. The EMPT-ANGINA trial examined the effect of empagliflozin on the angina burden in those with concurrent type 2 diabetes mellitus (T2DM) and refractory angina (RA).

METHOD

In this 8-week, double-blind, randomized, placebo-controlled trial, 75 patients with T2DM and RA were randomly assigned to one of two groups: empagliflozin (n = 37) and placebo (n = 38). The primary outcome was an improvement in angina, which was assessed by the Seattle Angina Questionnaire (SAQ). The secondary outcomes of this study included alterations in the SAQ domains and exercise test components.

RESULTS

The mean age of individuals in the empagliflozin and placebo groups was 67.46 ± 9.4 and 65.47 ± 7.0 years, respectively (p = .304). Patients who received empagliflozin showed a significant improvement in both the primary endpoint, which was the SAQ Summary Score (192.73 ± 20.70 vs. 224 ± 25.36, p < .001) and the secondary endpoints. Exercise test components, including treadmill exercise duration, time till angina, 1 mm ST-segment depression onset, and heart rate (HR) recovery, were all significantly improved in the empagliflozin group. This positive impact was reached with no clinically significant changes in resting and exertion HR or blood pressure. There were no significant side effects in the empagliflozin group (p = .125).

CONCLUSION

Empagliflozin can be safely added as a metabolic modulator agent to existing antianginal medications in individuals with concurrent T2DM and RA to reduce angina symptoms and enhance exercise capacity with minimal side effects.

The Impact of the COVID-19 Pandemic on Hospitalization Rates due to Prosthetic Valve Thrombosis

Background

Studies have shown a decline in the admission rates of various diseases during the COVID-19 pandemic. Prosthetic valve thrombosis (PVT) is a rare condition followed by surgical or transcatheter valvular interventions. Considering the lack of data on hospitalization rates due to PVT during the pandemic, this study evaluated the implications of the COVID-19 pandemic on PVT admissions and characteristics in a tertiary referral center.

Methods

Data from all the consecutive patients hospitalized due to PVT between February 2020 and February 2021 (the first year of the pandemic) were collected from medical records and compared clinically with the corresponding time before the pandemic (February 2019 through February 2020). Variables of interest included the number of hospitalization, patient and valve characteristics, diagnostic and management strategies, and in-hospital events.

Results

Forty patients (32.5% male, age: 54.0 [46.5-62.0 y] comprised the study population. We observed a considerable decline in hospitalization rates during the pandemic, from 31 to 9 patients. Admitted patients were 8 years younger, had a higher proportion of the New York Heart Association functional class III or IV symptoms (44.4% vs 22.6%), were more often treated with fibrinolysis (33.3% vs 22.6%) or surgical approaches (33.3% vs 22.6%), and were discharged 6 days sooner.

Conclusion

We described a reduction in PVT hospitalization. Patients presented with a higher proportion of severe dyspnea and had increased treatment with fibrinolysis/surgical approaches. These observations highlight the necessity of the active surveillance of patients with prosthetic valves by caregivers for timely diagnosis and appropriate management during the pandemic.

Five-year survival and complications of thoracic endovascular aortic repair (TEVAR): A single tertiary center registry for all-comers patients

INTRODUCTION

Studies on the mid and long-term outcomes of thoracic endovascular aortic repair (TEVAR) are scarce. This study aimed to investigate the long-term outcomes of TEVAR for all-comers patients with various types of thoracic aortic pathologies, predominantly thoracic aortic dissections and thoracic aortic aneurysms.

METHODS

Between January 2005 and December 2015, 123 consecutive patients with thoracic aortic pathologies underwent TEVAR. The patients were divided into groups based on aortic pathologies (dissections or aneurysms) and the type of procedure (hybrid TEVAR or non-hybrid TEVAR). Mortality, complications, and reintervention rates were compared between these four groups. The Kaplan-Meier curve and the Cox regression analysis were employed to estimate survivals and factors associated with 5-year mortality.

RESULTS

One hundred twenty-three consecutive patients with various aortic pathologies undergoing TEVAR were evaluated. Hypertension (79.7 %) and smoking (39 %) were the most common comorbidities in the study population. The patients were followed up for a mean duration of 58.1 ± 7.1 months to evaluate the postprocedural surveillance. Most complications occurred in the dissection and hybrid groups; however, these differences were nonsignificant. The overall 5-year surveillance and reintervention rates were 65 % and 12.1 %, respectively. A significant difference existed in 5-year survival between the patients with aneurysmal and aortic dissection pathologies based on the log-rank test (P = 0.01). On the other hand, no significant differences were observed in 5-year survival between the patients who underwent hybrid and non-hybrid TEVAR. The Cox regression analysis confirmed that chronic kidney disease, previous coronary artery bypass grafting, age >65 years, platelet counts <150∗ 10³/μL, aneurysmal aortic pathology, and ejection fraction ≤ 50 % were predictors of 5-year mortality.

CONCLUSIONS

The long-term outcomes of TEVAR for various aortic pathologies disclosed that this procedure was well-tolerated in a group of patients with high comorbid conditions. The five-year survival rate of TEVAR for thoracic aortic dissections was more favorable than that for thoracic aortic aneurysms, but there were no significant differences between hybrid and non-hybrid procedures regarding the mortality rate.

The relationship between cardiological parameters and PCR in patients with coronavirus infection: A cross-sectional study

Cardiovascular injuries induced by SARS CoV-2 have been reported repeatedly in various studies. Therefore, it is necessary to understand cardiac complications at a low cost, quickly. This study aimed to determine the relationship between cardiological parameters and polymerase chain reaction (PCR) in patients with coronavirus infection. : Patients who were admitted to the emergency department due to the ongoing pandemic, all patients with similar symptoms to coronavirus disease 2019 infection were initially admitted to the respiratory emergency room and underwent subsequent evaluations to confirm or rule out SARS-COV2 infection symptoms were assessed for eligibility. Patient were categorized into 2 groups 1. Positive PCR and negative PCR groups. Binary logistic regression was performed to assess the effect of several factors on the likelihood of developing positive troponin, reduced ejection fraction (EF), and Positive brain natriuretic peptide (BNP). Among 195 patients included, 115 (58.9%) had positive PCR. Patient in the positive PCR and negative PCR were 58.04 ± 18.03 and 59.19 ± 15.38 years of age, respectively. Patients in the "positive PCR" were significantly less likely to have chronic kidney disease (6.69% vs 17.5%, P value: .022), consume calcium channel blockers (6.69% vs 18.75%, P value:0.012). At the univariable level, positive PCR was significantly associated with fewer odds for positive BNP (OR:0.46, P = .019); nevertheless, the association was no longer significant after adjusting for confounders (adjusted OR:0.56, P = .158). Unadjusted positive PCR results were not found to have a significant association with positive troponin or reduced EF. Likewise, multivariable regression revealed no association between positive PCR and positive troponin (aOR:1.28, P = .529) and reduced EF (aOR:0.65, P = .369). PCR positivity did not result in positive troponin and BNP and did not appear to decrease EF. In other words, serial troponin and BNP checks and initial echocardiography in coronavirus disease 2019 respiratory emergencies do not make significant differences in diagnostic and therapeutic management and inpatient outcomes of patients with positive or negative PCR and are not specific findings. Evidence suggests some coronavirus-induced cardiac complications will be manifested in the long term.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Caspofungin-Induced Cardiotoxicity in Patients Treating for Candidemia

Echinocandins selectively inhibit fungal cell wall synthesis and, therefore, have few side effects. However, there are reports of hemodynamic and cardiac complications. We conducted this study to investigate the effects of caspofungin both on the noninvasive echocardiographic indices of myocardial function and myocardial injury based on serum high-sensitivity cardiac troponin I (hs-cTnI) levels. This study was conducted on patients treated for candidemia. The hs-cTnI level and echocardiographic parameters were measured before and 1 h after the infusion of the induction dose of caspofungin. Data were compared between central and peripheral venous drug administration routes. Fifteen patients were enrolled in the study. There were no significant differences in the echocardiographic parameters between the baseline and post-treatment period. The mean hs-cTnI level exhibited a significant rise following drug administration (0.24 ± 0.2 ng/mL vs 0.32 ± 0.3 ng/mL; p = 0.006). There was also a significant difference concerning the hs-cTnI level between central and peripheral venous drug administration routes (p = 0.034). Due to differences in the hs-cTnI level, it appears that the administration of caspofungin may be associated with myocardial injury. Our findings also showed a higher possibility of cardiotoxicity via the central venous administration route.

Comparison of Pulmonary Emboli Management Between Pulmonary Emboli Response Team and the Conventional Method: The First Study From Iran

BACKGROUND

We aimed to evaluate the effectiveness of the Pulmonary Embolism Response Team (PERT) for intermediate-high risk and high-risk pulmonary embolism (PE) patients.

METHODS

This single-blind clinical trial was performed in 2019-2021, evaluating patients with intermediate-high risk and high risk of PE. Patients in the intervention group were managed by the PERT team, and treatment plans were implemented as soon as possible. Patients in the other group received conventional PE treatments based on the hospital protocols. We compared the primary outcome of short-term mortality between the 2 groups and secondary outcomes, including right ventricle indices, hospital length-of-stay, time to decision, 30-day and in-hospital bleeding.

RESULTS

Data of 74 patients were analyzed. We found no significant differences between the 2 groups regarding short-term mortality (P = 0.642), bleeding, and other complications. However, the length-of-stay and time to decision were significantly lower in patients treated by the PERT team (P < 0.001 for both). Further evaluations revealed that patients in the intervention group had a more significant reduction in the right ventricle size and systolic pulmonary pressure compared with the control group (P = 0.015, P = 0.039, respectively). In addition, tricuspid annular plane systolic excursion and fractional area change increased more in the intervention group (P = 0.023, P = 0.016, respectively).

CONCLUSIONS

The PERT team led to significantly less time to make decisions, and it was able to select patients for advanced treatments more appropriately. Due to these facts, patients treated by PERT had significantly lower hospitalization duration and better right ventricle indices compared to controls.

Right ventricular diastolic function predicts clinical atrial fibrillation after coronary artery bypass graft

Background

Patients with moderate-severe left ventricular systolic dysfunction undergoing coronary artery bypass graft (CABG) surgery are at high risk of mortality and morbidity. Our aim is to evaluate the right ventricular (RV) diastolic function in these patients, and monitor its effects on postoperation outcomes.

Materials and Methods

In a cohort study, patients with moderate-severe left ventricular systolic dysfunction (ejection fraction ≤35%) who were candidate for CABG were included. Baseline transthoracic echocardiography (TTE) was performed, and RV diastolic function measures were obtained. After CABG, the length of intubation, inotrope dependency, hospital stay in intensive care unit and ward, in-hospital and after discharge mortality, postoperative atrial fibrillation (POAF) were evaluated in all patients.

Results

Sixty-seven patients were prospectively included in the study. The mean ± standard deviation age of our patients was 61.4 ± 9.3. There was no difference between grades of RV diastolic function and postoperative outcomes. However, we found significant difference between grades of RV diastolic function and onset of in hospital, and total POAF (P-value = 0.017). Multivariate analysis demonstrated that preoperative tricuspidEt/E't (ratio of peak early-diastolic flow rate across the tricuspid valve orifice to peak early-diastolic velocity at the lateral tricuspid annulus), left atrial volume and "high risk" Euroscore II were independent predictors for POAF during hospitalization and total POAF in patients with moderate to severely impaired left ventricular systolic function (P-values were 0.04, 0.003 and 0.001, respectively).

Conclusion

We believe that patients with increased tricuspid Et/E't are high risk for POAF; therefore, any risk score for POAF should include a comprehensive TTE including evaluation of RV diastolic function before surgery.

Clinical Features and Prognoses of Middle-Aged Women With ST-Elevation Myocardial Infarction With a Focus on Spontaneous Coronary Artery Dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) has become an increasingly recognized cause of acute coronary syndrome, particularly in young women, over the last decade. The goal of this study was to determine the prognoses and characteristics of adult women with SCAD who presented with ST-elevation myocardial infarction (STEMI).

METHODS

This retrospective cohort study enrolled all adult women under the age of 60 who had undergone coronary artery angiography in the setting of STEMI. The patients were divided into 3 groups based on their angiographic characteristics: STEMI-SCAD (STEMI due to SCAD), STEMI-ATH (STEMI caused by an atherosclerotic lesion), and STEMI-others (STEMI due to other etiologies including Takotsubo cardiomyopathy and myopericarditis, as well as STEMI despite a normal epicardial coronary angiography).

RESULTS

Fifteen women out of 311 female patients aged below 60 years with STEMI were diagnosed with SCAD (4.8%). There were no significant differences in body mass index, hypertension, dyslipidemia, smoking status, opium addiction status, family history, previous percutaneous coronary intervention, coronary artery bypass grafting, and cerebrovascular accidents between the STEMI-SCAD and STEMI-ATH groups. Nevertheless, the STEMI-SCAD and STEMI-others groups were more likely to be younger, less likely to be diabetic, and less likely to have 3 cardiovascular risk factors or more than was the STEMI-ATH group. The left anterior descending artery was the most common culprit lesion in the STEMI-SCAD group (80%) and the other 2 groups. Out of the 311 patients, 7 patients died during the index hospitalization: 1 patient in the STEMI-SCAD group, 6 patients in the STEMI-ATH group, and 0 patients in the STEMI-others group. None of the patients in the STEMI-others group experienced any major adverse cardiac events during the follow-up. In the other 2 groups, the most experienced outcomes were myocardial infarction and in-hospital cardiac death, followed by target lesion revascularization and target vessel revascularization.

CONCLUSIONS

STEMI-SCAD is one of the known causes of STEMI in young women. Still, despite the complexity of revascularization in our patients with STEMI-SCAD, they had more favorable prognoses in both conservative and revascularization management modalities than our patients with STEMI-ATH.

Perioperative Cardiac Troponin T and Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Graft Surgery

BACKGROUND

Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. We investigated whether perioperative cardiac troponin T (cTnT) is associated with the risk of AF after coronary artery bypass grafting (CABG).

METHODS

Two thousand four hundred twenty-one patients with isolated CABG were studied. High sensitivity cTnT (hs-cTnT) was assessed before and then at 80 hour and 24 hour after the operation. Logistic regression models were applied to investigate the association of perioperative hs-cTnT with postoperative AF. The ROC curve analysis was applied to determine the optimal cutoff values.

RESULTS

Postoperative AF was occurred in 356 (14.7%) patients. Age (adjusted odds ratio [ORs] 1.087-1.090), male gender (OR 1.390), left atrium size (ORs 1.055-1.111), on-pump coronary bypass (OR 1.561), and application of intra-aortic balloon pump (ORs 2.890-2.966) were independently associated with AF. Preoperative hs-cTnT was associated with AF in patients with off-pump coronary bypass (ORs 1.997-2.375). However, the area under the curve for preoperative hs-cTnT was 0.625 in this group. On-pump coronary bypass had major influence on postoperative hs-cTnT levels regardless of the occurrence of AF.

CONCLUSIONS

Preoperative hs-cTnT level is associated with the risk of AF after isolated CABG in patients undergoing off-pump coronary bypass, but the accuracy of this biomarker is yet inadequate. Postoperative levels of hs-cTnT have no predictive value considering large influence by the surgical technique and the cardiac surgery itself. Therefore, perioperative hs-cTnT is not a clinically useful biomarker for predicting AF following CABG.

Ventricular repolarization heterogeneity in patients with COVID-19: Original data, systematic review, and meta-analysis

BACKGROUND

Coronavirus disease-2019 (COVID-19) has been associated with an increased risk of acute cardiac events. However, the effect of COVID-19 on repolarization heterogeneity is not yet established. In this study, we evaluated electrocardiogram (ECG) markers of repolarization heterogeneity in patients hospitalized with COVID-19. In addition, we performed a systematic review and meta-analysis of the published studies.

METHODS

QT dispersion (QTd), the interval between T wave peak to T wave end (TpTe), TpTe/QT (with and without correction), QRS width, and the index of cardio-electrophysiological balance (iCEB) were calculated in 101 hospitalized COVID-19 patients and it was compared with 101 non-COVID-19 matched controls. A systematic review was performed in four databases and meta-analysis was conducted using Stata software.

RESULTS

Tp-Te, TpTe/QT, QRS width, and iCEB were significantly increased in COVID-19 patients compared with controls (TpTe = 82.89 vs. 75.33 ms (ms), p-value = .005; TpTe/QT = 0.217 vs. 0.203 ms, p-value = .026). After a meta-analysis of 679 COVID-19 cases and 526 controls from 9 studies, TpTe interval, TpTe/QT, and TpTe/QTc ratios were significantly increased in COVID-19 patients. Meta-regression analysis moderated by age, gender, diabetes mellitus, hypertension, and smoking reduced the heterogeneity. QTd showed no significant correlation with COVID-19.

CONCLUSION

COVID-19 adversely influences the ECG markers of transmural heterogeneity of repolarization. Studies evaluating the predictive value of these ECG markers are warranted to determine their clinical utility.

Evaluation of correlation between digital vs. mercury sphygmomanometer in a middle-income country: The role of socio-economic situation

BACKGROUND

Using manometer sphygmomanometers as standard measurement tool, there are controversial data regarding accuracy and validity of digital manometers for measurement of systolic (SBP) and diastolic blood pressure (DBP). Thus, we aimed to compare the accuracy of readings of digital sphygmomanometer in reference to mercury sphygmomanometer in a large population of healthy adults.

METHODS AND MATERIALS

This cross-sectional study was performed on 1119 healthy adults. We measured participant's blood pressure once with mercury sphygmomanometer, as gold standard and again with digital mercury sphygmomanometer. Blood pressure was measured in sitting position after 5 min of rest and preferentially from right arm unless deformed.

RESULTS

The mean ± standard deviation of age of participants was 37.25 ± 10.45 years. Majority of participants were male 588 (52.5%). The right/left SBP measured by digital sphygmomanometer were significantly higher compared with those measured by mercury sphygmomanometer: 115.37 ± 12.33 vs 110.95 ± 10.06/113.69 ± 11.77 vs 110.23 ± 10.34, respectively (P < .001), while an opposite result was observed about right/left DBP: 68.60 ± 8.55 vs 70.60 ± 8.31/69.39 ± 8.31 vs 70.75 ± 8.41, respectively (P < .001). In subgroup analysis in terms of marital status, education, and income, we observed similar findings.

CONCLUSION

According to the results of our data analysis, it was shown that the digital device measurements had significant incompatibility with the mercury sphygmomanometers and it seems that digital devices still cannot be used as the gold standard in blood pressure measurement.

Evaluating value of positive T wave in lead V1 and TV1 > TV6 pattern in predicting significant coronary artery disease in patients undergoing coronary angiography

BACKGROUND

The aim of this study was to predict significant coronary artery disease (CAD) in patients undergoing coronary angiography.

METHODS

In this cross-sectional study, data of 384 patients who underwent angiography during 2015-2017 were reviewed. Electrocardiograms (ECGs) were evaluated in terms of having positive T wave in lead V1 (TV1) described as T wave with amplitude of more than 0.15 mV and angiography records were assessed for presence of significant CAD defined as presence of ≥ 70% internal diameter stenosis in at least one major epicardial coronary artery or more than 50% stenosis in left main artery (LMA).

RESULTS

Out of 384 patients who participated in this study with mean age of 63.6 ± 10.2 years (40-89 years), 71.6% showed positive TV1 and significant CAD simultaneously and left anterior descending artery (LAD) and left circumflex artery (LCX) lesions were more frequently reported in coronary angiography. Based on chi-square test, the prevalence of significant CAD was obviously more in those with positive TV1 as compared to those without this finding [odds ratio (OR) = 2.74, 95% confidence interval (CI): 1.80-4.19, P < 0.001]. Mann-Whitney test showed significant difference in number of coronary arteries involved in CAD between presence of positive and negative T wave in lead V1 (P < 0.001). Great number of patients with significant CAD had remarkably higher T wave amplitude in lead V1 in comparison to lead V6 (OR = 6.22, 95% CI: 3.14-12.30, P < 0.001).

CONCLUSION

Positive TV1 and TV1 > TV6 pattern can be considered as a predictor for significant CAD in patients with otherwise normal ECG.

Outcomes of the Latarjet Procedure in Recurrent Anterior Shoulder Instability due to Tramadol-Induced Seizure

Background: This study was aimed to evaluate the final results of surgical treatment (Latarjet procedure) in the recurrent anterior shoulder instability following episodes of tramadol-induced seizure. Methods: From January 2005 to March 2013, 47 patients with recurrent anterior shoulder dislocation after suffering a seizure episode following tramadol use underwent surgical procedure. There were 53 shoulders in 47 male patients (six had bilateral recurrent dislocations). The mean age of the patients at the time of operation was 24.7 years (ranging from 20 to 44 years). The average number of episodes of anterior shoulder dislocation before surgery was 16. Results: External rotation with the elbow at the side improved from 45.8 ± 9.3° (30°-60°) pre-operatively to 61.5 ± 7.8° (45°-90°) postoperatively (P < 0.001). Forward elevation also increased significantly post-operatively (P = 0.002). Mean pre-operative Rowe score was 28.41 ± 4.30 (30-85) which increased to 73.57 ± 8.40 post-operatively. The Western Ontario Shoulder Instability Index (WOSI) score decreased from 1352 ± 74 to 618 ± 46 (P < 0.0001). Conclusion: Correcting glenoid bone loss by Latarjet procedure combined, if necessary, with humeral head defect reconstruction could be a proper treatment method in patients experiencing recurrent anterior shoulder dislocation after idiosyncratic seizure reaction of tramadol.

The relationship of the changes in lateral leads I and aVL in electrocardiogram with echocardiography and coronary angiography findings in patients with acute coronary syndrome

BACKGROUND

Electrocardiographic (ECG) study is a principle for the symptoms contributed to the acute myocardial infarction (AMI)/acute coronary syndrome (ACS). The diagnosis of involved coronary artery based on ECG changes is still a challenge. This study is aimed to evaluate the association of mere changes in I and aVL leads with the involved region found through echocardiography and involved coronary artery through angiography.

METHODS

This cross-sectional study was conducted on 100 patients referred with AMI/ACS symptoms that had mere ECG changes in I and aVL leads (ST elevation + Q wave/ST depression + inverted-T). Transthoracic echocardiography (TTE) and coronary angiography (CAG) were performed for the patients. The correlation of ECG with echocardiography and angiography was assessed.

RESULTS

Among the studied population, 39 patients (39%) were women with the mean ± standard deviation (SD) of age of 64.60 ± 9.39 years. There was no significant association between ECG changes in leads I and aVL with neither the stenosis of first diagonal (D1) coronary artery found through angiography (P = 0.580) nor the mid-anterior wall dyskinesia found through echocardiography (P = 0.380). A remarkable association between the echocardiographic findings representing mid-anterior wall ischemic dyskinesia with the stenosis of D1 coronary artery was detected (P < 0.001). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%, 54.54%, 94.68%, and 100% were respectively found as the diagnostic values of mentioned factors.

CONCLUSION

Our findings showed significant association between D1 involvement and mid-anterior dyskinesia in echocardiography, while the changes in ECG were associated neither with echocardiographic nor angiographic outcomes.

15-Year lipid profile effects on cardiovascular events adjusted for cardiovascular risk factors: a cohort study from Middle-East

BACKGROUND

Dyslipidaemia is a risk factor for cardiovascular disease (CVD); however, there are only a few long-term cohort studies. The aim of this unique study is to evaluate the effects of several lipid markers on cardiovascular outcomes during a 15-year follow-up from the Isfahan cohort study (ICS).

METHODS

This ongoing cohort study was started in 2001 in three cities of Iran. The study population includes 5432 individuals older than 35 years and with Iranian citizenship. All of the patients were evaluated every 2 years by telephone and a full medical examination with blood sampling was conducted every 5 years. The data were recorded in our checklists. Dyslipidaemia was defined according to the ATPIII criteria. Our endpoints in this study were any cardiovascular events such as stroke, sudden cardiac death, unstable angina or myocardial infarction (MI).

RESULTS

cardiovascular events were significantly higher in males, older people, diabetics, smokers, patients with higher BMIs, higher blood pressure, dyslipidaemia and less educational level, physical activity index and global dietary index. Our adjusted multivariable analysis (for cardiovascular risk factors and demographic factors) revealed that dyslipidaemia could increase the risk of 15-year cardiovascular events by 1.59 times (HR = 1.59 [1.23-2.06], p value  < .001) adjusted for demographic factors and baseline cardiovascular risk factors.

CONCLUSIONS

Dyslipidaemia, as an independent risk factor, was associated with future cardiovascular events. In this regard, serum lipid screening can help to decrease the risk of long-term cardiovascular events.

Functional and Quality of Life Outcomes of Surgery for Degenerative Cervical Myelopathy: a Quality Improvement Study

Background: This study aimed to determine the outcome of surgical treatments in patients with degenerative cervical myelopathy (DCM). During one-year follow-up period, we evaluated patient-reported functional and quality of life (QOL) measures.   Methods: In a retrospective single-center study, we collected data of patients with DCM who underwent cervical fusion surgeries in Imam Khomeini Hospital, Tehran, Iran, from 2011 to 2015. Patients underwent single or multi-level anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), or posterior laminectomy and fusion. We utilized patient-reported assessments including Short Form 36 (SF-36), Visual Analogue Scale (VAS), Neck Disability Index (NDI), and Nurick grade. Follow-up was performed at 6 weeks, 3 months, 6 months, and 12 months post-operatively to assess the outcome of surgery.   Results: Ninety patients (56 men, 34 women) with a mean age of 54.1 (27-87) years were included. Comparison of pre- and post-operative scores showed significant improvement in SF-36 parameters, VAS, NDI, and Nurick grade (P < 0.001). Also, women’s VAS scores improved more than men's VAS scores during the follow-up period (P < 0.050). Age and type of surgery did not significantly affect the SF-36 parameters, VAS, NDI, and Nurick grade (P > 0.05).   Conclusions: Cervical surgeries in patients with different severity of DCM can improve different aspects of QOL during one-year after surgery

The relationship between global longitudinal strain and pulmonary function tests in patients with scleroderma and normal ejection fraction and pulmonary artery pressure: a case-control study

This study examined the relationship between global longitudinal strain (GLS) and pulmonary function tests (PFT) in patients with systemic sclerosis (SS) and normal ejection fraction (EF) and pulmonary artery pressure (PAP) and healthy controls. Sixty patients in two groups underwent extensive screening, including echocardiography, physical examination, the modified Rodnan Skin Score, and pulmonary function tests. Pulmonary interstitial disease was diagnosed by the pulmonary function test and by CT scan in case of indication. GLS score was computed as the mean peak systolic strain for 17 segments. The mean GLS score was - 18.36 ± 2.1 in the case group and - 20.66 ± 1.6 in the control group (P value < 0.001). GLS scores had a significant inverse relationship with the forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio (P value = 0.049) and both FEV and FVC in patients younger than 35 years old (P = 0.046 and 0.049, respectively). GLS scores had no significant relationship with time elapsed since the onset of skin manifestations, and Raynaud phenomenon, Rodnan score, EF, systolic PAP, or the six-minute walk test results. The patients' six-minute walk test had a significant positive relationship with FVC and right ventricular end diastolic diameter (P value = 0.018 and 0.047, respectively). According to our findings, GLS is significantly lower in patients with SS (with normal EF & PAP) than in healthy individuals. It is also related with certain pulmonary function indices including FEV1/FVC. The reduction in GLS is associated with reduced pulmonary function strength.

The impact of topical Saint John's Wort (Hypericum perforatum) treatment on tissue tumor necrosis factor-alpha levels in plaque-type psoriasis: A pilot study

Context:

Psoriasis is an inflammatory disorder, formed by inappropriate interaction of T lymphocytes with keratinocytes, and consequent eruption of immune responses. High concentrations of tumor necrosis factor-alpha (TNFα) are found in the skin lesions and plasma of patients with psoriasis. Hypericum perforatum, a phytomedicine that has both anti-inflammatory and antiproliferative properties, has been recently reported to be clinically helpful for improvement of psoriatic lesions.

Aims:

The aim of the present study was to investigate the effects of topical H. perforatum on TNFα levels in psoriatic lesions for possible identification of the mechanism by which Hypericum reduces inflammation and modulates the disease in patients with plaque-type psoriasis.

Settings and Design:

A double-blind, placebo-controlled, pilot study with intraindividual comparison was conducted on twenty patients with mild to moderate plaque-type psoriasis.

Subjects and Methods:

TNFα levels in tissue samples were measured with immunohistochemistry method. Moreover, Psoriasis Area Severity Index (PASI) scores and histological and clinical changes were investigated after topical application of Hypericum extract.

Statistical Analysis Used:

The Wilcoxon signed-rank test was used to evaluate the possible differences between the drug and placebo group.

Results:

TNFα concentrations in dermis (p= 0.025), endothelial cells (p=0.033), and dendrite cells (p=0.014) were significantly reduced in lesions treated with drug and the reduction observed in epidermis was superior to placebo (p=0.046). Results of PASI scores showed that erythema, scaling, and thickness were significantly lower where the ointment had been applied compared to application of placebo (p=0.014, p=0.004, p=0.003, respectively). Moreover, significant improvement in clinical and histological features of treated lesions in comparison with untreated lesions was observed (p < 0.05).

Conclusions:

H. perforatum ointment can help decrease PASI scores and TNFα levels in psoriatic tissue. Its efficacy is probably related to its effect on lowering cytokines including TNFα.

National Joint Registry of Iran

Joint replacement is currently on the rise with a high community burden. A registry was designed to evaluate the costs, possible complications, and rate of revisions as well as finding the most effective techniques, risk factors associated with poor results, indications for revision surgeries, and also demographic evaluation of patients undergoing joint replacement surgery in Iran.

Chronic mucocutaneous candidiasis, a case study and literature review

Chronic mucocutaneous candidiasis (CMC) is a clinically heterogeneous disease. Some immunologic and hormonal abnormalities have been associated with CMC. The factors that predispose host to CMC infection could be autosomal or acquisitive. The disease usually occurs in childhood. Here, we reviewed the published literature on chronic mucocutaneous candidiasis and a four years old girl is presented with CMC. She had a history of recurrent thrush and otomycosis since the age of one. Candida albicans was detected in skin scraping and biopsy samples. Serum iron was low. TSH hormone level was high and T4 level was low. Giardia cysts were found in stool sample. Mucocutaneous and nail manifestations of the disease were disappeared after a period of Itraconazole therapy.

Is it safe to discharge blunt abdominal trauma patients with normal initial findings?

BACKGROUND

Trauma is the leading health concern among young adults. Blunt abdominal trauma (BAT) is the most common type of blunt traumas. BAT patients may prove normal in the initial clinical assessments, but since the time required for an intra-abdominal injury to be clinically apparent is not predictable, deciding when to safely discharge these patients could be a dilemma. The purpose of this study is to determine whether follow-up of the early discharged or further diagnostic assessment of the later discharged BAT patients with normal initial findings reveals any abnormal findings.

METHODS

Totally, 389 hemodynamically-stable patients suspected of BAT who arrived at the emergency department (ED) of two university hospitals in Tehran from September 2013 to September 2014 were included in this study. Upon arrival at the ED, all subjects underwent abdominal examination and FAST, and were assessed for hematocrit and base deficit levels and presence of hematuria. These assessments were repeated in the patients who were discharged after 6 h, at 6 or 12 h post-arrival. All patients were followed-up after 24 h and one week by phone call.

RESULTS

Out of all study participants, 158 patients (40.6%) had normal findings in all initial assessments. These patients were discharged from the ED after a median of 5 h. After one week of follow-up, none of them had any symptom or complication, or had sought medical attention after being discharged from the study hospitals. Out of these patients, 78 patients (49.4%) were discharged after 6 hours by their physician's decision, and underwent the same diagnostic assessments for the second or third time. None of these assessments revealed any abnormal findings.

CONCLUSIONS

A combination of normal abdominal exam, normal FAST, normal hematocrit, normal base deficit, and absence of hematuria rules out intra-abdominal injury in BAT patients. It is safe to discharge patients after they prove normal for these assessments. Longer observation and repeated diagnostic assessment of these patients does not yield any new findings, and seems to be unnecessary.

Evaluation of outcomes of suction drainage in patients with haemophilic arthropathy undergoing total knee arthroplasty

INTRODUCTION

Closed suction drainage has been extensively applied for orthopaedic procedures for the sake of avoiding fluid collections around the wound at the operated limb.

AIM

We believed that without application of suction drainage after total knee arthroplasty (TKA), the risk of infection and haematoma formation will not increase while the need for blood transfusion because of decreased blood loss will be lesser.

METHODS

In a prospective randomized clinical trial from April 2010 to April 2014, 176 patients with haemophilia who underwent TKA were included. The study group consisted of 88 patients (108 knees), in which we did not insert suction drain and the control group included 88 patients (106 knees), in which drain was inserted at the end of the surgery. All patients underwent TKA via anterior knee incision and medial parapatellar approach.

RESULTS

The mean follow-up period of study group and control group was 21 ± 11 months vs. 20 ± 9 months consecutively (P = 0.54). The mean hospital stay was 13 ± 8 days vs. 14 ± 8 days in study and control group consecutively (P = 0.40). In both groups, the major part of improvement in clinical knee society score was due to increase in pain subset (mean increase of 42 vs. 39 points consecutively) and to a lesser extent to alleviation of flexion contracture (mean increase of 13 vs. 15 points consecutively). We observed no differences in the mean visual analogue scale (VAS) value between both groups. Average functional outcome in both groups improved during follow-up visits.

CONCLUSION

We can conclude that there is no rationale for the use of drain after primary TKA.

Ponseti Casting Method in Idiopathic Congenital Clubfoot and Its Correlation with Radiographic Features Abstract

BACKGROUND

The aim of this study was to evaluate the idiopathic congenital clubfoot deformity treated by Ponseti method to determine the different factors such as radiological investigations that may have relations with the risk of failure and recurrence in mid-term follow-up of the patients.

METHODS

Since 2006 to 2011, 226 feet from 149 patients with idiopathic congenital clubfoot were treated with weekly castings by Ponseti method. Anteroposterior and lateral foot radiographies were performed at the final follow-up visit and the data from clinical and radiological outcomes were analysed.

RESULTS

In our patients, 191(84.9%) feet required percutaneous tenotomy. The successful correction rate was 92% indication no need for further surgical correction. No significant correlation was found between the remained deformity rate and the severity of the deformity and compliance of using the brace (P=0.108 and 0.207 respectively). The remained deformity rate had an inverse association with the beginning age of treatment (P=0.049). No significant correlation was found between the percutaneous tetonomy and passive dorsiflexion range (P=0.356).

CONCLUSION

According to our results treatment with the Ponseti method resulted in poor or no correlation. The diagnosis of clubfoot is a clinical judgment; therefore, the outcome of the treatment must only be clinically evaluated. Although the Ponseti method can retrieve the normal shape of the foot, it fails to treat the bone deformities and eventually leads to remained radiologic deformity. Further studiesare suggested to define a different modification that can address the abnormal angles between the foot and ankle bones to minimize the risk of recurrence.

Efficacy and safety of permethrin 5% topical gel vs. placebo for rosacea: a double-blind randomized controlled clinical trial

BACKGROUND

Rosacea is a chronic, multifactorial, dermatological condition. Increased density of Demodex folliculorum mites in the skin of rosacea patients suggests a possible role for these mites in the pathophysiology of rosacea.

OBJECTIVE

To evaluate the effects of permethrin 5% topical gel vs. placebo on Demodex density (Dd) and clinical presentations of rosacea patients, and also to further refine the quantitative assessment of Dd in the non-invasive standard skin surface biopsy (SSSB).

METHODS

Twenty patients with bilateral papulopustular rosacea and ≥5 mites/cm² were enrolled in the study. Participants and physicians were blinded to the group assignments. Each patient applied permethrin on one side and placebo on the other side of the face twice daily for 12 weeks. SSSB and photography and Rosacea Clinical Scorecard of the National Rosacea Society were used to assess the patients at the baseline, 2nd, 5th, 8th, and 12th weeks for both sides of the face. Causality and severity of adverse drug reactions (ADRs) were assessed by WHO Scale and Hartwig Scale, respectively.

RESULTS

Dd was not significantly different between the two groups at the baseline. In both groups, Dd significantly decreased after 12 weeks compared to the baseline. At the end of the 12th week, the Dd in the permethrin group was significantly lower than the placebo group. Severity of the clinical presentations decreased in both groups at the end of week 12 in comparison to the baseline, particularly in the permethrin group. ADRs were all mild and in most cases unlikely related to permethrin.

CONCLUSION

Permethrin 5% gel can significantly reduce the Dd and severity of presentations in rosacea patients and can be a safe and effective option in the management of this chronic disorder. This new SSSB technique offers an easy, quick, inexpensive, and non-invasive sampling method proper for quantitative assessment of Dd.

Differential expression of mRNA for T-bet and GATA-3 transcription factors in peripheral blood mononuclear cells of patients with vitiligo

BACKGROUND

There is accumulating evidence that aberrant T helper (Th)1 and Th2 cell responses play critical roles in the pathogenesis of autoimmune diseases. However, their importance in the pathobiology of vitiligo have yet to be elucidated.

AIM

To evaluate the expression profile of two transcription factors, namely, T-bet, a Th1-specific T box transcription factor and GATA binding protein 3 (GATA-3), a Th2-specific transcription factor, and to measure expression levels of interferon (IFN)-γ and interleukin (IL)-4 mRNAs as the signature cytokines of Th1 and Th2 cells, respectively.

METHODS

Gene expression analysis of peripheral blood mononuclear cells (PBMCs) was performed using real-time reverse transcriptase PCR.

RESULTS

In patients with vitiligo compared with controls, mRNA expression was significantly higher for T-bet and IFN-γ, and significantly lower for GATA-3 and IL-4 mRNAs (P ≤ 0.05).

CONCLUSION

These data suggest additional implications for the role of Th1/Th2 balance in the immunopathogenesis of vitiligo.

Involvement of nitric oxide in serotonin-induced scratching in mice

BACKGROUND

Serotonin is a pruritogenic substance in humans and animals, but the mechanisms of action through which serotonin induces itch response are not yet understood.

AIM

To examine the possible role of nitric oxide (NO) in the profile of scratching behaviour due to intradermal injection of serotonin in mice.

METHODS

Intradermal injection of serotonin (14.1-235 nmol per site) into the nape of the neck was used to elicit itch in mice. Scratching behaviour was evaluated by counting the number of bouts during 60 min after injection. To determine the possible involvement of the nitrergic system in serotonin-induced scratching, L-NG-nitroarginine methyl ester [L-NAME; a nonselective nitric oxide synthase (NOS) inhibitor], aminoguanidine [a selective inducible (i)NOS inhibitor] and L-arginine (an NO precursor) were administered intraperitoneally to control and serotonin-injected animals.

RESULTS

Intradermal serotonin caused scratching in mice with a bell-shaped dose-response correlation, and the peak effective dose was 141 nmol per site. The majority of scratching bouts in animals occurred 5-10 min after injection. Ineffective doses of L-NAME (3 mg/kg IP) and aminoguanidine (100 mg/kg IP) decreased the scratching induced by intradermal serotonin injection in animals (P < 0.001 and P < 0.001), while an subeffective dose of L-arginine (100 mg/kg IP) augmented the scratching effect of serotonin (P < 0.001).

CONCLUSIONS

We show for the first time that the scratching induced by intradermal serotonin is mediated by NOS, especially iNOS, activation. We conclude that NO may play a role in mediating itch responses. NO and NOS could be new targets for antipruritic agents.

Trichophyton Schoenleinii-induced widespread tinea corporis mimicking parapsoriasis

We report a case of extensive tinea corporis in an 80-year-old woman on her forearms, thighs, legs, buttocks and trunk, mimicking parapsoriasis due to Trichophyton schoenleinii, without scalp involvement. Diagnosis of Trichophyton schoenleinii was confirmed by microscopy and mycological culture specimens.

Possible association of the CD4 gene polymorphism with vitiligo in an Iranian population

BACKGROUND

Vitiligo is an acquired idiopathic and polygenic disorder with progressive depigmentation of circumscribed patches. Its exact pathogenesis is unknown. The CD4 gene plays an important role in the cell-mediated immune response and its association with type 1 diabetes mellitus, which is an autoimmune disease, has been previously reported.

METHODS

Based on the assumption that autoimmunity is also involved in vitiligo, the CD4 gene was selected for study using a candidate gene approach. The pyrimidine-rich pentanucleotide repeat length polymorphism located in the promoter of the gene was studied. We screened 144 unrelated Iranian patients with vitiligo and 144 healthy matched controls by PCR.

RESULTS

The CD4*A4 allele has a susceptibility association with the development of vitiligo in the Iranian population (OR = 1.68, 95% CI 1.18-2.42; P < 0.01, P(c) = 0.02). When we compared CD4*A4-containing genotypes in the case and control groups, even more significant positive association was identified (OR = 2.02, 95% CI 1.26-3.22; P < 0.01 and P(c) < 0.01). The CD4 gene polymorphism has a modest association with the development of vitiligo in Iranian patients.

Evaluation of Candida albicans allergens reactive with specific IgE in asthma and atopic eczema patients

Candida albicans (C. albicans) produces important allergenic components which can induce allergic reactions in sensitised patients. The purpose of this study was to extract the C. albicans antigens for evaluating the specific anti-Candida IgE in sera of atopic eczema (AE) and asthmatic patients (AS). 95 AE, 85 AS, and 70 non-atopic cases were selected with sequential trials. Candida albicans antigens were prepared and then skin prick test (SPT), ELISA and IgE-immunoblotting tests were performed for all patients. Positive SPT reactions were obtained on 52.6% of AE and 54.1% of AS patients and 4.3% of healthy controls (P < 0.05). Using ELISA, specific anti-C. albicans IgE antibody was detected in 32.6% and 41.2% of patients with AE and AS, respectively. No specific IgE antibody was detected in healthy controls (P < 0.05). In SDS-PAGE, protein bands with molecular weights between 13 and 135 kDa were detected, and some of them reacted with specific IgE in immunoblotting. In AE patients, the most important allergenic components were 25, 34, and 57 kDa protein bands, whereas in AS, 22, 25, and 34 kDa protein bands were observed as major allergens. Candida albicans produces different allergenic components that can induce allergic reactions and may be pathogenetically important in patients with AE and AS.

Immediate hypersensitivity to Malassezia furfur in patients with atopic dermatitis

Atopic dermatitis (AD) is a chronic pruritic dermatitis that has unknown aetiology. It seems that Malassezia furfur has a role in pathogenesis of AD. The purpose of this study was to evaluate skin responses to M. furfur antigens in AD patients. Malassezia furfur was grown and the yeasts were broken. Cells were centrifuged and supernatants were used as crude extracts (CE). Protein components of CE were separated by sodium dodecylsulphate-polyacrylamide gel electrophoresis (SDS-PAGE). In addition, to fractionate CE antigens, gel filtration chromatography was performed. One hundred and fifteen AD patients were selected for skin-prick test (SPT). In SDS-PAGE, CE showed a total of 19 different protein bands (10-100 kDa). Chromatographic gel filtration with M. furfur proteins showed four major fractions (F). The protein pattern of F(1) (tube no. 40) was between 22 and 100 kDa and it was selected for SPT. In SPT, 49.6% and 42.6% patients showed positive reactions with CE and F(1) antigens respectively. The most positive results were obtained in 20-29 aged group (P < 0.001). The allergens of M. furfur may have a role in AD signs; it is suggested to use F(1) antigens in allergy tests.

Identification of peptides specific for antibodies in vitiligo using a phage library

Patients with vitiligo produce specific autoantibodies that can be detected in their sera. These antibodies are believed to play a role in the pathogenesis of this disease. A random peptide library displayed on phage is a technique that can be used to identify the epitopes that react with monoclonal and polyclonal antibodies. We used this technique to identify the epitopes that react specifically with the vitiligo autoantibodies. By screening the random peptide phage library and using ELISA, two clones that showed a higher frequency of reactivity with the antibodies in the sera of patients with vitiligo were identified. The peptides do not show any similarity with the autoantigens so far implicated in vitiligo, indicating that these epitopes may mimic conformational epitopes in proteins.

Onychomycosis in Tehran, Iran: prevailing fungi and treatment with itraconazole

A total of 187 Patients with suspected onychomycosis were examined for causative fungal agents between 1996 and 1997. Laboratory examination confirmed onychomycosis in 115 patients, of which 97 cases were presented with positive microscopic and cultural examinations, and they were selected for itraconazole pulse therapy. From an etiological point of view, 48.4% of the nail infections, mainly toenail infections, were caused by dermatophytes, 43.3% were infected with Candida spp, specially infected fingernails, and 8.2% by non-dermatophytic molds. Trichophyton mentagrophytes var. interdigital and T. violaceum were the most prevalent species. Candida albicans and C. parapsilosis were the predominant species of the Genus Candida. Scopolariopsis brevicaulis was the most common non-dermatophyte molds observed. Female affected more frequently than male and in both sexes, those who were 30-49 years old, more infected. Toenails were affected more frequently than fingernails. In this study, itraconazole pulse therapy (400 mg daily) gave during the first week of per month for 3 months. The study included 51 patients with toenail onychomychosis (group 1) and 46 patients with fingernail infections (group 2). Patients were followed up for 9 months after the last treatment. Clinical response rates were 83% in the group 1, 95% in the group 2 at month 12; the corresponding mycological cure rates were 71 and 87%, respectively.

Case report: chronic dermatophyte infection in a patient with vitiligo and discoid lupus erythematosus

We report the case of a patient suffering from vitiligo and discoid lupus erythematosus. The nails of the left hand were involved with subungual hyperkeratosis. He was treated by local and systemic corticosteroid and chloroquine but hyperkeratotic lesions progressed on the affected sites and were found to be caused by Trichophyton violaceum.