'Inequalities in prevalence of hypertension, prehypertension, anti-hypertensive coverage, awareness, and effective treatment in 429 districts of Iran; a population-based STEPS 2016 small area spatial estimation model'

Purpose

While many studies have reported hypertension (HTN) and pre-hypertension (PHTN) in large geographic locations of Iran, information regarding district levels is missing. We aimed to examine inequalities in the prevalence of hypertension, prehypertension, anti-hypertensive coverage, awareness, and effective treatment of adults in districts of Iran.

Methods

We used 27,165 participants' data from the STEPS 2016 study in Iran. A small area estimation model was carried out to predict HTN in the 429 districts of Iran. HTN and PHTN were defined based on the American Heart Association Guideline. Awareness of being hypertensive, treatment coverage, and effective treatment were also estimated.

Results

HTN's crude prevalence was estimated to be in the range of 11.5-42.2% in districts. About PHTN, it was estimated to be 19.9-56.1%. Moreover, for awareness, treatment coverage, and effective treatment crude estimates ranged from 24.3 to 79.9%, 9.1 - 64.6%, and 19.5 - 68.3%, respectively, indicating inequalities in the distribution of aforementioned variables in 429 districts of Iran. Overall, better conditions were detected in central geographical locations and in females.

Conclusion

The inequality of increased blood pressure disorder and related measures are high in districts of Iran and pave the way for policymakers and local health organizers to use the findings of this study to address the inequity of existing resources and improve HTN control.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01186-5.

The national trend of the burden of Chronic Kidney Disease (CKD) in Iran from 1990 to 2019

Purpose

Chronic Kidney Disease (CKD) has become the 8th leading cause of death in Iran in 2017, 5 steps up from 1990. This is important as hypertension, diabetes, and chronic glomerulonephritis along with exposure to toxins or heavy metals are the main risk factors for the disease. Despite its heavy burden, there are limited studies on the incidence and prevalence of the disease in the Iranian adult population. The present article studies the burden of CKD at the national level in 2019, and its trend over the past three decades.

Methods

In 2019, the Global Burden of Disease (GBD) study provided an annual estimation of the burden of 369 diseases and injuries in 204 countries from 1990 until 2019. The data estimating CKD and related mortality in Iran were collected from the disease registry, survey, and scientific literature. All-ages and age-standardised indices of incidence, prevalence, deaths, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) were extracted for both sexes.

Results

Since 1990, the age-standardized incidence (34.7% (95% uncertainty interval 30.8 - 38.8)) and prevalence (19.6% (17.7 - 21.8)) of CKD have risen, while a 21.5% (-28.8 - -15.4) and 18.0% (-35.4 - -10.8) decrease were noted in age-standardized DALYs and deaths rates, respectively. The lowest prevalence was reported in the eastern and western provinces.

Conclusion

Current study provides comprehensive knowledge about the CKD burden, suggesting the Iranian healthcare system has been more effective in averting deaths rather than managing morbidities. Multi-sectoral action plans are needed to strengthen preventive and early detection programs in high-risk areas.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01298-y.

"Current incidence of injuries in Iran; findings of STEPS survey 2021"

Background

The updated epidemiology of injuries at the national and sub-national levels are required for policymakers to effectively handle the burden of injuries. This paper aimed to assess the incidence and risk factors of different injuries in Iran based on a recent national survey.

Methods

We used data from Iran Stepwise approach to surveillance (STEPS) Survey 2021, a population-based study in urban and rural areas of Iran's 31 provinces. A multistage clustered probability design and weighting adjustments were used to select eligible individuals and generate estimations. We estimated the incidence of injuries, assessed sociodemographic variables, and identified potential behavioral risk factors associated with injuries, and results were reported for sociodemographic and geographic stratifications.

Result

Data from 27,874 participants of the STEPS survey were assessed, of which 1538 (5.5 %, 95 % CI: [5.2-5.8]) reported having an injury in the past 12 months. Falls (44.4 %) were the most common cause of injury, followed by road traffic injury (21.7 %) and exposure to mechanical forces (16.5 %). Except for falls and burns, males had a higher proportion of all types of injuries. Logistic regression analysis showed that being male (OR: 1.7, [1.5, 2.0]) and being an occasional or heavy alcohol drinker (OR: 2.0, [1.3, 3.0] and OR: 2.7, [1.7, 4.1] respectively) were significant risk factors associated with road traffic injuries. Seatbelt use was 90.0 % among both drivers and front-seat passengers, while the use of safety car seats for children was as low as 9.4 %. Injury incidence varied significantly among provinces, with the highest incidence among males observed in Razavi Khorasan (11.2 %) and among females observed in Tehran (12.0 %).

Conclusion

This study investigated the updated epidemiology of injuries in Iran and revealed socioeconomic and geographic disparities across country. This epidemiological information can be used to modify injury prevention programs.

Prevalence of plasma lipid abnormalities and associated risk factors among Iranian adults based on the findings from STEPs survey 2021

The study aimed to estimate the prevalence of lipid abnormalities in Iranian adults by demographic characterization, geographical distribution, and associated risk factors using national and sub-national representative samples of the STEPs 2021 survey in Iran. In this population-based household survey, a total of 18,119 individuals aged over 25 years provided blood samples for biochemical analysis. Dyslipidemia was defined by the presence of at least one of the lipid abnormalities of hypertriglyceridemia (≥ 150 mg/dL), hypercholesterolemia (≥ 200 mg/dL), high LDL-C (≥ 130 mg/dL), and low HDL-C (< 50 mg/dL in women, < 40 mg/dL in men), or self-reported use of lipid-lowering medications. Mixed dyslipidemia was characterized as the coexistence of high LDL-C with at least one of the hypertriglyceridemia and low HDL-C. The prevalence of each lipid abnormality was determined by each population strata, and the determinants of abnormal lipid levels were identified using a multiple logistic regression model. The prevalence was 39.7% for hypertriglyceridemia, 21.2% for hypercholesterolemia, 16.4% for high LDL-C, 68.4% for low HDL-C, and 81.0% for dyslipidemia. Hypercholesterolemia and low HDL-C were more prevalent in women, and hypertriglyceridemia was more prevalent in men. The prevalence of dyslipidemia was higher in women (OR = 1.8), obese (OR = 2.8) and overweight (OR = 2.3) persons, those residents in urban areas (OR = 1.1), those with inappropriate physical activity (OR = 1.2), patients with diabetes (OR = 2.7) and hypertension (OR = 1.9), and participants with a history (OR = 1.6) or familial history of CVDs (OR = 1.2). Mixed dyslipidemia prevalence was 13.6% in women and 11.4% in men (P < 0.05). The prevalence of lipid abnormalities was highly heterogeneous among provinces, and East Azarbaijan with 85.3% (81.5-89.1) and Golestan with 68.5% (64.8-72.2) had the highest and lowest prevalence of dyslipidemia, respectively. Although the prevalence of high cholesterol and LDL-C had a descending trend in the 2016-2021 period, the prevalence of dyslipidemia remained unchanged. There are modifiable risk factors associated with dyslipidemia that can be targeted by the primary healthcare system. To modify these risk factors and promote metabolic health in the country, action plans should come to action through a multi-sectoral and collaborative approach.

Evaluation of the diabetes care cascade and compliance with WHO global coverage targets in Iran based on STEPS survey 2021

This study aimed to investigate the diabetes mellitus (DM) and prediabetes epidemiology, care cascade, and compliance with global coverage targets. We recruited the results of the nationally representative Iran STEPS Survey 2021. Diabetes and prediabetes were two main outcomes. Diabetes awareness, treatment coverage, and glycemic control were calculated for all population with diabetes to investigate the care cascade. Four global coverage targets for diabetes developed by the World Health Organization were adopted to assess the DM diagnosis and control status. Among 18,119 participants, the national prevalence of DM and prediabetes were 14.2% (95% confidence interval 13.4-14.9) and 24.8% (23.9-25.7), respectively. The prevalence of DM treatment coverage was 65.0% (62.4-67.7), while the prevalence of good (HbA1C < 7%) glycemic control was 28.0% (25.0-31.0) among all individuals with diabetes. DM diagnosis and statin use statics were close to global targets (73.3% vs 80%, and 50.1% vs 60%); however, good glycemic control and strict blood pressure control statistics, were much way behind the goals (36.7% vs 80%, and 28.5% vs 80%). A major proportion of the Iranian population are affected by DM and prediabetes, and glycemic control is poorly achieved, indicating a sub-optimal care for diabetes and comorbidities like hypertension.

An Efficient Capsule-based Network for 2D Left Ventricle Segmentation in Echocardiography Images

The segmentation of cardiac chambers is essential for the clinical diagnosis and treatment of cardiovascular diseases. It is demonstrated that in cardiac disease, the left ventricle (LV) is extensively involved. Therefore, segmentation of the LV in echocardiographic images is critical for the precise evaluation of factors that influence cardiac function such as LV volume, ejection fraction, and LV mass. Although these measurements could be obtained by manual segmentation of the LV, it would be time-consuming and inaccurate because of the poor quality and low contrast of these images. Convolutional neural networks, commonly referred to as CNNs, have emerged as a highly favored deep learning technique for medical image segmentation. Despite their popularity, the pooling layers in CNNs ignore the spatial information and do not consider the part-whole hierarchy relationships. Furthermore, they require a large training dataset and a large number of parameters. Therefore, Capsule Networks are proposed to address the CNNs limitations. In this study, for the first time, an optimized capsule-based network for object segmentation called SegCaps is proposed to achieve accurate LV segmentation on echocardiography images applied to the CAMUS dataset. The result was compared against the standard 2D-UNet. The modified SegCaps and 2D-UNet achieved an average Dice similarity coefficient (DSC) of 84.48% and 83.28% on LV segmentation, respectively. The capabilities of the CapsNet led to an improvement of 1.44% in DSC with 92.77% fewer parameters than the U-Net. The results indicate that the proposed method leads to accurate and efficient LV segmentation.Clinical Relevance- From a clinical point of view, our findings lead to more precise evaluations of critical cardiac parameters, including ejection fraction as well as left ventricle volume at end-diastole and end-systole.

Psoriatic arthritis, axial spondyloarthritis and rheumatoid arthritis in Norway: nationwide prevalence and use of biologic agents

OBJECTIVE

To estimate the prevalence of psoriatic arthritis (PsA), axial spondyloarthritis (axSpA) and rheumatoid arthritis (RA) and the use of biologic agents in these diseases in Norway.

METHODS

From the Norwegian Patient Registry (NPR), we identified as PsA, axSpA and RA patients ≥18 years those with ≥2 recorded episodes with diagnostic coding for index disease (L40.5, M07.0-M07.3 for PsA; M45, M46.0, M46.1, M46.8 and M46.9 for axSpA; M05-M06 for RA). We calculated the point prevalence of PsA, axSpA and RA as per the 1^st of January 2017 in the Norwegian adult population (age ≥18). Dispensed disease-modifying antirheumatic drug (DMARD) prescriptions were obtained from the Norwegian Prescription Database and biologic DMARDs given in hospitals from the NPR.

RESULTS

The point prevalence of PsA, axSpA, RA, and any of these diseases in total was 0.46%, 0.41%, 0.78%, and 1.56%, respectively. Among women, the prevalence of PsA, axSpA, and RA was 0.50%, 0.37%, and 1.10%, and among men 0.43%, 0.45%, and 0.46%, respectively. In 2017, 27.3% of RA patients, 25.7% of PsA patients and 35.1% of axSpA patients used biologic DMARDs. Treatment with biologics was more frequent in younger age groups in all three diseases, and became more infrequent especially after age ≥55 years.

CONCLUSION

In Norway, the combined prevalence of PsA, axSpA, and RA was over 1.5%. Reflecting the good overall access to highly effective but costly biologic treatments, more than a fourth of these patients used biologic agents, which corresponds to over 0.4% of Norwegian adult population.

Is elevated ALT associated with lifestyle risk factors? A population-based survey

Purpose

Given the high prevalence of non-alcoholic fatty liver disease (NAFLD) and the role of Alanine aminotransferase (ALT) in diagnosing liver injury along with the increasing prevalence of lifestyle risk factors, we aimed to evaluate the association between serum ALT level and lifestyle risk factors in a population-based survey.

Methods

This was a population-based study conducted in rural and urban areas of Iran in 2016. Cluster sampling method was applied to enroll a total of 31,050 participants aged ≥ 18. Demographic data, anthropometric measures, and laboratory samples were gathered. Multivariate logistic regression analyses were performed using three different cut-off levels for elevated ALT to assess the relationship between elevated ALT and lifestyle risk factors.

Results

The prevalence of elevated ALT was significantly higher in men with elevated body mass index (BMI), waist-to-hip ratio (WTH), hip circumference, and salt consumption, likewise, in women with higher BMI and WTH. In the multivariate logistic model adjusted for age and sex, high WTH (adjusted odds ratio: 1.73; 95% CI 1.52-1.96), BMI > 25 (1.51; 95% CI 1.29-1.76), hip circumference (1.26; 95% CI 1-1.58), and current smoking (0.67; 95% CI 0.56-0.8) were associated with elevated ALT levels using American cut-off (ALT > 33U/L for male and ALT > 25U/L for female). Only physical measurements (BMI, WTH) but not lifestyle risk factors were related to the increased ALT regardless of the selected cut-offs.

Conclusion

As elevated ALT was associated with several lifestyle risk factors, stewardship programs should be established to modify lifestyle risk factors, such as abdominal obesity and physical inactivity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01137-6.

A year of experience with COVID-19 in patients with cancer: A nationwide study

BACKGROUND

Cancer is a major public health problem and comorbidity associated with COVID-19 infection. According to previous studies, a higher mortality rate of COVID-19 in cancer patients has been reported.

AIMS

This study was undertaken to determine associated risk factors and epidemiological characteristics of hospitalized COVID-19 patients with cancer using a nationwide COVID-19 hospital data registry in Iran for the first time.

METHODS

In this retrospective study, we used a national data registry of hospitalized patients with Severe Acute Respiratory Syndrome (SARS) symptoms and patients with confirmed positive COVID-19 PCR between 18 February 2020 and 18 November 2020. The patients were classified into two groups patients with/without malignancy. Logistic regression model was utilized to analyze demographic factors, clinical features, comorbidities, and their associations with the disease outcomes.

RESULTS

In this study, 11 068 and 645 186 in-patients with SARS symptoms with and without malignancy were included, respectively. About 1.11% of our RT-PCR-positive patients had cancer. In patients with malignancy and COVID-19, older ages than 60 (OR: 1.88, 95% CI: 1.29-2.74, p-value: .001), male gender (OR: 1.43, 95% CI: 1.16-1.77, p-value: .001), concomitant chronic pulmonary diseases (CPD) (OR: 1.75, 95% CI: 1.14-2.68, p-value: .009), and presence of dyspnea (OR; 2.00, 95% CI: 1.60-2.48, p-value: <.001) were associated with increased mortality rate.

CONCLUSION

Given the immunocompromised state of patients with malignancy and their vulnerability to Covid-19 complications, collecting data on the comorbidities and their effects on the disease outcome can build on a better clinical view and help clinicians make decisions to manage these cases better; for example, determining special clinical care, especially in the shortage of health services.

Estimating the burden of diseases attributable to lead exposure in the North Africa and Middle East region, 1990-2019: a systematic analysis for the Global Burden of Disease study 2019

BACKGROUND

Lead exposure (LE) and its attributable deaths and disability-adjusted life years (DALYs) have declined in the recent decade; however, it remains one of the leading public health concerns, particularly in regions with low socio-demographic index (SDI) such as the North Africa and Middle East (NAME) region. Hence, we aimed to describe the attributable burden of the LE in this region.

METHODS

Data on deaths, DALYs, years of life lost (YLLs), and years lived with disability (YLDs) attributable to LE in the NAME region and its 21 countries from 1990 to 2019 were extracted from the Global Burden of Disease (GBD) 2019 study.

RESULTS

In 2019, the age-standardized death and DALY rates attributable to LE were 23.4 (95% uncertainty interval: 15.1 to 33.3) and 489.3 (320.5 to 669.6) per 100,000 in the region, respectively, both of which were higher among men than women. The overall age-standardized death and DALY rates showed 27.7% and 36.8% decreases, respectively, between 1990 and 2019. In this period, Bahrain, the United Arab Emirates, and Turkey had the highest decreases in the age-standardized death and DALY rates, while Afghanistan, Egypt, and Yemen had the lowest ones. Countries within high SDI quintile had lower attributable burden to LE compared with the low SDI quintile. Cardiovascular diseases and chronic kidney diseases accounted for the 414.2 (258.6 to 580.6) and 28.7 (17.7 to 41.7) LE attributable DALYs per 100,000 in 2019, respectively. The attributable YLDs was 46.4 (20.7 to 82.1) per 100,000 in 2019, which shows a 25.7% reduction (-30.8 to -22.5%) over 1990-2019.

CONCLUSIONS

The overall LE and its attributed burden by cause have decreased in the region from 1990-2019. Nevertheless, the application of cost-effective and long-term programs for decreasing LE and its consequences in NAME is needed.

A global, regional, and national survey on burden and Quality of Care Index (QCI) of bladder cancer: The global burden of disease study 1990-2019

INTRODUCTION

Bladder cancer (BCa) is the second most common genitourinary cancer and among the leading causes of cancer-related deaths. We aimed to assess BCa quality of care (QOC) utilizing a novel multi-variable quality of care index (QCI).

MATERIALS AND METHODS

Data were retrieved from the Global Burden of Disease 1990-2019 database. QCI scores were calculated using four indices of prevalence-to-incidence ratio, Disability-Adjusted Life Years-to-prevalence ratio, mortality-to-incidence ratio, and Years of Life Lost-to-Years Lived with Disability ratio. We used principal component analysis to allocate 0-100 QCI scores based on region, age groups, year, and gender.

RESULTS

Global burden of BCa is on the rise with 524,305 (95% UI 475,952-569,434) new BCa cases and 228,735 (95% UI 210743-243193) deaths in 2019, but age-standardized incidence and mortality rates did not increase. Global age-standardized QCI improved from 75.7% in 1990 to 80.9% in 2019. The European and African regions had the highest and lowest age-standardized QCI of 89.7% and 37.6%, respectively. Higher Socio-demographic index (SDI) quintiles had better QCI scores, ranging from 90.1% in high SDI to 30.2% in low SDI countries in 2019; however, 5-year QCI improvements from 2014 to 2019 were 0.0 for high and 4.7 for low SDI countries.

CONCLUSION

The global QCI increased in the last 30 years, but the gender disparities remained relatively unchanged despite substantial improvements in several regions. Higher SDI quintiles had superior QOC and less gender- and age-based inequalities compared to lower SDI countries. We encourage countries to implement the learned lessons and improve their QOC shortcomings.

Protocol Design for Surveillance of Risk Factors of Non-communicable Diseases During the COVID-19 Pandemic: An Experience from Iran STEPS Survey 2021

BACKGROUND

Regarding the growing burden of non-communicable diseases (NCDs) and exposure to their risk factors, and the continuous need for nationwide data, we aimed to develop the latest round of the STEPwise Approach to NCD Risk Factor Surveillance (STEPS) survey in 2021 in Iran, while the COVID-19 pandemic was still present.

METHODS

In addition to the three main steps of this survey, including questionnaires, physical measurements, and laboratory assessments, we adapted the survey with the situation caused by the COVID-19 pandemic, by adding to various aspects of study phases and changing some scientific and executive procedures in this round of STEPS survey in Iran. These changes were beyond the initial novelties embedded within the survey before the pandemic, by refining the study protocol benefiting from the previous experiences of the STEPS survey.

RESULTS

By amending the required changes, we could include a total of 27874 individuals in the first step of the survey. This number was 27745 and 18119 for the second and third steps. Comparing the preliminary results with the previous nationwide surveys, this study was highly representative on both national and provincial levels. Also, implementing the COVID-19 prevention and control strategies in all stages of survey led to the least infection transmission between the study investigators and participants.

CONCLUSION

The novel initiatives and developed strategies in this round of Iran STEPS survey provide a state-of-the-art protocol for national surveys in the presence of an overwhelming catastrophe like the COVID-19 pandemic and the triggered limitations and shortages of resources.

Metabolic signatures of insulin resistance in non-diabetic individuals

BACKGROUND

Insulin resistance (IR) evolved from excessive energy intake and poor energy expenditure, affecting the patient's quality of life. Amino acid and acylcarnitine metabolomic profiles have identified consistent patterns associated with metabolic disease and insulin sensitivity. Here, we have measured a wide array of metabolites (30 acylcarnitines and 20 amino acids) with the MS/MS and investigated the association of metabolic profile with insulin resistance.

METHODS

The study population (n = 403) was randomly chosen from non-diabetic participants of the Surveillance of Risk Factors of NCDs in Iran Study (STEPS 2016). STEPS 2016 is a population-based cross-sectional study conducted periodically on adults aged 18-75 years in 30 provinces of Iran. Participants were divided into two groups according to the optimal cut-off point determined by the Youden index of HOMA-IR for the diagnosis of metabolic syndrome. Associations were investigated using regression models adjusted for age, sex, and body mass index (BMI).

RESULTS

People with high IR were significantly younger, and had higher education level, BMI, waist circumference, FPG, HbA1c, ALT, triglyceride, cholesterol, non-HDL cholesterol, uric acid, and a lower HDL-C level. We observed a strong positive association of serum BCAA (valine and leucine), AAA (tyrosine, tryptophan, and phenylalanine), alanine, and C0 (free carnitine) with IR (HOMA-IR); while C18:1 (oleoyl L-carnitine) was inversely correlated with IR.

CONCLUSIONS

In the present study, we identified specific metabolites linked to HOMA-IR that improved IR prediction. In summary, our study adds more evidence that a particular metabolomic profile perturbation is associated with metabolic disease and reemphasizes the significance of understanding the biochemistry and physiology which lead to these associations.

Trends in Global, Regional, and National Burden and Quality of Care Index for Liver Cancer by Cause from Global Burden of Disease 1990-2019

Despite the tremendous burden of liver cancer and its underlying causes on humankind, there appear to be heterogeneities in coping approaches. The objective of this study was to compare the burden and the quality-of-care of liver cancer by causes among different countries and regions in both sexes and various age groups 1990-2019. Data of liver cancer and underlying causes, including hepatitis B virus (HBV), hepatitis C virus (HCV), alcohol use, nonalcoholic steatohepatitis (NASH), and other causes were obtained from the Global Burden of Diseases 2019. Incidence, prevalence, death, and disability-adjusted life-years (DALYs) were assessed. Principal component analysis was used to combine age-standardized mortality-to-incidence ratio, DALY-to-prevalence ratio, prevalence-to-incidence ratio, and years of life lost-to-years lived with disability into a single proxy named Quality of Care Index (QCI). Globally, the age-standardized incidence, DALYs, and death rates decreased from 1990 to 2019, while the QCI scores increased by 68.5%. The QCI score of liver cancer was from as high as 83.3 in high Sociodemographic Index (SDI) countries to values as low as 26.4 in low SDI countries in 2019. Japan had the highest QCI score (QCI = 100). The age-standardized death rates of liver cancer due to all underlying causes were decreasing during the past 30 years, with the most decrease for HBV. Consistently, the global QCI scores of liver cancer due to HBV, HCV, alcohol use, NASH, and other causes reached 53.5, 61.8, 54.3, 52.9, and 63.7, respectively, in 2019. Conclusion: Although the trends in burden are decreasing and the QCI improved from 1990 to 2019 globally, there is a wide gap between countries. Given the inequities in health care quality, there is an urgent need to address discrimination and bridge the gap.

POS0516 PLASMA CALPROTECTIN WAS ASSESSED IN MULTIPLE BIOLOGICAL TREATMENT STRATEGIES FOR EARLY RHEUMATOID ARTHRITIS

Background

Plasma calprotectin is a sensitive inflammatory marker in patients with rheumatoid arthritis (RA) and reflects activation of granulocytes and macrophages. Plasma calprotectin has not previously been studied in a head-to-head trial of multiple biological mechanisms of action versus active conventional therapy (ACT) with methotrexate and prednisolone.

Objectives

To assess the effect of treatment on plasma calprotectin levels in patients with early RA by determining the 24-week change in the four arms of the NORD-STAR Study, a large multicenter randomized head-to-head clinical trial of ACT versus tumor necrosis factor inhibition, T-cell co-stimulation inhibition, and interleukin-6 inhibition (1).

Methods

Calprotectin was analyzed in plasma samples at baseline, week 4 and week 24 from 400 treatment naïve patients with early RA in the NORD-STAR Study. Samples were analyzed using a calprotectin ELISA alkaline phosphatase (ALP) kit from CalproLab (Oslo, Norway) in a Dynex DS2 processing system (normal levels <910 µg/L). Patients were assessed by clinical (CRP, 28 SJC/TJC, physician global) and patients’ reported assessments. Crude and adjusted linear regression analyses were performed in R 4.0.3 with calprotectin levels at week 24 as the outcome. The four arms were represented by three dummy variables. The adjustment variables were age, sex, anti-CCP status and country. Both analyses were adjusted for baseline calprotectin levels.

Results

At baseline, the mean time since diagnosis was 15.7 days (SD) (22.9), mean age 53.7 (15.0) years, ACPA positive 81%, and female 66%. Mean calprotectin levels were 1931 (1495) µg/L at baseline, 866 (951) µg/L at week 4, and 629 (661) µg/L at week 24. At baseline, normal calprotectin levels (<910 µg/L) were observed in 27% of all patients (ACT 22%, certolizumab-pegol and methotrexate 30%, abatacept and methotrexate 25%, tocilizumab and methotrexate 31%). At week 24, normal calprotectin levels were observed in 82% of all patients (ACT 68%, certolizumab-pegol and methotrexate 91%, abatacept and methotrexate 80%, tocilizumab and methotrexate 90%).

Observed calprotectin levels at week 24 were significantly lower in patients treated with certolizumab-pegol and methotrexate -336µg/L (97) (p< 0.006) or tocilizumab and methotrexate -284 (99) (p < 0.004), versus ACT when adjusted for age, sex, anti-CCP status, baseline calprotectin level, and country; however, a significant difference was not observed in patients treated with abatacept and methotrexate -110 (96) (p = 0.25). The Figure 1 shows the average percentage change in calprotectin levels from baseline to week 24 for all treatment groups.

Figure 1.

Average percentage change in calprotectin levels from baseline to week 24. ACT: active conventional therapy, CZP+MTX: certolizumab-pegol and methotrexate, ABA+MTX: abatacept and methotrexate, TCZ+MTX: tocilizumab and methotrexate.

Conclusion

Calprotectin, a sensitive biomarker of inflammation, normalized in the majority of patients. The decline differed between treatment groups and was largest in patients treated with a TNF inhibitor and methotrexate, suggesting that calprotectin reflects the activity of specific inflammatory pathways rather than overall inflammation. The findings of this study should be further explored.

References

[1]Hetland ML, et. al., Active conventional treatment and three different biological treatments in early rheumatoid arthritis: phase IV investigator initiated, randomised, observer blinded clinical trial. BMJ. 2020 Dec 2;371:m4328. doi: 10.1136/bmj.m4328. PMID: 33268527; PMCID: PMC7708829.

Acknowledgements

I would like to acknowledge the NORD-STAR Study group.

Disclosure of Interests

David Stevens: None declared, Marte Heiberg: None declared, Amirhossein Kazemi: None declared, Ronald van Vollenhoven: None declared, Jon Lampa: None declared, Anna Rudin: None declared, Kristina Lend: None declared, Merete Lund Hetland: None declared, Mikkel Østergaard: None declared, Michael Nurmohamed: None declared, Kim Hørslev-Petersen: None declared, Dan Nordström Consultant of: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Björn Gudbjornsson: None declared, Till Uhlig: None declared, Espen A Haavardsholm: None declared, Hilde Berner Hammer Speakers bureau: AbbVie, Novartis, and Lilly.

Assessing the effect of socioeconomic factors on prevalence of dyslipidemia among iranian adult population; district level analysis from 2016 STEPS national study using small area estimation

Background

Atherosclerotic Cardiovascular Disease (CVD) is the leading cause of death globally and dyslipidemia plays a critical role in the development of this condition. This study aimed to analyze the potential impact of socioeconomic factors on the prevalence of dyslipidemia at district level in Iran. Understanding these factors is important for development of future risk factor control programs.

Methods

We used the nationwide Iran STEPwise approach to risk factor Surveillance (STEPS) 2016 survey as a representative dataset on the Non-Communicable Diseases (NCDs) risk factors in Iran. To obtain a district level dyslipidemia estimates, we utilized the small area estimation method with a Bayesian spatial hierarchical multilevel regression and multilevel mixed models. The principal component analysis was applied to derive household wealth index. For evaluation of education, successful years of schooling was calculated at district level. Urbanization ratio was defined as the proportion of residents in the urban area to the urban and rural areas for each district.

Results

The highest difference was found for hypercholesterolemia coverage with 9.11 times difference among the lowest and highest prevalence across the country's district for males. Men with lower income, lower urbanization, and lower education levels had lower values of high-density lipoprotein (HDL) cholesterol, and higher level of hypercholesterolemia, and hypertriglyceridemia (P-value < 0.001). Triglyceride levels were directly correlated with all analyzed socioeconomic factors in both females and males (P-value < 0.001).

Conclusion

We demonstrated that there is an inverse relationship between socioeconomic levels and dyslipidemia indices as populations with higher socioeconomic levels consistently had higher mean dyslipidemia levels. Our findings provide an excellent fundamental framework for healthcare administrators and policymakers to set goals and pursue effective preventive strategies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01027-x.

The global, regional, and national burden and quality of care index (QCI) of colorectal cancer; a global burden of disease systematic analysis 1990-2019

Background

Colorectal cancer (CRC) is among the five most incident and lethal cancers in world and its burden varies between countries and sexes. We aimed to present a comprehensive measure called the quality of care index (QCI) to evaluate the inequity and healthcare quality of care regarding CRC by sex and location.

Methods

Data on the burden of CRC were extracted from the Global Burden of Disease study 2019. It was transformed to four ratios, including mortality-to-incidence, disability-adjusted life years (DALYs)-to-prevalence, prevalence-to-incidence, and years of life lost (YLLs)-to-years lived with disability (YLDs). Principal component analysis was implemented on the four ratios and the most influential component was considered as QCI with a score ranging from zero to 100, for which higher scores represented better quality of care. Gender Disparity Ratio (GDR) was calculated by dividing QCI for females by males.

Results

The global incidence and death numbers of CRC were 2,166,168 (95% uncertainty interval: 1,996,298–2,342,842) and 1,085,797 (1,002,795–1,149,679) in 2019, respectively. Globally, QCI and GDR values were 77.6 and 1.0 respectively in 2019. There was a positive association between the level of quality of care and socio-demographic index (SDI) quintiles. Region of the Americas and African Region had the highest and lowest QCI values, respectively (84.4 vs. 23.6). The QCI values started decreasing beyond the age of 75 in 2019 worldwide.

Conclusion

There is heterogeneity in QCI between SDI quintiles. More attention should be paid to people aged more than 75 years old because of the lower quality of care in this group.

Red flags of poor prognosis in pediatric cases of COVID-19: the first 6610 hospitalized children in Iran

INTRODUCTION

COVID-19 clinical course, effective therapeutic regimen, and poor prognosis risk factors in pediatric cases are still under investigation and no approved vaccinehas been introduced for them.

METHODS

This cross-sectional study evaluated different aspect of COVID-19 infection in hospitalized COVID-19 positive children (≺18 years oldwith laboratory confirmed COVID-19 infection, using the national COVID-19 registry for all admitted COVID-19 positive cases from February 19 until November 13,2020, in Iran.

RESULTS

We evaluated 6610 hospitalized children. Fifty-four percent (3268) were male and one third of them were infants younger than 1 year. Mortality rate in total hospitalized children was 5.3% and in children with underlying co-morbidities (14.4%) was significantly higher (OR: 3.6 [2.7-4.7]). Chronic kidney disease (OR: 3.42 [1.75-6.67]), Cardiovascular diseases (OR: 3.2 [2.09-5.11]), chronic pulmonary diseases (OR: 3.21 [1.59-6.47]), and diabetes mellitus (OR: 2.5 [1.38-4.55]), resulted in higher mortality rates in hospitalized COVID-19 children. Fever (41%), cough (36%), and dyspnea (27%) were the most frequent symptoms in hospitalized children and dyspnea was associated with near three times higher mortality rate among children with COVID-19 infection (OR: 2.65 [2.13-3.29]).

CONCLUSION

Iran has relatively high COVID-19 mortality in hospitalized children. Pediatricians should consider children presenting with dyspnea, infants≺ 1 year and children with underlying co-morbidities, as high-risk groups for hospitalization, ICU admission, and death.

Opium tincture for opioid substitution treatment

Introduction

Opium tincture (OT) is widely used for opioid substitution treatment (OST) in Iran.

Objectives

To determine if OT is a safe and effective medication for OST.

Methods

Opium Trial was a multicenter, double‐blind, noninferiority randomized controlled trial, with 204 participants with opioid dependence in Iran. Participants were then randomized to OT or methadone arms with an allocation ratio of 1:1 and were followed for 12 weeks. The primary outcome was retention in treatment, compared between the two groups using both intention-To-Treat (ITT) and Per-Protocol (PP) analyses.

Results

A total of 70 participants (IT: 68.6%, PP: 69.3%) in methadone arm and 61 participants (ITT: 59.8%, PP: 60.4%) in OT arm remained in the treatment. The relative retention rate was 1.15 (0.97, 1.36) in both analyses in favour of methadone. A total of 46 out of 152 (30.3%) participants in OT arm and 83 out of 168 (49.4%) participants in methadone arm reported opioid use outside the treatment. The difference in these two proportions (OT - methadone) was 19%: (10%, 28%) in favour of OT. The proportion of patients with adverse events were not different between the two arms (P = 0.06). There was no serious AE in OT arm.

Conclusions

Opium tincture is a clinically effective and safe medication, but this study could not conclude if it was as equally effective as methadone in retaining participants in treatment, but it showed that OT was superior to methadone in reducing opioid use outside the treatment.

Disclosure

No significant relationships.

Distribution of Dietary Risk Factors in Iran: National and Sub-National Burden of Disease

BACKGROUND

Non-communicable diseases (NCDs) are one of the greatest threats to public health, and have been related to poor quality dietary patterns. This study was conducted to determine the distribution of dietary risk factors in Iran.

METHODS

Cross-sectional data was gathered between April and November 2016 from 30,541 eligible adults (out of 31 050 individuals who were selected through systematic proportional to size cluster random sampling) living in urban and rural areas, using the WHO-based STEPs risk factor questionnaire. Low intakes of fruits, vegetables, dairy products, and fish, and high intakes of salty processed food (SPF), as well as daily intake of hydrogenated fat (HF) were considered as nutritional risk factors.

RESULTS

At the national level, 82.8% (95% CI: 82.4-83.2), 57.8% (95% CI: 57.2-58.4), 80.6% (95% CI: 80.1-81) and 90.3% (95% CI: 90-90.6) of participants of all age groups had sub-optimal intakes of fruits, vegetables, dairy products and fish, respectively. Furthermore, 12.8% (95% CI: 12.4-13.1), and 29.4% (95% CI: 28.9-29.9) of respondents had high SPF intakes and HF use, respectively. At the sub-national level, the highest distribution of suboptimal intake of fruits (97.2%; 95% CI:96-98.3), vegetables (79.2%; 95% CI: 76.3-82.1) and dairy products (92.9%; 95% CI: 91-94.7) was observed in Sistan and Baluchistan. Except for Boushehr and Hormozgan, the majority of the population of other provinces consumed fish less than twice a week. Similarly, the high intake of SPF was found mostly in the population of Yazd (23.7; 95% CI: 20.2-27.2). HF consumption was the highest in North Khorasan (64.2%; 95% CI: 60.3-68.1).

CONCLUSION

These findings highlight the widespread distribution of dietary risk factors in Iran, which should be a priority for the people and the politicians in order to prevent NCDs.

Effect of probiotic and prebiotic versus placebo on appetite in patients with major depressive disorder: post hoc analysis of a randomised clinical trial

BACKGROUND

Poor appetite and weight loss are common in melancholic depression. Probiotics and prebiotics have the capacity to affect host behaviour, appetite and weight change by modulating the gut microbiome. The aim of this post hoc analysis was to investigate the effect of supplementation with probiotic and prebiotic on appetite, in parallel with body mass index (BMI), weight and energy intake, in patients with major depressive disorder (MDD).

METHODS

We extracted data from a clinical trial with 81 patients. The participants were randomly assigned to receive probiotic (Lactobacillus helveticus and Bifidobacterium longum), prebiotic (galactooligosaccharide) or placebo for 8 weeks. Appetite, weight, BMI, dietary intake, serum leptin and physical activity were measured. Subjective appetite rating was evaluated every 2 weeks using visual analogue scales (VAS) to assess satiety, hunger, fullness and desire to eat. Serum leptin was measured by an enzyme-linked immunosorbent assay. Physical activity was measured using the international physical activity questionnaire. A repeated measures analysis of variance model was used to analyse VAS data and analysis of variance/analysis of covariance models for dietary intake, BMI, weight and leptin data.

RESULTS

VAS data analyses indicated no significant intervention-time interactions but did show a significant increase over time for desire to eat within the probiotic group (P = 0.025). No significant difference in either BMI or weight was seen among the groups. Energy intake and leptin were significantly increased in the probiotic group compared to the prebiotic.

CONCLUSIONS

Overall, probiotic supplementation for 8 weeks among MDD patients resulted in improvement of appetite, whereas prebiotic administration had no significant effect on appetite.

The effects of weight loss approaches on bone mineral density in adults: a systematic review and meta-analysis of randomized controlled trials

We assessed the impact of weight loss strategies including calorie restriction and exercise training on BMD in adults using a systematic review of randomized controlled trials. Weight reduction results in reduced BMD at the hip, but has less effect on the spine. Both calorie restriction and a combination of calorie restriction and exercise result in a decrease in hip bone density, whereas weight loss response to exercise training without dietary restriction leads to increased hip BMD.

INTRODUCTION

Findings are not consistent on the effect of weight loss on bone mineral density (BMD). We conducted a systematic review on the randomized controlled trials to assess the effect of weight loss strategies, including calorie restriction and exercise programs on BMD in adults.

METHODS

A structured and comprehensive search of MEDLINE and EMBASE databases was undertaken up to March 2016. Study-specific mean differences (MD) were pooled using a random-effects model. Subgroup analysis and meta-regression were used to find possible sources of between-study heterogeneity.

RESULTS

Thirty-two randomized controlled trials met predetermined inclusion criteria. The meta-analysis revealed no significant difference on total BMD (MD 0.007, 95 % CI -0.020-0.034, p = 0.608). In contrast, the pooled data of studies showed a significant effect of weight loss on hip BMD (MD -0.008, 95 % CI -0.09 to -0.006 g/cm(2), p < 0.001) and also lumbar spine BMD (MD -0.018 g/cm(2), 95 % CI -0.019 to -0.017, p < 0.001). BMD in the hip site decreased after more than 4 months, especially in those who were obese. Moreover, calorie restriction interventions longer than 13 months showed a significant decreased in lumbar spine BMD.

CONCLUSION

Weight loss led to significant decreases at the hip and lumbar spine BMD but not at the total. Weight loss response following calorie restriction resulted in a decrease in hip and lumbar spine bone density especially more than 1 year; whereas an exercise-induced weight loss did not.

Endocarditis associated with Erysipelothrix rhusiopathiae in a fat-tailed ram

Endocarditis is rarely reported in sheep and information presented for ovine endocarditis is based mostly on comparative findings in the cattle. Infective vegetative endocarditis of the right heart was diagnosed in a 3-year-old fat-tailed ram. Clinical findings included tachycardia, marked brisket edema, jugular veins distention and pulsation and pale mucous membranes. Hematologic abnormality included neutrophilic leukocytosis. Necropsy confirmed severe right atrioventricular and pulmonary valves vegetative endocarditis with evidence of right heart failure. Erysipelothrix rhusiopathiae was isolated from those vegetative lisions.

Endovascular treatment of symptomatic intracranial atheromatous stenosis: a single center study of 21 consecutive cases

OBJECTIVES

This retrospective single-center study evaluated the technical success as well as the periprocedural and long-term complications of angioplasty with stenting of symptomatic intracranial atheromatous stenosis.

PATIENTS AND METHODS

From January 2005 to December 2010, 21 patients were treated by angioplasty with stent implantation for symptomatic atheromatous intracranial stenosis greater or equal to 50% at least 7 days after a stroke.

RESULTS

The median population age was 65 years (range: 41-88 years), and 76% (16/21) of the candidates had a history of transient ischemic attack (TIA) or stroke before the event qualifying them for an endovascular procedure. In addition, 86% (18/21) were taking antithrombotic medication at the time of the qualifying event. Technical success was obtained in all cases. The periprocedural stroke or death rate was 9.5% (2/21), and there was no other stroke or death after 30 days during the mean follow-up of 1.4 years.

CONCLUSION

Endovascular treatment of symptomatic intracranial atherothrombotic stenosis can lead to severe complications, particularly during the periprocedural period, but it also represents the only alternative treatment for patients who fail with medical therapy. Future studies need to focus on improvement of periprocedural complications. Essentially, this should include more rigorous selection of candidates as well as a better understanding of the pathophysiological mechanism(s) of the ischemic phenomenon related to stenosis.

Isolation and characterization of some moderately halophilic bacteria with lipase activity

Lipases are an important class of enzymes which catalyze the hydrolysis of long chain triglycerides and constitute the most prominent group ofbiocatalysts for biotechnological applications. There are a number of lipases, produced by some halophilic microorganisms. In this study, some lipase producing bacteria from Maharlu salt lake located in south of Iran were isolated. All isolates were screened for true lipase activity on plates containing olive oil. The lipase activity was measured using titrimetric methods. Among thirty three isolates, thirteen strains demonstrating orange zone around colonies under UV light, were selected for identification using the molecular methods and some morphological characteristics. The bacterium Bacillus vallismortis BCCS 007 with 3.41 +/- 0.14 U/mL lipase activity was selected as the highest lipase producing isolate. This is the first report of isolation and molecular identification of lipase producing bacteria from Maharlu lake.

Classification of Iranian patients with Glanzmann's Thrombasthenia using a flow cytometric method

Glanzmann's Thrombasthenia (GT) is a rare inherited autosomal recessive platelet disorder caused by a deficiency or dysfunction of the GPIIb-IIIa receptor on platelets, which is characterized by a lack of platelet aggregation in response to multiple physiologic agonists and a life-long bleeding disorder. Flow cytometry is a rapid and highly sensitive method that can detect reduced levels of receptors, as well as absolute deficiency. The aim of this study was to classify Iranian GT patients by a flow cytometric method, and to correlate these findings with the severity of clinical bleeding. The expression of GPIIb-IIIa on the platelet surface was assessed in 123 GT patients using quantitative flow cytometry to determine the most common subtype among these patients. We used a panel of antibodies to detect the expression of glycoproteins GPIb, GPIIb, GPIIIa, as well as Integrin αv. Patients were also interviewed with regard to the severity and frequency of bleeding, according to history and gender, in order to evaluate the nature of their bleeding phenotype, and classify them as mild, moderate or severe bleeders, in accordance with the Glanzmann's Thrombasthenia Italian Team (GLATIT) protocol. In the detailed analysis of the results of our investigation, 95 out of 123 (77.5%) were classified as type I; 20 (16%) as type II with residual GPIIb-IIIa, and eight (6.5%) as GT variants. The variant type was diagnosed by the inability of GPIIb-IIIa to bind fibrinogen, as evidenced by the absence of platelet aggregation in response to physiologic agonists. There was no significant correlation between bleeding severity and different subtypes of GT. This study demonstrates that GT type I is the most common subtype among Iranian patients. There was no correlation between severity of symptoms and cytometric phenotype of the disease. The identification of families at risk may significantly decrease the incidence of the severe form of the disorder if genetic counseling is provided.

Effect of Fe2+ and Fe3+ ions on human plasma cholinesterase activity

OBJECTIVES

Metals such as iron are needed for physiological functions of the body. However, their excess may cause serious damage including poisoning. The effects of Fe2+ and Fe3+ ions on human plasma cholinesterase activity were investigated.

MATERIAL AND METHODS

Plasma were obtained (n = 24) from healthy male volunteers, and treated with five various concentrations of Fe2+ and Fe3+ ions. Activity of butyryl cholinesterase (BChE) was assayed according to colorimetric EIIman procedure. The activity was calculated as micromole of hydrolyzed substrate, per minute in each ml.

RESULTS

Both ferric (Fe3+) and ferrous (Fe2+) ions significantly decreased the BChE activity in all tested concentrations. The effect of ferric (Fe3+) ions on the reduction of plasma enzyme activity was more pronounced than ferrous (Fe2+) ions (p < 0.001, respect to control group).

CONCLUSIONS

The present paper represents the effect of Fe2+ and Fe3+ ions on ButyrylChE activity in human plasma. It reveals that both ions suppress BChE activity.

pH of pus collected from periapical abscesses

AIM

To determine the pH of pus collected from periapical abscesses.

METHODOLOGY

Forty patients (Male = 17/Female = 23) between the ages 17 and 37 years, each with a periapical abscess and with no relevant medical history, were recruited. All the participants had moderate-to-severe pain on percussion accompanied by localized or generalized swelling. At least 1 mL of pus was aspirated from each participant using a No 20 gauge needle. A pH meter was used to define the pH of the pus immediately following aspiration.

RESULT

The mean pH of pus from the periapical abscesses of patients was 6.68 +/- 0.324 with a range between 6.0 and 7.3. There was no statistically significant difference in pH by gender or age.

CONCLUSION

The mean pH of pus from periapical abscesses was generally acidic, but some samples (two female and three male) were neutral and some samples (four female and one male) were alkaline.

Cholesteryl ester transfer protein I405V polymorphism influences apolipoprotein A-I response to a change in dietary fatty acid composition

The aim of the present study was to investigate whether the cholesteryl ester transfer protein (CETP) I405V polymorphism modifies the response to changes in the dietary ratio of polyunsaturated to saturated fat (P:S). The population included 85 healthy subjects with the different I405V genotypes (35 II, 36 IV, and 14 VV) assigned to two consecutive 28-day experimental period. All subjects consumed a high-P:S with P:S of 1.2 for the first period and a low-P:S with a P:S of 0.3 for the next 28-day period. At the first and end of each dietary period, serum lipid, lipoprotein, and CETP concentrations were measured. At screening, lipid or lipoprotein concentrations were not significantly different among CETP I405V genotype groups. After the low-P:S diet, subjects carrying V allele had greater reduction in apoA-I and HDL cholesterol (HDL-C) than subjects with II genotype. A genotype-by-diet interaction effect was observed on apoA-I (p=0.016) concentrations. In conclusion, the CETP I405V polymorphism contributes to the unfavorable changes of apoA-I and HDL-C when a high-P:S diet was replaced with a low-P:S diet.

Serum level of anti-hepatitis B surface antigen 6-8 years after hepatitis B vaccination at birth

The duration of protection after hepatitis B vaccination in children is unknown. We determined the serum level of antibody to hepatitis B surface antigen (anti-HBsAg) in 273 randomly selected 7-9-year-old schoolchildren from Zanjan City, Islamic Republic of Iran, who had been fully vaccinated against hepatitis B starting at birth. Titres < or = 10 mlU/mL were considered unprotective. Just over half of the children (52%) had titres < or = 10 mlU/mL with no difference between the sexes, while 81 (29.7%) had no anti-HBsAg (0 mlU/mL). Three of the children had antibodies to hepatitis B core protein. More studies are needed to determine the necessity for or timing of booster doses.