The Roles of the Nurses in Family Physician Team: A Qualitative Systematic Review

Background

There are various approaches in primary health care regarding the key role of nurses. This systematic review investigates the roles of nurses, as part of the family medicine team.

Materials and Methods

All published articles related to the role of nurses in the family medicine team from January 2000 to March 2022 were the subjects of this study. The eligibility criteria included original articles published in English or Persian in the last two decades. International credible scholarly databases (PubMed, Scopus, Magiran, IranMedex, and SID) were searched using keywords and syntax. Some of the keywords included "Family Health Nurse," "Nurses in Primary Care," "Family Medicine," "Family Physician Care Program," "General Physician Program," "Role," and "Nurse." Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) technique and reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Results

Of 147 identified publications by the search strategy, eight eligible empirical studies were included. The results showed that besides providing nursing care, nurses play vital roles in communication and teamwork, assessment, securing health services relevant to communities' needs, education, empowerment, clinical practice, health promotion, prevention, reflective research practice, and counseling.

Conclusions

This study identified different roles nurses could play in providing primary health care. These findings are helpful for the replanning or reform of primary health care in countries, which aimed to expand the Family Physician Program (FPP) in their countries, including Iran.

Developing and validating a national set of standards for undergraduate medical education using the WFME framework: the experience of an accreditation system in Iran

BACKGROUND

Defining standards is the first step toward quality assurance and improvement of educational programs. This study aimed at developing and validating a set of national standards for the Undergraduate Medical Education (UME) program through an accreditation system in Iran using the World Federation for Medical Education (WFME) framework.

METHODS

The first draft of standards was prepared through consultative workshops with the participation of different UME program stakeholders. Subsequently, standards were sent to medical schools and UME directors were asked to complete a web-based survey. The content validity index at the item level (I-CVI) was computed using criteria including clarity, relevance, optimization and evaluability for each standard. Afterward, a full-day consultative workshop was held and a wide range of UME stakeholders across the country (n = 150) discussed the survey results and made corrections to standards.

RESULTS

Analysis of survey results showed that relevance criteria had the best CVI as only 15 (13%) standards demonstrated CVI < 0.78. More than two-thirds (71%) and a half (55%) of standards showed CVI < 0.78 for optimization and evaluability criteria. The final set of UME national standards was structured in 9 areas, 24 sub-areas, 82 basic and 40 quality development standards, and 84 annotations.

CONCLUSIONS

We developed and validated national standards as a framework to ensure the quality of UME training with input from UME stakeholders. We used WFME standards as a benchmark while addressing local requirements. The standards and participatory approach to developing standards may guide relevant institutions.

Molecular Method Is Essential to Identify Asymptomatic Malaria Reservoirs: A Successful Experience in the Malaria Elimination Program in Iran

Background: The accurate diagnosis of malaria cases, especially asymptotic and low-parasitemia patients, using robust molecular methods (nested-PCR) have been emphasized. The goal of this study was to detect active cases of malaria in areas with a history of local malaria transmission focusing on the use of molecular tools to ensure that the malaria elimination program has been implemented successfully. Methods: In this cross-sectional study, 816 blood samples were taken from immigrants and local residents of malaria-endemic areas in Hormozgan province, Iran. In order to identify asymptomatic malaria parasite reservoirs, the samples were examined using microscopic, RDT, and nested-PCR techniques. Results: About twelve positive asymptomatic malaria cases were identified when the molecular method (nested-PCR) was used. The positivity rates among immigrants and local residents were 2.07% and 0.93%, respectively. No positive cases were detected using microscopic and RDT methods. Conclusions: The finding of the research emphasize that in addition to microscopy and RDTs methods, sensitive molecular tools as a standard and essential strategy are needed in the diagnosis and detection of asymptomatic parasite reservoir.

Withdrawal Notice: The Performance of Interferon-gamma Release Assays and Tuberculin Skin Tests in the Diagnosis of Latent Tuberculosis Infection among Immune-mediated Inflammatory Diseases: A Meta-analysis Study

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Online assessment in two consequent semesters during COVID-19 pandemic: K-means clustering using data mining approach

BACKGROUND

Education and assessment have changed during the COVID-19 pandemic so that online courses replaced face-to-face classes to observe the social distance. The quality of online assessments conducted during the pandemic is an important subject to be addressed. In this study, the quality of online assessments held in two consecutive semesters was investigated.

MATERIALS AND METHODS

One thousand two hundred and sixty-nine multiple-choice online examinations held in the first (n = 535) and second (n = 734) semesters in Birjand University of Medical Sciences during 2020-2021 were examined. Mean, standard deviation, number of questions, skewness, kurtosis, difficulty, and discrimination index of tests were calculated. Data mining was applied using the k-means clustering approach to classify the tests.

RESULTS

The mean percentage of answers to all tests was 69.97 ± 19.16, and the number of questions was 34.48 ± 18.75. In two semesters, there was no significant difference between the difficulty of examinations (P = 0.84). However, there was a significant difference in the discrimination index, skewness, and kurtosis of tests (P < 0.001). Moreover, according to the results of the clustering analysis in the first semester, 43% of the tests were very hard, 16% hard, and 7% moderate. In the second semester, 43% were hard, 16% moderate, and 41% easy.

CONCLUSION

To evaluate the tests' quality, calculating difficulty and discrimination indices is not sufficient; many factors can affect the quality of tests. Furthermore, the experience of the first semester had changed characteristics of the second-semester examinations. To enhance the quality of online tests, establishing appropriate rules to hold the examinations and using questions with higher taxonomy are recommended.

Angiotensin-converting enzyme 1 and voltage-gated potassium channel-interacting protein 4 gene polymorphisms in COVID-19 patients from east of Iran

Background

Coronavirus disease 2019 (COVID-19), the infectious respiratory disease caused by a newly discovered pathogen (severe acute respiratory syndrome coronavirus 2), is a pandemic that places a burden on the health care system. Recently, most research on COVID-19 has emphasized its profound impact on specific regions and ethnic groups. A possible explanation for these variations in disease presentation and severity might be differences in the gene pool of populations. This study therefore attempted to clarify possible involvements of genetic factors affecting COVID-19 pathogenesis with a focus on voltage-gated potassium channel-interacting protein 4 (KCNIP4) and angiotensin-converting enzyme 1 (ACE1) gene polymorphisms.

Materials and methods

In this case-control study, the polymorphisms were genotyped using PCR in 194 COVID-19 patients and 194 healthy controls.

Results

COVID-19 susceptibility and severity appeared to be unaffected by these polymorphisms. However, this study supported the relevance of ACE1 II genotype frequency to a decreased number of deaths due to the infection. We found that COVID-19 patients with the ACE1 II genotype have a statistically significant better chance of survival (p = 0.008).

Conclusion

This study strengthens the idea that the ACE1 I/D polymorphism can be a novel prognostic factor indicating the outcome of COVID-19.

Decoding clinical biomarker space of COVID-19: Exploring matrix factorization-based feature selection methods

One of the most critical challenges in managing complex diseases like COVID-19 is to establish an intelligent triage system that can optimize the clinical decision-making at the time of a global pandemic. The clinical presentation and patients' characteristics are usually utilized to identify those patients who need more critical care. However, the clinical evidence shows an unmet need to determine more accurate and optimal clinical biomarkers to triage patients under a condition like the COVID-19 crisis. Here we have presented a machine learning approach to find a group of clinical indicators from the blood tests of a set of COVID-19 patients that are predictive of poor prognosis and morbidity. Our approach consists of two interconnected schemes: Feature Selection and Prognosis Classification. The former is based on different Matrix Factorization (MF)-based methods, and the latter is performed using Random Forest algorithm. Our model reveals that Arterial Blood Gas (ABG) O₂ Saturation and C-Reactive Protein (CRP) are the most important clinical biomarkers determining the poor prognosis in these patients. Our approach paves the path of building quantitative and optimized clinical management systems for COVID-19 and similar diseases.

Seroprevalence of SARS-COV-2 antibodies among health-care workers exposed to COVID-19 patients in a large reference hospital, Iran

Background and Objectives

Health care workers (HCWs) are a high-risk group for acquiring and transmitting severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Aim of the study was the evaluation of seroprevalence of SARS-CoV-2 in a random sample of HCWs at a large acute care hospital in Iran.

Materials and Methods

We collected blood samples of 180 medical staffs from September 22, 2020 to January 26, 2021. The enzyme linked immunosorbent assays (ELISA) tests were used for evaluation of the presence of IgG antibodies. Participants completed a self-report questionnaire, comprising demographics, occupational, the work area, and personal protection data.

Results

Of the 180 HCWs who participated in this study, 44 (24.4%) were seropositive for anti-SARS-CoV-2 IgG. The percentage of IgG positivity was higher in males than females (P<0.05). Also, there was statistically significant difference between presence of the antibodies and the occupation, location, and infecting family members with Covid -1 (P<0.05). Other factors did not associate significantly to antibody presence against SARS-CoV-2 (P>0.05).

Conclusion

According to this point that the number of COVID-19 cases is still growing rapidly among HCWs. So, the epidemiological estimate of SARS-CoV-2 infection remains a major challenge that is needed to prevent the spread of infection in the hospitals.

Strategies for sharing pedagogical knowledge in clinical education in adapting to the impact of COVID-19

BACKGROUND

The extent and complexity of knowledge in the field of medicine necessitate modern education systems. Rational performance in the education system depends on the synergy of educators through knowledge sharing as the basis of education. The aim of this study was to investigate the knowledge-sharing strategies in clinical education and its changes during the COVID-19 pandemic.

MATERIALS AND METHODS

The content analysis was conducted in 2019 at Birjand University of Medical Sciences. Twenty-seven clinical instructors with enough experience and knowledge in the field of clinical education were chosen based on purposive theoretical sampling. Data collection was done by semi-structured interviews, which continued until data saturation. The interviews were recorded, transcribed, and read several times to obtain a whole understanding. Next, the meaning units and initial codes were identified, and then, they were classified into subcategories and categories. To ensure the trustworthiness of the data, Lincoln and Guba criteria were considered.

RESULTS

The results of the study include five pedagogical knowledge-sharing strategies: "peer-helping, clinical education workplace," "use of cyberspace," "student mediation," "working teams," and "scientific communities." Coronavirus pandemic was identified as the "facilitator" and the "culturalization factor" of knowledge sharing. In addition, "lack of shared knowledge management," "lack of compliance with needs," and "dispersion of content" were considered as barriers to the efficiency of pedagogical knowledge sharing during the coronavirus pandemic.

CONCLUSIONS

Sharing knowledge in a clinical education setting could continue by various strategies. The results can be used in planning for the professional development of professors.

Evaluation of the effect of sofosbuvir and daclatasvir in hospitalized COVID-19 patients: a randomized double-blind clinical trial (DISCOVER)

Background

The combination of sofosbuvir and daclatasvir has shown preliminary efficacy for hospitalized patients with COVID-19 in four open-label studies with small sample sizes. This larger trial aimed to assess if the addition of sofosbuvir/daclatasvir to standard care improved clinical outcomes in hospitalized patients with COVID-19.

Methods

This was a placebo-controlled, double-blind, randomized clinical trial in adults hospitalized with COVID-19 at 19 hospitals in Iran. Patients were randomized to oral sofosbuvir/daclatasvir 400/60 mg once-daily or placebo in addition to standard of care. Patients were included if they had positive PCR or diagnostic chest CT, O₂ saturation <95% and compatible symptoms. The primary outcome was hospital discharge within 10 days of randomization. Secondary outcomes included mortality and time to clinical events. The trial is registered on the Iran Registry of Clinical Trials under IRCT20200624047908N1.

Results

Between July and October 2020, 1083 patients were randomized to either the sofosbuvir/daclatasvir arm (n = 541) or the placebo arm (n = 542). No significant difference was observed in the primary outcome of hospital discharge within 10 days, which was achieved by 415/541 (77%) in the sofosbuvir/daclatasvir arm and 411/542 (76%) in the placebo arm [risk ratio (RR) 1.01, 95% CI 0.95–1.08, P = 0.734]. In-hospital mortality was 60/541 (11%) in the sofosbuvir/daclatasvir arm versus 55/542 (10%) in the placebo arm (RR 1.09, 95% CI 0.77–1.54, P = 0.615). No differences were observed in time to hospital discharge or time to in-hospital mortality.

Conclusions

We observed no significant effect of sofosbuvir/daclatasvir versus placebo on hospital discharge or survival in hospitalized COVID-19 patients.

Over 60 years of age as an independent prognostic factor of in-hospital mortality among COVID-19 patients: a cohort study in an Iranian high-incidence area

Objectives

COVID-19 continues to cause devastation throughout the world. Various factors influence the perioperative course and prognosis of COVID-19. This study aims to collate the independent prognostic factors among hospitalised COVID-19 patients in east Iran.

Study design

In this cohort study, all patients with a confirmed diagnosis of COVID-19 between 19 February 2020 and 1 August 2020 who were admitted to nine public hospitals of South Khorasan province, Iran, were enrolled.

Methods

Univariate analysis (chi-square [χ²], and Mann–Whitney U test) and multiple logistic regression were performed.

Results

This study included 1290 participants; 676 patients (52.4%) were male. A total of 1189 (92.2%) recovered, and 101 (7.8%) died. The results show that in-hospital mortality increases with advanced age (the optimal cut-off point = 62 years). The following three variables were shown to have the most significant role in in-hospital mortality: age >60 years (odds ratio [OR] = 8.01, 95% confidence interval [CI] 4.8–13.35), shortness of breath (OR = 2.65, 95% CI: 1.4–69.17) and atypical radiological manifestations in a chest X-ray on admission (OR = 2.16, 95% CI: 1.3–28.64). In the univariate analysis, associated comorbidities, such as cardiovascular diseases, influenced the in-hospital mortality rate, while the same could not be replicated in the multiple variable analysis.

Conclusions

This study revealed the potential predictors of COVID-19 and highlighted the need to be cautious with advanced age and heightened clinical symptoms at the time of admission.

A systematic and meta-analysis study on the prevalence of tuberculosis and relative risk factors for prisoners in Iran

INTRODUCTION

This study aimed to evaluate the incidence of Tuberculosis (TB) among prisoners in Iran, by performing a systematic and meta-analysis study on the related articles.

METHODOLOGY

Scopus, Iran doc, Cochrane, Pubmed, Medline, Embase and Iran Medex, Magiran, SID, Google Scholar, and EBSCO were searched. After quality assessment of the articles, a fixed or random model, as appropriate, was used to pool the results in a meta-analysis. Heterogeneity between the studies was assessed using I-square and Q-test.

RESULTS

The overall sample size of included studies was 19562 that 64 of them were with TB. The highest prevalence of tuberculosis was related to the study of Rasht, 517 in 100,000 but the lowest rate was related to the study of Sought Khorasan, 25 in 100,000. The ES of the random effect model is 0.003 (95% CI, 0.001-0.005) and p-value <0.0001. The Higgins' I2 of all studies is 86.55%, and the p-value of the Cochrane Q statistics is <0.001, indicating that there is heterogeneity. Based on the Egger regression plot (t=2.18, p = 0.08, CI 95%: -0.001, 0.005) no publication bias existed.

CONCLUSION

The frequency of TB among the prisoners in Iran was low. Due to important limitations in this study, it is not possible to indicate the exact prevalence of TB among prisoners in Iran and compare this with the general population. More studies are needed to assess the related risk factor for designing health interventions plan to decrease the incidence rate of TB among prisoners.

Decoding Clinical Biomarker Space of COVID-19: Exploring Matrix Factorization-based Feature Selection Methods

One of the most critical challenges in managing complex diseases like COVID-19 is to establish an intelligent triage system that can optimize the clinical decision-making at the time of a global pandemic. The clinical presentation and patients’ characteristics are usually utilized to identify those patients who need more critical care. However, the clinical evidence shows an unmet need to determine more accurate and optimal clinical biomarkers to triage patients under a condition like the COVID-19 crisis. Here we have presented a machine learning approach to find a group of clinical indicators from the blood tests of a set of COVID-19 patients that are predictive of poor prognosis and morbidity. Our approach consists of two interconnected schemes: Feature Selection and Prognosis Classification. The former is based on different Matrix Factorization (MF)-based methods, and the latter is performed using Random Forest algorithm. Our model reveals that Arterial Blood Gas (ABG) O 2 Saturation and C-Reactive Protein (CRP) are the most important clinical biomarkers determining the poor prognosis in these patients. Our approach paves the path of building quantitative and optimized clinical management systems for COVID-19 and similar diseases.

Comparison of the use of personal protective equipment and infection control in dentists and their assistants before and after the corona crisis

BACKGROUND

Coronavirus disease 2019 is a new viral outbreak in the world. Dentists and their assistants are at greatest risk of exposure to the virus, due to close contact with patients and dealing with aerosols. Hence, the aim of this study was to compare the use of personal protective equipment (PPE) and supplementary protective equipment (SPE) and observance of the principles of infection control (PIC) in dentists and their assistants before and after the corona crisis.

MATERIALS AND METHODS

This cross-sectional study was conducted using an online survey from May 6 to 20, 2020. Convenience sampling was used to select individuals. The questionnaire, consisting of four general categories about the use of PPE and SPE and the observance of PIC by dentists and their assistants before and after corona crisis, was registered at Porsline website (https://survey.porsline.ir/s/KUt7VQB). Frequencies in each subcategory were calculated and comparisons were done using Chi-square test, Fisher's exact test, and paired sample t-test. A P < 0.05 was considered statistically significant.

RESULTS

There were significant differences in the frequency of use of PPE by dentists before and after corona crisis for oral and dental examination and also dental procedures (P < 0.001). There were significant differences in the frequency of use of SPE and observance of PIC before and after corona crisis, except for different types of suction types (P = 0.22), dental handpiece (P = 0.66), and dental unit (P = 1). There were significant differences in the frequency of use of PPE by dental assistants before and after corona crisis (P < 0.001).

CONCLUSIONS

Although the frequency of use of PPE and observance of PIC increased among dentists and their assistants, this increase is not sufficient, especially for dental assistants, and a higher level of use of PPE and PIC observance in face of highly contagious and life-threatening viruses such as corona is required.

Possible Potential Effects of Honey and Its Main Components Against Covid-19 Infection

Coronavirus disease 2019 (COVID-19) is a viral pneumonia that is spreading rapidly worldwide. The main feature of this disease is a severe acute respiratory syndrome and caused by coronavirus 2 (SARS-CoV-2). There are several unknowns about the pathogenesis and therapeutically treatment of COVID-19 infection. In addition, available treatment protocols have not been effective in managing COVID-19 infection. It is proposed that natural anti-oxidants such as lemon, green tea, saffron, curcuma longa, etc. with high flavonoids like safranal, crocin, crocetin, catechins, resveratrol, calebin A, curcumin have therapeutic potential against viral infections. In this context, honey and its main components are being investigated as an option for patients with COVID-19. The present study may indicate that honey and its main components inhibit the entry of the virus into the host cell and its replication as well as modulate the inflammatory cascade. This review provides basic information for the possible potential effects of honey and its main components for fighting with SARS-CoV-2.

Tuberculosis: A Cunning Disease Presenting with Endopericarditis-Associated Bilateral Uveitis

Mycobacterium tuberculosis can spread through the entire body but rarely involves the eye. We report a patient with endophthalmitis in one eye and simultaneous retinal vasculitis in the fellow eye. Systemic work-up suggested infective endopericarditis. Polymerase chain reaction analyses of the vitreous and pericardial fluid were positive for M. tuberculosis. We initiated a four-drug antituberculous treatment regimen (isoniazid, ethambutol, pyrazinamide, and rifampin). After two weeks, we discontinued all the medications due to drug-induced hepatitis. We restarted isoniazid and rifampin, but hepatitis recurred. Finally, we chose isoniazid/ethambutol combination for 18 months, and also administered short-term systemic corticosteroid. His vision improved considerably with no recurrence of hepatitis or tuberculosis for 3 years after completion of treatment. Ocular tuberculosis can masquerade as other causes of intraocular inflammation, and a medical team consisting of an ophthalmologist and an infectious disease specialist might be needed for the diagnosis and management.

Uncovering psychobehavioural implications of SARS-CoV-2 infection in Iran

Iran is the country in Western Asia most impacted by the COVID-19 outbreak. A survey was conducted among the general public in Iran aimed at investigating psychobehavioural issues related to the COVID-19 outbreak, namely (a) barriers to preventive measures against SARS-CoV-2 infection; (b) negative emotions towards SARS-CoV-2 infection; and (c) anxiety levels among the general public in Iran. A cross-sectional, web-based survey using an online questionnaire was carried out between 16 March and 1 April 2020. The six-item version of the State-Trait Anxiety Inventory (STAI-6) was used to assess anxiety levels. A total of 1,789 complete responses were received. Nearly 60% reported having difficulty in wearing a face mask to protect against SARS-CoV-2 infection. The mean and standard deviation (SD) for the total prevention barrier score was 35.8 (SD ± 7.1; range 18-68) out of a possible score of 72. Male respondents [odds ratio (OR) = 1.25; 95% confidence interval (CI) 1.03-1.51] and respondents who perceived their health status as poor/fair (OR = 1.49; 95% CI 1.31-1.82) were predictors of high prevention barriers. Negative emotions such as fear (74.6%) followed by depression (43.4%) and stigma (23.0%) associated with SARS-CoV-2 infection were reported. Respondents who perceived their health as poor/fair (OR = 2.19; 95% CI 1.57-3.04) reported a higher likelihood of having higher negative emotions. Findings on anxiety level revealed 68.0% (95% CI 65.8-70.1) reported moderate to severe anxiety. Respondents who perceived their health as poor/fair (OR = 3.46; 95% CI 12.22-5.40) and who were females (OR = 1.91; 95% CI 1.55-2.36) were predictors of moderate to severe anxiety. In conclusion, psychobehavioural interventions are needed to facilitate management and control of the COVID-19 outbreak.

Chrysin attenuates inflammatory and metabolic disorder indices in aged male rat

Advanced age is a major risk factor for metabolic disorders. Accelerated inflammatory processes with increased age can contribute to the pathogenesis of metabolic disturbances. Chrysin is a natural flavonoid ingredient of honey and propolis. Chrysin has been effective in decreasing cholesterol and glucose levels preventing metabolic disturbances. The aim of this study was to evaluate the effects of chrysin against age-associated inflammation, hyperglycemia, and hypercholesterolemia. Male Wistar rats (2, 10, and 20 month-old) were intraperitoneally (i.p.) injected with chrysin (20 mg/kg) for 30 days. The findings showed elevated inflammatory cytokines, glucose, and lipid parameters in the sera of aged rats when compared with young ones. However, chrysin treatment ameliorated these alterations. Furthermore, chrysin reduced the levels of adiponectin, HDL-C, and insulin in 20 month-old rats. The current study showed that chrysin was effective in attenuating age-related lipid abnormalities, glucose elevation, and inflammation.

Molecular evolution and phylodynamics of hepatitis B virus infection circulating in Iran

Previous local and national Iranian publications indicate that all Iranian hepatitis B virus (HBV) strains belong to HBV genotype D. The aim of this study was to analyze the evolutionary history of HBV infection in Iran for the first time, based on an intensive phylodynamic study. The evolutionary parameters, time to most recent common ancestor (tMRCA), and the population dynamics of infections were investigated using the Bayesian Monte Carlo Markov chain (BMCMC). The effective sample size (ESS) and sampling convergence were then monitored. After sampling from the posterior distribution of the nucleotide substitution rate and other evolutionary parameters, the point estimations (median) of these parameters were obtained. All Iranian HBV isolates were of genotype D, sub-type ayw2. The origin of HBV is regarded as having evolved first on the eastern border, before moving westward, where Isfahan province then hosted the virus. Afterwards, the virus moved to the south and west of the country. The tMRCA of HBV in Iran was estimated to be around 1894, with a 95% credible interval between the years 1701 and 1957. The effective number of infections increased exponentially from around 1925 to 1960. Conversely, from around 1992 onwards, the effective number of HBV infections has decreased at a very high rate. Phylodynamic inference clearly demonstrates a unique homogenous pattern of HBV genotype D compatible with a steady configuration of the decreased effective number of infections in the population in recent years, possibly due to the implementation of blood donation screening and vaccination programs. Adequate molecular epidemiology databases for HBV are crucial for infection prevention and treatment programs.

Prevalence and phylogenic study of human T-lymphotropic virus 1 in patients with thalassemia in the northeast of Iran

Aim: This study aimed to investigate the frequency and phylogenetic distribution of human T-lymphotropic virus type 1 (HTLV-1) in thalassemia cases. Methods: Between 2006 and 2013, a total of 100 thalassemic individuals were investigated for HTLV-1 infections. Results: Four people (4%) were reactive for HTLV antibodies. No considerable correlation was seen between factors such as age, blood transfusion history, surgery, marital status, gender and blood types. All HTLV-1 sequences belonged to the transcontinental (A) subgroup in the cosmopolitan (a) subtype. Conclusion: In addition to phylogenetic distribution, our results demonstrate that the prevalence of HTLV-1 infection among thalassemia patients in Mashhad is higher than that of previous studies.

Evolution of hepatitis B virus surface gene and protein among Iranian chronic carriers from different provinces

BACKGROUND AND OBJECTIVES

Iranian chronic HBV carrier's population has shown a unique pattern of genotype D distribution all around the country. The aim of this study was to explore more details of evolutionary history of carriers based on structural surface proteins from different provinces.

MATERIALS AND METHODS

Sera obtained from 360 isolates from 12 Different regions of country were used for amplification and sequencing of surface proteins. A detailed mutational analysis was undertaken.

RESULTS

The total ratio for Missense/Silent nucleotide substitutions was 0.96. Sistan and Kermanshah showed the lowest rate of evolution between provinces (P = 0.055). On the other hand, Khorasan Razavi and Khoozestan contained the highest ratio (P = 0.055). The rest of regions were laid between these two extremes. Azarbayjan and Guilan showed the highest proportion of immune epitope distribution (91.3% and 96%, respectively). Conversely, Sistan and Tehran harbored the least percentage (66.6% and 68.8%, respectively). Kermanshah province contained only 5.2%, whereas Isfahan had 54.5% of B cell epitope distribution. In terms of T helper epitopes, all provinces showed a somehow homogeneity: 22.58% (Fars) to 46.6% (Khuzestan). On the other hand, distribution of substitutions within the CTL epitopes showed a wide range of variation between 6.6% (Khuzestan) and 63% (Kermanshah).

CONCLUSION

Further to low selection pressure found in Iranian population, the variations between different regions designate random genetic drift within the surface proteins. These finding would have some applications in terms of specific antiviral regimen, design of more efficient vaccine and public health issues.

Severe falciparum malaria in iran: a very rare case from an endemic region

Introduction:

Malaria is a protozoal disease, transmitted to humans by female Anopheles mosquito bite. Plasmodium falciparum, compared to other kinds of Plasmodium, causes more severe malaria and is associated with a higher mortality rate. Annually, one to three million deaths occur due to malaria, especially by P. falciparum.

Case Presentation:

In this report, we introduce an Iranian patient suffering from P. falciparum. Peripheral blood smear for malaria parasites showed severe infection of P. falciparum, with 75 to 85 percent of red blood cells containing one to five parasites per cell. However, the patient revealed a fast response to treatment and a good prognosis, suggesting a high level of relative immunity in the patient. To confirm this hypothesis, we conducted a comparative study by comparing the rate of clinical response to treatment as well as the level of prognosis of our patient with similar patients from different regions around the world. These included some malaria cases (caused by P. falciparum) chosen from endemic and nonendemic regions, such as Africa, South Europe and Canada.

Discussion:

The findings revealed that generally, patients from endemic regions significantly show a greater response to treatment and also a better prognosis in comparison to the patients from nonendemic regions. These differences can plausibly be attributed to a high level of relative immunity in endemic regions. Consequently, we would strongly support the hypothesis that response to treatment and prognosis of malaria is a matter of patients’ living environment circumstances. In other words, people who live in endemic regions acquire a high relative immunity leading to a greater response to treatment and a better prognosis.

AIDS and hepatitis B and C high risk behaviors among 15 to 45 years old individuals in Bandar Abbas (Iran) in 2012

BACKGROUND

AIDS and hepatitis are two of the most important health issues in the world. Adolescents and individuals in their reproductive years are important population for interventions in order to reduce high risk behaviors for transmission of sexually transmitted disease. However the prevalence of AIDS and hepatitis B and C is high in Bandar Abbas, no study is available about high risk behaviors related to these diseases in Bandar Abbas. The aim of the current study was to investigate high risk behaviors related to AIDS and hepatitis B and C among 15- to 45 year old individuals in Bandar Abbas, Southern Iran.

METHOD

In this analytical study, 1938 participants between 15- and 45 years of age in Bandar Abbas in 2012 were selected to participate in this study. For each individual, the following information was sought: shared syringes, phlebotomy, tattoos, prisoning, drug abuse, amphetamine, alcohol, smoking, unsafe sexual contacts, as well as demographic information including age, sex, marital status, and education level. Data were analysed using SPSS version 16 (SPSS Inc. Chicago, Illinois, United States) using descriptive statistics and chi-square tests.

RESULTS

A total of 8.4% reported having had tattoos; 10.3% reported previous phlebotomy. Individuals with prison history included 7.3% of our study population and their mean age was 31.4 years. Unsafe sexual contact was reported in 10.7% of the study sample. High risk behaviors were more common among individuals with a low educational level, and in alcohol users and amphetamine users (P<0.05).

CONCLUSION

High risk behaviors are more common among individuals in their reproductive years. Increasing educational level and knowledge translation are effective in preventing AIDS and hepatitis high risk behaviors.

Hepatitis B virus surface protein mutations clustered mainly in CTL immune epitopes in chronic carriers: results of an Iranian nationwide study

Mutations within the coding region of hepatitis B surface antigen (HBsAg) have been found naturally in chronic carriers. To characterize the mutations of HBsAg from Iranian chronic carriers who were vaccine and/or medication naive. The surface genes from 360 patients were amplified and directly sequenced. The distribution of amino acid substitutions was classified according to different immune epitopes of the surface protein. All isolates belonged to genotype D. 222 (61.6%) of 360 patients contained at least one amino acid substitution. 404 (74.5%) of 542 amino acid changes occurred in different immune epitopes of HBsAg, of which 112 (27.7%) in 32 residues of B-cell epitopes (62 in the 'a' determinant); 111 (27.4%) in 32 residues of T helper; and 197 (48.7%) in 32 residues inside cytotoxic T lymphocyte (CTL) epitopes. One Th (186-197) and two CTL (28-51 and 206-215) epitopes were found to be hotspot motifs for the occurrence of 213 (52.7%) substitutions. 20 stop codons were identified in different epitopes. There was a significant association between amino acid substitutions and anti-HBe seropositivity; however, the correlation between such changes with viral load and ALT levels was not significant. In chronic hepatitis B virus(HBV) carriers, positive selection in particular outside the 'a' determinant appeared to exert influence on the surface proteins. These changes could be immune escape mutations naturally occurring due to the host immune surveillance especially at the T-cell level.

Vector ecology and susceptibility in a malaria-endemic focus in southern Islamic Republic of Iran

This study aimed to carry out a malaria situation analysis, species composition and susceptibility levels of the main malaria vector, Anopheles stephensi, to different insecticides in Bashagard. A longitudinal survey was conducted in 2 randomly selected villages in Bashagard. Malaria vectors were sampled by dipping method for the larvae and hand catch, night-biting catch, total catch, and shelter pit collection for the adults. Standard WHO susceptibility tests were used for a variety of insecticides on F1 progeny of An. stephensi reared from wild-caught females. In total, 693 adult anopheline mosquitoes and 839 third and fourth-instar larvae were collected and identified. They comprised 7 species; the most abundant adult and larvae anopheline mosquito was An. dthali (40.7% and 30.5% respectively). An. culicifacies (24.2%) and An. stephensi (16.7%) were the next most common species for adult mosquitoes. An. stephensi was fully susceptible to malathion and pyrethroid insecticides but resistant to DDT and tolerant to dieldrin.

Drug-related mutational patterns in hepatitis B virus (HBV) reverse transcriptase proteins from Iranian treatment-naïve chronic HBV patients

BACKGROUND

Immunomodulators and Nucleotide analogues have been used globally for the dealing of chronic hepatitis B virus (HBV) infection. However, the development of drug resistance is a major limitation to their long-term effectiveness.

OBJECTIVES

The aim of this study was to characterize the hepatitis B virus reverse transcriptase (RT) protein variations among Iranian chronic HBV carriers who did not receive any antiviral treatments.

MATERIALS AND METHODS

Hepatitis B virus partial RT genes from 325 chronic in active carrier patients were amplified and directly sequenced. Nucleotide/amino acid substitutions were identified compared to the sequences obtained from the database.

RESULTS

All strains belonging to genotype D.365 amino-acid substitutions were found. Mutations related to lamivudine, adefovir, telbivudine, and entecavir occurred in (YMDD) 4% (n = 13), (SVQ) 17.23% (n = 56), (M204I/V + L180M) 2.45% (n = 8) and (M204I) 2.76% (n = 9) of patients, respectively.

CONCLUSIONS

RT mutants do occur naturally and could be found in HBV carriers who have never received antiviral therapy. However, mutations related to drug resistance in Iranian treatment-naïve chronic HBV patients were found to be higher than other studies published formerly. Chronic HBV patients should be monitored closely prior the commencement of therapy to achieve the best regimen option.

Field evaluation of permethrin long-lasting insecticide treated nets (Olyset(®)) for malaria control in an endemic area, southeast of Iran

Long lasting insecticide treated nets (LLINs) have been advocated as an effective tool for prevention and control of malaria. Olyset net was the first LLINs which became commercially available and obtained WHO approval. According to the national strategic plan on evaluation of Olyset net, a field trial was conducted to determine the efficacy of these nets against malaria vectors in an endemic area in the southeast of Iran. Fourteen villages with similar topographical and epidemiological situations were selected and randomly assigned to two clusters of the study: Olyset net and untreated net. Distribution of nets was carried out to cover 100% of the population in Olyset net and untreated net cluster. Anopheline mosquitoes were collected monthly using different WHO standard methods in both areas to determine their abundance, feeding pattern and resting behaviour. Human blood index was determined using ELISA test. Additionally, Olyset nets were evaluated for their biological activity using WHO cone bioassay test by susceptible colony of Anopheles stephensi (Beech strain) and then for insecticide residues by employing high performance thin layer chromatography. Malaria incidence was measured by passive and active case detection from all study population. In total 2115 adult anopheline mosquitoes were collected and identified using morphological characters. They comprised of seven species: Anopheles dthali (Liston), A. culicifacies (Giles), A. stephensi (Liston), A. superpictus (Grassi), A.fluviatilis (James), A. moghulensis (Christophers) and A. turkhudi (Liston). A. dthali, A. culicifacies and A. stephensi were most prevalent species in both areas. In the Olyset net study area, there was a significant reduction of 41.1%, 54.4%, 59.39% and 64.1% in the indoor-resting density of A. culicifacies, A. stephensi, A. dthali and A. superpictus, respectively, with an overall reduction of 39.3% in total mosquitoes in comparison with untreated net area. A significant reduction was also observed in human blood index of vector species in the Olyset net villages. Bioefficacy test results of Olyset nets showed that the median knockdown time was 1.48 and 3.25min, while the average mortality rate was 100% and 72.3%±7.07 in baseline and after 1 year of intervention, respectively. The average permethrin content reached to 68.31% (683.1mg/m(2)) of the initial insecticide dose of 937±21.69mg/m(2) (nearly 1000mg/m(2)) at the end of intervention. Malaria incidence was reduced by 96.6% and 64.8% in the village with Olyset nets and in the villages with untreated nets, respectively. During intervention period, there was a reduction of 93.2% in malaria incidence in Olyset net area as compared to the untreated area. This study indicated that Olyset nets have a major impact on malaria vectors and disease burden; therefore it could be recommended as an effective personal protection tool for malaria control in malarious areas.

Larval habitats and biodiversity of anopheline mosquitoes (Diptera: Culicidae) in a malarious area of southern Iran

BACKGROUND & OBJECTIVES

Malaria is the most important mosquito-borne disease in Iran. It is endemic in south to southeastern part of the country. Knowledge about bio-ecology of vectors will support authorities for appropriate management of the disease. Bashagard district is one of the main endemic areas for malaria in south of Iran. This study was conducted to determine anopheline fauna, diversity and affinity in the area, characterization of larval habitats, and mapping their potential distribution across the district.

METHODS

The potential aquatic habitats for Anopheles larvae were extracted from Indian Remote Sensing Satellite (IRS) image and digital elevation model of the area using GIS. Surface water bodies were sampled monthly during 2009–10 for anopheline larvae, while characteristics of their physical environment were recorded and water samples were analyzed.

RESULTS

A total of 4511 Anopheles larvae were found during the year with the lowest and highest frequencies in February and April, respectively. Dominant species was Anopheles culicifacies. The Shanon diversity index ranged from 0.570–0.829 at fixed collection sites, while the affinity index was significant among some vector species.

CONCLUSION

Riversides and riverbeds were the main breeding places which provided sandy, rocky, and clay beds for different species. The potential breeding places as well as distribution of collected species were mapped. Knowledge about ecology of malaria vectors provides information to health sector for effective control programs.

Identification of Hepatitis B Virus Surface Antigen (HBsAg) Genotypes and Variations in Chronic Carriers from Isfahan Province, Iran

BACKGROUND

Hepatitis B virus (HBV) gene and protein variations are frequently been seen in chronic patients. The aims of study were to determine the genotypes as well as the patterns of variations distribution in chronically-infected patients from the central part of Iran.

METHODS

The surface gene was amplified, sequenced and subsequently aligned using international and national Iranian database.

RESULTS

All strains belonged to genotype D, subgenotype D1 and subtype ayw2. Of all 62 mutations occurred at 39 nucleotide positions, 31 (50%) were missense (amino acid altering) and 31 (50%) were silent (no amino acid changing). At the amino acid level, 30 substitutions occurred, however, 3 were in positions 122 and 127, corresponded to subtypic determination. 22 (73%) out of 30 amino acid mutations occurred in different immune epitopes within surface protein, of which 12 (54.54%) in B cell epitopes in 10 residues; 5 (45.45%) in T helper epitopes in positions; 5 (22.73%) in inside CTL epitopes in 4 residues.

CONCLUSION

The distribution of amino acid mutations as well as the ratio between silent and missense nucleotide mutations showed a narrowly focused immune pressure had already been on the surface protein in these patients, led to the emergence of escape mutants in these patients.

Entomological and epidemiological attributes for malaria transmission and implementation of vector control in southern Iran

Bashagard is an important malaria endemic area in south of Iran. An epidemiological and entomological survey was performed during 2002-2010. The aim of study was to determine malaria situation, species composition of anopheline mosquitoes and susceptibility status of main vectors to insecticides/larvicides. A total of 13,490 malaria cases were recorded, Plasmodium vivax (99.64%), P. falciparum (0.35%) and mix cases (0.01%). The highest and lowest Annual Parasite Incidence (API) were observed in 2007 (145.72/1000) and 2009 (6.29/1000), respectively. Anopheles culicifacies, An. dthali, An. stephensi, An. superpictus, An. fluviatilis, An. moghulensis, An. turkhudi and An. apoci were collected from the area. Two peak activities occur in April and October. The first five species were confirmed as malaria vectors in Iran. No indication of sporozoite in mosquitoes using molecular method was performed. Susceptibility tests using diagnostic dose of insecticides and larvicides showed only resistance of An. stephensi to DDT. Tolerance in An. stephensi to deltamethrin and bendiocarb is reported. The same phenomenon was observed in An. culicifacies to DDT, propoxur and deltamethrin, and in An. dthali to malathion and deltamethrin. Larvae of vectors were susceptible to all larvicides, except for An. stephensi that exhibited tolerance to fenthion. In conclusion it should be emphasized that malaria transmission is a complex process in Bashagard. This event is attributed to five proven vectors with different behaviors which are active in the area. Regarding tolerance of vectors to deltamethrin, resistance management is suggested by using new insecticide with novel mode of action.

Effects of educational intervention on long-lasting insecticidal nets use in a malarious area, southeast Iran

Long-lasting insecticidal nets (LLINs) have been advocated as an effective tool against malaria transmission. However, success of this community based intervention largely depends on the knowledge and practice regarding malaria and its prevention. According to the national strategy plan on evaluation of LLINs (Olyset nets), this study was conducted to determine the perceptions and practices about malaria and to improve use of LLINs in Bashagard district, one of the important foci of malaria in southeast Iran. The study area comprised 14 villages that were randomized in two clusters and designated as LLINs and untreated nets. Each of households in both clusters received two bed nets by the free distribution and delivery. After one month quantitative data collection method was used to collect information regarding the objectives of the study. On the basis of this information, an educational program was carried out in both areas to increase motivation for use of bed nets. Community knowledge and practice regarding malaria and LLIN use assessed pre- and post-educational program. The data were analyzed using SPSS ver.16 software. At baseline, 77.5% of respondents in intervention and 69.4 % in control area mentioned mosquito bite as the cause of malaria, this awareness increased significantly in intervention (90.3%) and control areas (87.9%), following the educational program. A significant increase also was seen in the proportion of households who used LLINs the previous night (92.5%) compared with untreated nets (87.1%). Educational status was an important predictor of LLINs use. Regular use of LLIN was considerably higher than the targeted coverage (80%) which recommended by World Heaths Organization. About 81.1% and 85.3% of respondents from LLIN and control areas reported that mosquito nuisance and subsequent malaria transmission were the main determinants of bed net use. These findings highlight a need for educational intervention in implementation of long-lasting insecticidal nets; this should be considered in planning and decision-making in the national malaria control program during the next campaigns of LLINs in Iran.

Knowledge, attitudes and practices regarding malaria control in an endemic area of southern Iran

Iran is in the malaria pre-elimination stage. In this situation community based strategies are important for malaria control. In order to intensify elimination activities we need to have a better understanding of the knowledge, attitudes and practices (KAP) of malaria prevention in the community. We carried out a KAP study in one malaria endemic district in southern Iran in 2009 using a structured questionnaire. Five villages with indigenous malaria cases during the previous year and a high potential for anopheline mosquito breeding were selected. All the households in each village were visited and the head of the household or other responsible adult was interviewed. Data were analyzed using SPSS 11.5. A total of 494 respondents from the five villages participated. More than 33% of people in the study area were living in sheds with poor facilities. The illiteracy level of the studied population was high (44.2%) and significantly affected the knowledge and practices of the respondents about malaria control (p<0.05). Descriptive analysis showed significant differences between sex, job and history of malaria infection of the respondents and their knowledge and practices about malaria control (p<0.05). Knowledge of the respondents about the route of transmission in malaria was good; 72.1% knew mosquitoes were the vector. Most people knew at least one symptom of the disease. The practices of respondents were 59.5% for bednet use and 9.3% for screening windows. The knowledge, attitudes and practices of respondents in this survey about malaria control were good in some cases, but in general needed to be improved with educational programs.

Significance of blood-related high-risk behaviors and horizontal transmission of hepatitis B virus in Iran

Hepatitis B virus (HBV) is a significant public health problem and a leading cause of morbidity and mortality, and approximately 30% of the world's population is infected with HBV. The objective of our study was to determine the seroprevalence of HBV and major risk factors associated with its occurrence. Four thousand eighty-seven healthy Iranian subjects aged 8-80 years were screened for HBV serological markers by an enzyme immunoassay method. A structured questionnaire was administered to all participants. Multiple logistic regression, an unpaired t-test for continuous data and the χ (2) test for categorical data were performed. A total of 4087 participants were tested for hepatitis B surface antigen (HBsAg), of which 62 (1.5%) were seropositive. Fifteen percent of the subjects were positive for anti-HBs, 6.3% were positive for isolated anti-HBc and 12.5% were positive for both anti-HBs and anti-HBc. Laborers showed a higher HBsAg(+) seroprevalence and risk compared with jobless participants (Pearson's = 8.276, P = 0.004; OR = 4.1, 95% CI: 1.5-11.2). Bivariate logistic regression revealed that the following variables were significantly associated with HBV seropositivity: phlebotomy (P = 0.002; OR = 5.0, 95% CI: 2.1-11.9), tattooing (P = 0.003; OR = 3.4, 95% CI: 1.6-7.0), intravenous drug use (P = 0.001; OR = 2.4, 95% CI: 1.4-4.1). The adjusted prevalence ratios remained significantly associated with HBV seropositivity and thus likely served as possible risk factors for HBV. The overall positive seroprevalence was 1.5%. Among the variables, only phlebotomy, tattooing and intravenous drug injection emerged as major potential risk factors for hepatitis B infection and responsible for transmission of the disease.

Association of the Co-stimulatory Molecules Polymorphisms with CMV Infection in Liver Transplant Recipients

BACKGROUND

Co-stimulatory molecules play a critical role in regulating T-cell function during CMV infection after liver transplantation.

OBJECTIVE

To investigate the relationship between the polymorphisms of the co-stimulatory genes and the susceptibility to CMV infection after liver transplantation.

METHODS

Single nucleotide polymorphisms (SNPs) in PD-1 gene (PD1.1 A/G, PD1.3 A/G, PD1.9 C/T) ICOS (-693 A/G, 1720 C/T), CTLA-4 gene (318 C/T, 1722 T/C, 1661 A/G, 49 A/G) and CD28 (+17 C/T) were analyzed by PCR-RFLP in 70 liver transplant patients. CMV infection was determined in these patients by antigenemia test.

RESULTS

CTLA-4 49G showed significant association with CMV infection (p=0.03, OR=3.82, 95% CI: 0-3.5; p=0.01, OR=004, 95% CI: 0-1.3). G and T alleles in CTLA-4 gene (318 C/T and 1661 A/G) (p=0.03, OR=0, 95% CI: 0-3.5; p=0.01, OR=0.04, 95% CI: 0-1.3) were significantly higher in CMV-infected rejector group.

CONCLUSION

CTLA-4 have significant role in CMV pathogenesis and rejection among CMV-positive liver transplant patients.

Molecular Monitoring of Plasmodium vivax Infection after Radical Treatment in Southeastern Iran

BACKGROUND

The aim was to evaluate the relapse risk of vivax malaria in patients who received radical treatment in Hormozgan Province, a malarious area located on southeast of Iran.

METHODS

A total of 95 symptomatic vivax malaria infected patients were enrolled in urban health centers of Bandar-Abbas, Minab, Bandar-Jask and Bashagard districts of Hormozgan Province, southeast of Iran from January 2008 to March 2009 for consideration as a case- series study. DNA was extracted from parasite infected whole blood samples. A polymorphic region of Plasmodium vivax merozoite surface protein 1 (pvMSP1) was selected and a PCR method was employed for all the samples to amplify the specific variable gene fragment. The obtained fragments in primary and secondary samples were sequenced. Both nucleotide and amino acid sequences of the samples were investigated for returned patients.

RESULTS

3.2% of the patients experienced a second attack between 83-199 days after the initial episode of infection. Alignment of nucleotide and their deduced amino acid sequences between pair sequences of primary and secondary isolates revealed 8 and 6 dissimilarities respectively for the first case, and 9 and 7 dissimilarities for the second case. Although microscopical examination of recurrent thick blood smear of the third patient confirmed new P. vivax infection, the venous blood sample was accidentally missed. Sequencing results of primary and returned isolates 1P, 1S, 2P, 2S and 3P in this study showed an identity with BP13, T117, BP13, TC28 and Chesson genotypes respectively.

CONCLUSION

The returned (secondary) isolates may account to be for the sake of reinfection.