Mental Health Status of Healthcare Workers During the Coronavirus Disease 2019 Pandemic: A Survey of Hospitals in Shiraz, Iran

BACKGROUND

Healthcare workers (HCWs) directly or indirectly involved in the coronavirus disease 2019 (COVID-19) treatment process may experience severe mental consequences of the pandemic. Hence, this study aimed to evaluate the mental health status of HCWs in hospitals affiliated with Shiraz University of Medical Sciences, Iran.

MATERIALS AND METHODS

This cross-sectional study was performed on 503 HCWs from five hospitals in Shiraz, including one COVID-19 front-line hospital, two COVID-19 second-line hospitals, and two without COVID-19 wards. Then, to assess the levels of anxiety, depression, insomnia, and post-traumatic stress disorder (PTSD) among HCWs, the Persian versions of the Hospital Anxiety and Depression Scale (HADS), Insomnia Severity Index (ISI), and Global Psychotrauma Screen (GPS) questionnaires were placed, respectively.

RESULTS

The mean age of participants was 33.94±8.26 years, and 252 (50.1%) were females. Anxiety, depression, insomnia, and moderate to high levels of PTSD were observed in 40.4%, 37.8%, 24.5%, and 71% of participants, respectively. A history of mental disorders was associated with all four outcomes (P0.05). Females gender and living with elderly and/or children were correlated with anxiety and PTSD (P0.05). Working at COVID-19 front- and second-line hospitals were similarly linked to higher insomnia and PTSD levels (P0.05). Also, working in COVID-19 wards or non-clinical settings was associated with anxiety and depression (P0.05).

CONCLUSION

Most of the HCWs in this study may experience mental difficulties. Some factors may increase their risk of experiencing these difficulties. Hence, in the crisis era, mental health monitoring and identification of groups with predisposing factors are required to provide appropriate care as quickly as feasible.

Public Trust in Healthcare System in Iran: A Rapid Assessment During the COVID-19 Epidemic in Iran

Background and aims: Public health policies and programs should be adapted to the level of public trust in the healthcare system, as an indicator of the public support level. Accordingly, the data about public trust level in the healthcare system is considered as a critical requirement for managing public health crises. This study aimed to rapidly assess the public trust in the healthcare system during the COVID-19 epidemic in Iran, as well as to evaluate the effect of socioeconomic status (SES) on this trust. Methods: This cross-sectional and web-based study which was conducted in Iran during the COVID-19 epidemic included adults aged 18-60 years. A probability proportional to size multistage random sampling was applied and performed in 15 provinces of the country. Data on the main sources of information about COVID-19, trust in healthcare system, fear level of COVID-19, and demographics were collected via an electronic questionnaire. Multiple linear regression was applied, and adjusted regression coefficients and 95% confidence intervals (CIs) were estimated. Results: A total of 5250 adults (response rate: 76%) were included in the study. The mean of reported trust scores was 50.3±22.8, and that of fear scores was 72.0±17.8. The highest (65%) and lowest (28%) levels of trust were observed among participants from the lowest and highest SES, respectively. Gender (male) (P=0.006), higher levels of education (P<0.001), higher socio-economic status (P<0.001), and higher fear scores (P<0.001) were independently correlated with the lower level of ⦰ trust in healthcare system. Conclusion: It was found that the public trust in Iran’s healthcare system was not high enough at the time of the COVID-19 epidemic in the country, especially among higher social class population.

Incidence Trends of Gastric Cancer in Southern Iran: Adenocarcinoma and Non-cardia Gastric Cancer Are More Rising Among Younger Ages

BACKGROUND

Gastric Cancer (GC) is still one of the major causes of cancer mortality. Due to health-related transitions, the epidemiology of GC subtypes may change. These changes may have profound effects on clinical approaches as well as on public health management of GC. Iran, as a developing country, has experienced huge demographic and epidemiological transitions during the recent decades. This study aimed to investigate the subtype-specific population-based incidence trends of GC in southern Iran.

METHODS

We used data on GC incidence in southern Iran during 2001-2015. Data preparation and subtype grouping were done based on the ICD-O-3. The trends of Age-Standardized incidence Rate (ASR), truncated ASRs, incidence rate of adenocarcinoma, and cardia GC, and age-gender specific rates were analyzed using joinpoint regression modeling. Annual Percentage Change (APC) and its 95% Confidence Intervals (CIs) were estimated.

RESULTS

Overall APC was estimated as 7.2 for males and 8.7 for females. The estimated APCs for the trends of overall GC, and gastric adenocarcinoma were stable in both genders during 2009-2015. Nonetheless, cardia GC showed increasing trends in both genders. The estimated APCs for the trends of non-cardia GC was also stable.

CONCLUSION

The overall trends of the GC incidence in southern Iran were stable during the past decade. However, significant and different changes have occured in the pattern of GC. Thus, etiological and prognostic studies are needed for the improvement of GC management in Iran.

Autopsy diagnosis of leptomeningeal carcinomatosis, the first manifestation of gastric adenocarcinoma: a rare case report and review of the literature

This study aimed to report an unusual presentation of an advanced gastric adenocarcinoma. Leptomeningeal carcinomatosis is a rare event in gastric adenocarcinoma. It is much more uncommon as the primary manifestation in post-mortem evaluation of the cause of death in a patient presenting with headache and neurological signs and symptoms. Herein, we discuss our experience with a case of gastric adenocarcinoma, who was diagnosed after death, presenting with neurological signs and symptoms of leptomeningeal carcinomatosis. A 52-year-old gentleman presented with intractable headache and neck pain as well as vertigo. His physical examination showed only decreased deep tendon reflexes. He died after a short period of coma. Post-mortem evaluation showed numerous signet ring cells in the subarachnoid space as well as gastric malignant ulcer. In patients with intractable headache with no identifiable cause, meningeal involvement and infiltration should be considered as the probable underlying cause. Radiologic findings are not significant; however, lumbar puncture can be diagnostic.

Estimation and Projection of Prevalence of Colorectal Cancer in Iran, 2015-2020

Background:

Population aging and more prevalent westernized lifestyle would be expected to result in a markedly rising burden of colorectal cancer (CRC) in the future years. The aim of this study is to estimate the limited-time prevalence of CRC in Iran between 2015 and 2020.

Materials and Methods:

Aggregated CRC incidence data were extracted from the Iranian national cancer registry (IR.NCR) reports for 2003–2009 and from GLOBOCAN-2012 database for 2012. Incidence trends were analyzed by age groups, genders, histopathologic, and topographic subtypes to estimate annual percentage changes. Incidence was projected for 2020. The prevalence was estimated applying an adopted version of a previously introduced equation to estimate limited–time prevalence based on the incidence and survival data. Monte Carlo sensitivity analyses were applied to estimate 95% uncertainty levels (ULs). In each scenario, incidence, survival, annual percentage changes, and completeness of case ascertainment at IR.NCR were replaced under pre-assumed distributions.

Results:

Number of estimated within 1, 2-3 and 4-5-year CRC patients in 2015 were 13676 (95% UL: 10051–18807), 20964 (15835–28268), and 14485 (11188–19293), respectively. Estimated 5-year prevalence for 2020 (99463; 75150–134744) was 2.03 times of that for 2015. Highest 5-year prevalence was estimated in ages 55–59 for females and 75 + for males. Adenocarcinoma (41376; 31227 55898) was the most prevalent histologic subtype. The most prevalent tumor location was colon (30822, 23262–41638).

Conclusion:

A substantial growth in the prevalence of CRC survivors is highly expected for future years in Iran. Establishment of specialized institutes is highly recommended to provide medical and especially social supports for Iranian CRC survivors.

Prevalence of HIV/AIDS among Iranian Prisoners: A Review Article

BACKGROUND

Worldwide, prisoners are more at risk of being infected by human immunodeficiency virus (HIV) as well as hepatitis C and B in comparison with other risk groups. The combination of acquired immune deficiency syndrome (AIDS), addiction and prison are factors that threaten the health of our society. Influence of risky behaviors is so common on transmission of AIDS into prisoners' bodies. This study used available information and reports to investigate the prevalence of HIV in Iranian prisons.

METHODS

The following review of documents available in national and foreign databases, a total of 26 studies were investigated and required information was extracted from both the full papers and abstracts.

FINDINGS

The selected studies differed methodologically in their sampling method and data collection tools. Within the 26 studies analyzed, there was a combined study cohort of 39707 people in whom HIV prevalence varied between 0% and 24.40%.

CONCLUSION

In this study, HIV prevalence ranged widely among the prisoners, and in most of these studies, the rate in Iran was higher than that of other countries. The prevalence of disease was highest among intravenous drug users. Unless proper preventive and control plans among risk groups such as prisoners are not implemented in a timely and suitable manner, the risk of infection in the broader society will increase.

A randomized pilot trial on the effect of granulocyte-colony stimulating factor on antibody response in hemodialysis patients who had not responded to routine hepatitis B virus vaccine

Background: Various strategies have been applied to improve the response to hepatitis B virus (HBV) vaccination in hemodialysis patients.

Objectives: The present study was under taken to compare the seroconversion rate of hemodialysis patients who had not respond to 3 intramuscular (IM) doses (40 μg each) of HBV vaccine , after a fourth IM dose (40 μg) of HBV vaccine that was administered alone or with subcutaneous granulocyte-colony stimulating factor (G-CSF) (5 μg/kg).

Patients and Methods: Twenty six hemodialysis patients who had not responded to 3 IM injections of HBV vaccine were randomized into 2 groups: Group 1 received a booster dose of 40 μg HBV vaccine IM, group 2 received a booster dose of 40 μg HBV vaccine IM plus 5 μg/kg subcutaneous G-CSF. Antibody to hepatitis B surface antigen was measured 1 month after the booster dose.

Results: Seroconversion rate in group 1 was 40%. There was a trend towards a higher seroconversion rate at 60% in group 2 patients; however, because of the small number of patients it did not reach statistical significance.

Conclusions: Larger number of patients and other innovative strategies should be applied for vaccination of this group of patients. More prolonged follow up of the patients is needed to evaluate the duration of protection induced by each method of vaccination.

Differentiation and transplantation of human induced pluripotent stem cell-derived hepatocyte-like cells

The generation of human induced pluripotent stem cells (hiPSCs) with a high differentiation potential provided a new source for hepatocyte generation not only for drug discovery and in vitro disease models, but also for cell replacement therapy. However, the reported hiPSC-derived hepatocyte-like cells (HLCs) were not well characterized and their transplantation, as the most promising clue of cell function was not reported. Here, we performed a growth factor-mediated differentiation of functional HLCs from hiPSCs and evaluated their potential for recovery of a carbon tetrachloride (CCl4)-injured mouse liver following transplantation. The hiPSC-derived hepatic lineage cells expressed hepatocyte-specific markers, showed glycogen and lipid storage activity, secretion of albumin (ALB), alpha-fetoprotein (AFP), urea, and CYP450 metabolic activity in addition to low-density lipoprotein (LDL) and indocyanin green (ICG) uptake. Similar results were observed with human embryonic stem cell (hESC)-derived HLCs. The transplantation of hiPSC-HLCs into a CCl4-injured liver showed incorporation of the hiPSC-HLCs into the mouse liver which resulted in a significant enhancement in total serum ALB after 1 week. A reduction of total serum LDH and bilirubin was seen when compared with the control and sham groups 1 and 5 weeks post-transplantation. Additionally, we detected human serum ALB and ALB-positive transplanted cells in both the host serum and livers, respectively, which showed functional integration of transplanted cells within the mouse livers. Therefore, our results have opened up a proof of concept that functional HLCs can be generated from hiPSCs, thus improving the general condition of a CCl4-injured mouse liver after their transplantation. These results may bring new insights in the clinical applications of hiPSCs once safety issues are overcome.

Pandemic 2009 influenza A (H1N1) infection among 2009 Hajj Pilgrims from Southern Iran: a real-time RT-PCR-based study

BACKGROUND

Hajj is a mass gathering undertaken annually in Mecca, Saudi Arabia. The 2009 Hajj coincided with both the pandemic influenza A/H1N1 2009 (A(H1N1)pdm09) and seasonal types of influenza A viruses. The interaction between pandemic influenza and Hajj could cause both a high level of mortality among the pilgrims and the spread of infection in their respective countries upon their return home.

OBJECTIVE

The present study attempted to determine the point prevalence of A(H1N1)pdm09 among returning Iranian pilgrims, most of whom had been vaccinated for seasonal influenza but not A(H1N1)pdm09.

METHODS

Pharyngeal swabs were collected from 305 pilgrims arriving at the airport in Shiraz, Iran. RNA was extracted from the samples and A(H1N1)pdm09 and other seasonal influenza A viruses were detected using TaqMan real-time PCR. For A(H1N1)pdm09-positive samples, the sensitivity to oseltamivir was also evaluated.

RESULTS

Subjects included 132 (43.3%) men and 173 (56.7%) women, ranging in age from 24 to 65 years. The A(H1N1)pdm09 virus was detected in five (1.6%) pilgrims and other influenza A viruses in eight (2.6%). All the A(H1N1)pdm09 were sensitive to oseltamivir.

CONCLUSIONS

Only five cases were found to be positive for A(H1N1)pdm09, and it seems unlikely that the arrival of infected pilgrims to their homelands would cause an outbreak of a new wave of infection there. Thus, the low morbidity and mortality rates among the pilgrims could be attributed to the characteristics of A(H1N1)pdm09, which causes morbidity and mortality in a way similar to the seasonal influenza infections, absence of high-risk individuals among the Iranian pilgrims, and the instructions given to them about contact and hand hygiene, and respiratory etiquette.

Polymorphism of the promoter region of C-509T of transforming growth factor-beta1 gene and ulcerative colitis

BACKGROUND

Transforming growth factor-beta is a regulatory protein that plays a key role in inflammatory, fibrotic, and immunological events in the intestinal mucosa. Recently, attention has been focused on the role of transforming growth factor-beta in the etiopathogenesis of inflammatory bowel disease. Enhanced expression of transforming growth factor-beta mRNA in the lamina propria and a disordered expression pattern of transforming growth factor-beta1 receptors I and II in epithelial cells have been documented in the colonic mucosa of patients with ulcerative colitis and Crohn's disease. Based on these associations, we report in this study, the restriction fragment length polymorphism-polymerase chain reaction and allele frequencies of the transforming growth factor-beta gene polymorphisms in a population of Iranian patients with ulcerative colitis and healthy controls. We analyzed whether these two polymorphisms are related with the disease characteristics.

METHODS

One hundred fifty-seven (75 males and 82 females) unrelated patients with ulcerative colitis attending the Departments of Gastroenterology, Nemazi and Faghihi Hospitals, affiliated to Shiraz University of Medical Sciences, Shiraz, Iran were enrolled into this study. Ninety-four age- and sex-matched healthy volunteers with no history of chronic bloody diarrhea and abdominal pain (41 males and 53 females) served as the control group. The change at position -509 (C/T) of the transforming growth factor-beta1 gene was studied using restriction fragment length polymorphism-polymerase chain reaction in this study.

RESULTS

The mean age of patients was 36.4 (range: 23 - 51) years. The genotype at position -509 (C/T) in 58 (37%) patients with ulcerative colitis, and 39 (41.5%) normal subjects, were homozygous as CC. In addition, 65 (41.5%) patients and 44 (47%) normal individuals were heterozygous as CT. Thirty-four (21.5%) of 157 patients, and 11 (11.5%) of 94 normal individuals, were homozygous as TT. There was no statistically significant difference between patients and normal female individuals in respect to genotype distribution and allele frequency at the said position (P = 0.138).

CONCLUSION

No association could be found between transforming growth factor-beta1 -509 (C/T) promoter gene polymorphism and patients with ulcerative colitis.

Does delayed gastric emptying shorten the H pylori eradication period? A double blind clinical trial

AIM: To evaluate the gastric emptying inhibitory effects of sugar and levodopa on H pylori eradication period.

METHODS: A total of 139 consecutive patients were randomized into 6 groups. The participants with peptic ulcer disease or non-ulcer dyspepsia non-responding to other medications who were also H pylori-positive patients either with positive rapid urease test (RUT) or positive histology were included. All groups were pretreated with omeprazole for 2 d and then treated with quadruple therapy regimen (omeprazole, bismuth, tetracycline and metronidazole); all drugs were given twice daily. Groups 1 and 2 were treated for 3 d, groups 3, 4 and 5 for 7 d, and group 6 for 14 d. Groups 1 to 4 received sugar in the form of 10% sucrose syrup. Levodopa was prescribed for groups 1 and 3. Patients in groups 2 and 4 were given placebo for levodopa and groups 5 and 6 received placebos for both sugar and levodopa. Upper endoscopy and biopsies were carried out before treatment and two months after treatment. Eradication of H pylori was assessed by RUT and histology 8 wk later.

RESULTS: Thirty patients were excluded. Per-protocol analysis showed successful eradication in 53% in group 1, 56% in group 2, 58% in group 3, 33.3% in group 4, 28% in group 5, and 53% in group 6. Eradication rate, patient compliance and satisfaction were not significantly different between the groups.

CONCLUSION: It seems that adding sugar or levodopa or both to anti H pylori eradication regimens may lead to shorter duration of treatment.

Results of liver transplantation: analysis of 140 cases at a single center

The Shiraz Organ Transplant Center in southern Iran has been performing all liver transplantations in Iran and certain neighboring countries for 12 years. This study evaluated the 140 operations performed from April 1993 through November 2004. Sixty-one percent of the recipients were men and 39% were women. The average recipient age was 29.9 +/- 14.0 years. One hundred twenty-eight patients has a full-size cadaveric transplant. Most frequent causes of cirrhosis were cryptogenic and viral. An acute rejection episode occurred in 47.5% of cases, and two episodes in 8%. Most frequent short-term complications included respiratory, neurologic, and biliary problems. The 1-, 2-, and 3-year patient survival rates were 92%, 89%, and 85%, respectively. The experience that the Shiraz Organ Transplant Center has had with liver transplantation indicated success comparable to that noted in other reports. The calculated trend suggests that a goal of 100 transplantations for 2005 is within reach.

Biliary Tract Complications After Liver Transplantation in a Single Center

Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to determine the incidence of biliary complications and analyze methods of treatment. From 1993 to 2004, 14 cases (10%) among 140 patients who had undergone liver transplantation developed biliary complications, third to respiratory and neurologic complications. In addition to biliary leakage in six cases, obstruction/stenosis occurred in three cases. One case of biliary fistula and one vanishing bile duct syndrome were observed. There was no death or need for retransplantation; all cases were treated surgically without recurrence. Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory and safe in selected cases.

Symptom association probability and symptom sensitivity index: preferable but still suboptimal predictors of response to high dose omeprazole

BACKGROUND

Twenty four hour oesophageal pH monitoring is frequently used to quantify the association between a patient's symptom and gastro-oesophageal reflux. Three indices (symptom association probability (SAP), symptom index (SI), and symptom sensitivity index (SSI)) are used to quantify and establish this relation.

AIMS

The aim of the present study was to compare these indices against the omeprazole test (OT) as an objective indicator of reflux induced symptoms.

METHODS

Fifty two patients with a predominant symptom of heartburn were enrolled from gastroenterology and primary care clinics. Baseline symptom score was calculated at the fist visit. All patients underwent 24 hour oesophageal pH monitoring, and symptom-reflux association indices were calculated. All patients were placed on high dose omeprazole (40 mg in the morning, 20 mg at night) after completion of pH monitoring and symptom score was recorded again after one week.

RESULTS

Thirty eight patients completed the study. All three indices were significantly related to each other (p<0.001). SAP and SSI (with a new cut off of 1.3, but not with the commonly used 5%) had statistically significant relations with OT (p<0.05 for both). SSI had the highest positive and negative predictive values and sensitivity. The specificity of SSI and SAP was equal and lower than SI. Areas under the receiver operating characteristic (ROC) curve for the three indices were not significantly different from each other or from a hypothetical non-discriminating test. Per cent time pH <4, sex, and age had no relation to OT and no effect on its correlation with association indices. No cut off point could be found at which the results of SI could be related significantly to the OT results.

CONCLUSION

SAP and SSI are significantly related to symptomatic response to high dose omeprazole; however, they are far from perfect, with a significant number of discordant cases as well as relatively small areas under the ROC curves. We suggest that the new cut off of 1.3 be used for SSI in the future. Further research is needed to identify possible methods to improve the discrimination power of these indices or to identify possible patient characteristics that may affect this relation.