Development and validation of a risk score for diabetic kidney disease prediction in type 2 diabetes patients: a machine learning approach

PURPOSE

This study aims to develop and validate a risk score to predict the occurrence of DKD in individuals with type 2 diabetes using a machine learning (ML) approach.

METHODS

By implementing Recursive Feature Elimination with Cross-Validation (RFECV) and RFE on the Diabetes Clinic of Imam Khomeini Hospital Complex (IKHC) dataset, the most critical features were identified. These features were used in the multivariate logistic regression (LR) analysis, and the discrimination and calibration of the model were evaluated. Finally, external validation of the model was assessed.

RESULTS

The development dataset included 1907 type 2 diabetic patients, 763 of whom developed DKD over 5 years. The predictive model performed well in the development dataset by implementing RFECV with the RF algorithm and considering six features (AUC: 79%). Using these features, the LR-based risk score indicated appropriate discrimination (AUC: 75.5%, 95% CI 73-78%) and acceptable calibration ([Formula: see text]= 7.44; p value = 0.49). This risk score was then used for 1543 diabetic patients in the validation dataset, including 633 patients with DKD over 5 years. The results showed sufficient discrimination (AUC: 75.8%, 95% CI 73-78%) of the risk score in the validation dataset.

CONCLUSIONS

We developed and validated a new risk score for predicting DKD via ML approach, which used common features in the periodic screening of type 2 diabetic patients that are readily available. In addition, a web-based online tool that is readily available to the public was developed to calculate the DKD risk score.

Molecular Characterization of Streptococcus Pneumoniae from Patients Diagnosed with Pneumonia: Recommendation for Vaccination Program

Background: Infections caused by Streptococcus pneumoniae (S. pneumoniae) have remained a significant public health concern worldwide. In developed countries, the highest prevalence of S. pneumonia has been reported among the elderly. The aim of this study was to evaluate the coverage of genotypes in the 13-valent pneumococcal conjugate vaccine (PCV-13) in the Iranian elderly population. Methods: A total of 41 isolates of S. pneumoniae were collected in the current retrospective cross-sectional study. The samples comprised 33 inpatients hospitalized for pneumococcal pneumonia and 8 outpatients. Multiplex polymerase chain reaction assay was performed to categorize the bacteria isolated into specific genotypes. Statistical analyses were performed using SPSS software, and the chi-square test was used to assess the statistical significance in percentages. Results: A total of 68 genotypes were identified in this study, in which 39 isolates (57.3%) were associated with invasive infections. The most common genotypes were 6A/B [8 (19.5%)], 1 [7 (17.5%)], 14 [5 (12.2%)], and 19A [4 (9.75%)], respectively. The coverage rates of PCV-7, PCV-10, and PCV-13 vaccines were 51.17%, 70.7%, and 99.9%, respectively. According to our results, the pneumococcal coverage rate of PCV-7, PCV-10, and PCV-13 vaccine types is estimated to be 51.2%, 70.7%, and 99.9%, respectively. Furthermore, the trend of pneumococcal serotypes included in the PCV-13 was steadily increasing during the study period. Conclusion: It can be concluded that the most circulating pneumococcal serotypes were in accordance with specific serotypes included in the PCV-13 vaccine types. Therefore, including PCV-13 vaccines in immunization programs against pneumococcus in the elderly can effectively reduce the rate of infections.

Prevalence of Chlamydia trachomatis infection and evaluation of its genotypes among pregnant women in Tehran, Iran

Background and Objectives

Chlamydia trachomatis is an obligate intracellular pathogen. Infection with C. trachomatis in pregnant women can result in maternal and fetal death, due to pelvic inflammatory disease. Therefore, we aimed to evaluate this infection in pregnant women and identify circulating genotypes of C. trachomatis in Tehran, Iran.

Materials and Methods

Endocervical swabs were obtained from 101 pregnant women and tested by PCR assay to detect cryptic plasmid gene. Positive isolates were analyzed for C. trachomatis genotypes through amplification and sequencing of the omp1 gene and alignment with deposited sequences in Gene Bank.

Results

Infection with C. trachomatis was observed in 11 cases, yielding an overall prevalence of 10.8% in total. The majority of infected women were asymptomatic and the rate of infection was found more in women at the age of ≥30 years. However, no statistical association was found between C. trachomatis infection and risk factors in pregnant women. Analysis of isolated sequences revealed genotypes E (44.4%), D and F (both 22.2%), and K (11.2%) as main genotypes of C. trachomatis in this region.

Conclusion

Results of this study showed the prevalence of C. trachomatis infections among pregnant women is relatively high. Identifying the precise rate of infection and associated genotypes in other regions is suggested.

First Report of Nasal Myiasis Caused by Lucilia sericata in the Pediatric Age Group from Tehran, Iran

Myiasis is an infestation caused by dipterous larvae. Nosocomial myiasis usually occurs in bedridden patients. Herein, we report a nasal myiasis in a 12-year-old female with cerebral palsy (CP) from Tehran, Iran and provide morphological identification of Lucilia sericata as the causative agent. The infection was identified 10 days after the hospital admission. It can be categorized as a nosocomial infection. As far as we are aware, this is the first report of nasal myiasis in the pediatric age group from Tehran, Iran.

Tropheryma whipplei in the stool samples of children with acute diarrhea: a study from Tehran, Iran

Background

Recently, Tropheryma whipplei has been suggested as one of the causative agents of diarrhea among children worldwide. Limited data is available on the prevalence of T. whipplei among children with diarrhea in most countries such as Iran. This study was conducted to evaluate the prevalence of T. whipplei in children with acute diarrhea in Iran.

Methods

In this study, the stool samples were collected from 130 children under 10 years old with acute diarrhea from children's hospitals in Tehran city. Genomic DNA was extracted from stool samples and was tested for the presence of DNA of T. whipplei using the SYBR Green Real-time PCR method. Positive T. whipplei samples were finally confirmed by PCR Product sequencing.

Results

The mean age of participants was 32.5 months, and 54.6% of children were female. Using the SYBR Green Real-time PCR, 9.23% (12/130) of samples were positive for T. whipplei, which were confirmed by sequencing. 66.67% of positive cases were males. The duration of diarrhea in infected children with T. whipplei (83.3%) was significantly longer (OR: 5.93, 95% CI 1.24–28.22) compared to children with negative results (45.8%). Other demographic factors and clinical signs had not a statistically significant relationship with T. whipplei infection.

Conclusions

In this study, T. whipplei was detected in stool samples of children with acute diarrhea. The results indicated that T. whipplei could be associated with childhood diarrhea in Iran. The health care system and physicians should be aware of the presence of T. whipplei infection in Iran, especially in childhood diarrhea.

Immunogenicity and Safety of Three WHO Prequalified (DTwP -HB-Hib) Pentavalent Combination Vaccines Administered As Per Iranian National Immunization Plan in Iranian Infants: A Randomized, Phase III Study

BACKGROUND

The pentavalent vaccine Pentavac was officially introduced in the Iranian National Immunization Plan in November, 2014.

OBJECTIVE

To compare the immunogenicity and safety of Pentavac vaccine (Serum Institute of India Ltd.) with two other pentavalent vaccines available in Iran, i.e., Pentabio (PT Bio Farma (Persero)) and Shan 5 (Shantha Biotechnics Ltd.).

DESIGN

Randomized, phase III study.

PARTICIPANTS

900 infants attending the study sites to receive the vaccine at 2, 4, and 6 months of age.

INTERVENTION

Infants were randomly assigned to one of the Pentavac, Pentabio, and Shan 5 vaccine groups.

OUTCOMES

The antibody titers were measured against five antigens, diphtheria, tetanus, pertussis, Haemophilus influenzae B, and hepatitis B before receiving the first dose and one month after the last dose. The adverse events following vaccination after each dose were recorded in the adverse events diary.

RESULTS

All vaccines showed similar immunogenicity against four of the five antigens except pertussis. While vaccination with Shan 5 resulted in the highest immunogenicity against pertussis, Pentabio was significantly lower than the other two vaccines (P<0.001). The incidence of local adverse events significantly differed among the three vaccine brands (P<0.001), but the incidence of most of the evaluated systemic adverse events was similar (P>0.05).

CONCLUSIONS

Pentavac and Shan 5 had similar immunogenicity, the former having better immunogenicity against pertussis than Pentabio. Pentavac and Pentabio had a comparable safety profile.

Comparison of real-time PCR and nested PCR for toxoplasmosis diagnosis in toxoplasmic retinochoroiditis patients

Backgrounds

PCR is a proper technique that significantly improves toxoplasmosis diagnosis. However, a more sensitive technique is required. This study compared real-time PCR with nested PCR using B1, SAG-4, and MAG-1 bradyzoite genes to diagnose toxoplasmosis in toxoplasmic retinochoroiditis patients.

Methods

Blood samples were collected from 10 patients with active toxoplasmic chorioretinal lesions and 10 healthy individuals. Blood samples including peripheral blood mononuclear cells (PBMCs), serum and whole blood samples were used for DNA extraction. Serum was also used to detect anti-toxoplasma IgG and IgM antibodies. Nested PCR and real-time PCR were performed using B1, SAG-4, and MAG-1 target genes.

Results

Five (50%) out of the 10 patients were tested positive for toxoplasmosis with nested PCR using the PBMC samples. All the five patients tested positive with nested PCR were also tested positive for toxoplasmosis with real-time PCR using the PBMC samples. The real-time PCR results demonstrated that 9(90%) out of the 10 patients were positive based on B1 and the remaining one (10%) was positive only based on MAG-1. In general, of the patients, five (50%) were positive using SAG-4 and three (30%) were positive in term of MAG-1 using PBMCs with real-time PCR.

Conclusion

It appears that PBMC samples have the best performance as the PCR extraction method and are a good source for toxoplasmosis diagnosis. The use of B22 and B23 target genes due to their high sensitivity and specificity along with bradyzoite genes are recommended for toxoplasmosis diagnosis using PBMC samples with real-time PCR.

Is it time to administer acellular pertussis vaccine to childbearing age/pregnant women in all areas using whole-cell pertussis vaccination schedule?

Background:

Whole-cell pertussis (wP) vaccine administration is still advocated for children under 7 years of age in Iran. However, there is no recommendation for the administration of a dose of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to childbearing age/pregnant women in the Iranian vaccination program and it has increased the risk of infection through waning immunity during women’s childbearing age life. The study aimed to assess the levels of anti-Bordetella pertussis antibodies in childbearing age women of different ages in Iran.

Methods:

A cross-sectional study was conducted on a total number of 360 childbearing age women divided into six age groups, with 5-year intervals from 15 to 45 years old, in 2018–2019. Then, the levels of immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin G (IgG) antibodies against B. pertussis were evaluated using enzyme-linked immunosorbent assay (ELISA). The IBM SPSS Statistics software (version 16.0) (SPSS Inc., Chicago, IL, USA) was used for data analysis.

Results:

The mean age of the participants was 30.01 ± 8.35 years (range 14–45 years). All the cases were IgM negative, but two IgA-positive individuals (in the age groups of 14–19 and 30–34 years) were reported. Overall, 239 (66.4%) cases were IgG positive. The mean age of IgG-positive cases was 30.37 ± 8.37 years. The IgG-positive cases were mostly in the age groups of 30–34 and 35–39 years [43 (71.1%)]. The odds of IgG positivity were 1.97. The highest odds of IgG positivity were seen in 30–34 and 35–39 years groups (2.52) and the lowest odds were seen in the 20–24 and 25–29 years groups (1.60). Using the Jonckheere–Terpstra test, the increasing trend of IgG changes in different age groups was not statistically significant (Tπ=5.78, p = 0.09).

Conclusion:

The infants of women of childbearing age might be prone to pertussis in countries using the wP vaccination schedule. It is suggested to administer a dose of Tdap to women before or during pregnancy to increase the immunity of their infants against this disease during early infancy.

Global prevalence and genotype distribution of norovirus infection in children with gastroenteritis: A meta-analysis on 6 years of research from 2015 to 2020

In the post rotavirus vaccine era, norovirus (NoV) plays an increasingly important role in epidemic and sporadic gastroenteritis among children. This study was designed to provide an updated meta-analytic review of the prevalence of NoV among paediatric patients with gastroenteritis and to clarify the relationship between NoV infection and gastroenteritis. Systematic searches of the literature for potentially relevant studies were carried out from 1 January 2015 to 29 May 2020. The inverse variance method was chosen for weighting of the studies, and the random-effects model was used to analyse data. To determine the association between NoV infection and gastroenteritis in children, pooled odds ratio (OR) and its 95% confidence interval (CI) were computed for case-control studies. The pooled prevalence of NoV infection among 12,0531 children with gastroenteritis from 45 countries across the world was 17.7% (95% CI: 16.3%-19.2%). There were 28 studies with a case-control design, and the pooled prevalence of NoV infection among 11,954 control subjects was 6.7% (95% CI: 5.1%-8.8%). The pooled OR of the association of NoV infection and gastroenteritis was 2.7 (95% CI: 2.2-3.4). The most common NoV genotypes were GII.4 (59.3%) and GII.3 (14.9%). The highest frequency of NoV was found in the age group below 1 year. Our findings indicated a substantial burden of gastroenteritis caused by NoV globally, with GII.4 and GII.3 the major genotypes responsible for the majority of NoV-associated gastroenteritis cases among children. Younger age and male sex can be considered risk factors for NoV-associated gastroenteritis among children.

A comparison of post vaccination hepatitis B surface antibody level on the large and appropriate for gestational age infants

Purpose

The aim of this study was to compare the hepatitis B surface antibody (HBs Ab) titer 1 month after the 4th dose of hepatitis B vaccine administration on the large and appropriate for gestational age infants.

Materials and Methods

This cross-sectional study was conducted on 7-month-old cases (n=132) divided into two groups of 2-4 kg (group 1: appropriate for gestational age, 63 cases) and >4 kg (group 2: large for gestational age, 69 cases), whom were vaccinated with a four-dose schedule of hepatitis B vaccine in 2016, Tehran, Iran.

Results

Mean birth weight of the groups was 2.98±0.528 and 4.19±0.190 kg, respectively. Hepatitis B surface antigen and hepatitis B core antibody were negative in all cases. HBs Ab level in group 1 and 2 was 13,701.00±11,744.439 and 8,997.15±2,827.191, respectively (95% confidence interval of difference, -7,607.44 to -1,800.25). There was a significant difference between the two groups in antibody titration and antibody logarithm level (p=0.002, p=0.0001).

Conclusion

Birth weight may affect the response to the hepatitis B virus vaccine administration.

A meta-analysis on association between viral infections and Kawasaki disease in children

Aim: To investigate the association between different viral infections and the development of Kawasaki disease (KD) in children. Materials & methods: Electronic databases were searched for relevant studies published from inception to May 2020. The pooled odds ratios (ORs) of the association of different viral pathogens with KD were estimated using a random-effects model weighted by the inverse variance method. Results: The strongest associations were found between KD and human parvovirus B19 viremia (OR = 41.05; 95% CI: 5.13–328.28; I-square = 0%), EBV IgM seropositivity (OR = 7.18; 95% CI: 3.65–14.12, I-square = 0%) and human herpesvirus-6 IgG seropositivity (OR = 5.83; 95% CI: 1.06–32.01). Conclusion: Human parvovirus B19, EBV and human herpesvirus-6 are highly suspected to be key contributors to the development of KD.

The First Detection of Co-Infection of Double-Stranded RNA Virus 1, 2 and 3 in Iranian Isolates of Trichomonas vaginalis

Background

The Totiviridae family includes a number of double-stranded RNA viruses that can infect Trichomonas vaginalis. Some T. vaginalis isolates are infected with one or more double-stranded RNA (dsRNA) viruses. In this study, different strains of double-stranded RNA virus in Iranian isolates of T. vaginalis were evaluated for the first time in Iran.

Methods

Vaginal swabs were collected from 1550 participants who were referred to hospitals associated with Iran University of Medical Sciences, Tehran, Iran from June to November 2018. T. vaginalis isolates were cultured in Diamond's modified medium. After the extraction of nucleic acids using a DNA/RNA extraction kit, RT-PCR was performed and PCR products were purified and sequenced.

Results

In general 9 (0.6%) isolates were confirmed as T. vaginalis among 1550 collected vaginal samples. Among 9 isolates of T. vaginalis, three of them were infected with TVV1. One isolate has multiple infections with T. vaginalis virus (TVV1, TVV2 and TVV3) as coinfection. The nucleotide BLAST indicated that the T. vaginalis virus 1(TVV1) isolates were most closely related to TVV1-OC5, TVV1-UR1-1.The T. vaginalis virus 2 (TVV2) sequence had also a similarity with TVV2-UR1-1, TVV2-UR1 and TVV2-OC3. The sequence of T. vaginalis virus 3(TVV3) had similarity with TVV3-OC5, TVV3-UR1-1 and TVV3-UR1.

Conclusion

Three dsRNA viruses T. vaginalis virus (TVV1, TVV2 and TVV3) were detected using RT-PCR in T. vaginalis Iranian isolates. The coinfection of TVV1, TVV2 and TVV3 in one isolate of T.vaginalis was observed for the first time in Iran.

Serotype distribution of Streptococcus pneumoniae among healthy carriers and clinical patients: a systematic review from Iran

Streptococcus pneumoniae is associated with high morbidity and mortality in the world. Commercially licensed and available pneumococcal conjugate vaccines (PCVs) contain 10 (PCV10) and 13 (PCV13) pneumococcal serotypes. The most common serotypes of S. pneumoniae causing clinical diseases and carriers of S. pneumoniae in Iran are not yet known. Reviewing and reporting trends in the distribution of pneumococcal serotypes in Iran will be useful for policy-making as PCV is being introduced into Iran's routine immunization program. Here, we report a systematic literature review of studies regarding S. pneumoniae serotype distribution in clinical and carrier patients in Iran. MEDLINE (via PubMed), Scopus, Embase, Ovid, Google Scholar, Web of Science, and the Iranian Database were used to identify relevant papers published from 1 January 2000 to 21 August 2019. The search returned 8 relevant articles. Among serotypes causing invasive pneumococcal diseases (IPD), serotype 23F (16.4%) was the most circulating serotype followed by 19F (15.2%), 19A (11.3%), 6A/B (9.2%), 9 V (5.8%), and 11A (5.14%). In carrier patients, the most common serotypes were, in rank order, 6A/B (10%), 19F (9%), 14(6.2%), 17F (4.8%), and 20(4.5%). Vaccine coverage among IPD patients would be 67.1% for PCV10-TT and 73.8% for PCV13. The present review demonstrates that the serotypes which were most responsible for disease in Iran are included in PCV10-TT and PCV13. However, sentinel surveillance must be continued in representative parts of the country to assess changing trends in the distribution of pneumococcal serotypes and their implications for vaccine selection and rollout in Iran.

Incidence of intussusception in children less than five years of age: a pre-rotavirus vaccine survey from Iran, 2010-2015

Background: The aim of this study was to determine the baseline statistics of intussusception in the under-five- year age group in Iran to facilitate the monitoring of potential side effects after administration of rotavirus vaccine. Methods: This hospital-based historical cohort study reviewed children under 60 months of age with the final diagnosis of intussusception, ICD-10 code K56.1, using census in all hospitals of Tehran, Iran from March 2010-2015. Demographic (sex, age, hospital stay duration), clinical manifestations (such as currant jelly stool, abdominal pain, vomiting, and fever),diagnostic and treatment methods (contrast enema, ultrasonography, laparotomy, and laparoscopy), and outcome data of patients aged less than 5 years with the diagnosis of intussusception were collected and analyzed using SPSS Version 16.0 (SPSS Inc., Chicago, IL, USA) Results: In this study, 759 patients were diagnosed with intussusception; 309 (40.7%) cases were less than 12 months old. The annual incidence of intussusception was 66.54 cases per 100.000 in children less than one-year-old and 31.61 cases per 100.000 in children less than five years old. The most common symptoms and signs were abdominal pain/irritability (94.2%) and tenderness (24.2%), respectively. The diagnostic method was ultrasound in 75.9% of cases. The most frequent anatomic location was the ileocolic region (87.87%) and the most common treatment method was barium enema. Conclusion: This research has provided a baseline statistic for childhood intussusception in Tehran prior to the administration of the rotavirus vaccine to provide a better comparison with post-introduction data.

Serum levels of C1q/TNF-related protein-3 in inflammatory bowel disease patients and its inverse association with inflammatory cytokines and insulin resistance

Ulcerative colitis (UC) and Crohn's disease (CD) are two major forms of inflammatory bowel disease (IBD), which is an inflammatory disease. Studies have shown that adipose tissue and inflammation play important roles in the pathogenesis of IBD. C1q/TNF-related protein-3 (CTRP3) is a newly discovered adipokine playing a substantial role during inflammatory process, and for the first time in the present study, serum levels of this adipokine were measured in the UC and CD patients. This case-control study included 70 control, 50 UC, and 50 CD patients who were diagnosed by standard criteria. Serum levels of adiponectin, IL-6, TNF-α, TGF-β, and CTRP3 were evaluated using ELISA kits. Serum levels of IL-6, TNF-α, and TGF-β elevated in the UC and CD patients compared with the controls while adiponectin and CTRP3 diminished in the patient's groups compared with the control. Furthermore, decrease in CTRP3 serum levels was associated with the risk of UC and CD diseases. Moreover, CTRP3 indicated negative correlation with BMI, FBS, insulin, homeostasis model assessment of insulin resistance, IL-6, TNF-α, and TGF-β and also a positive correlation with adiponectin in both the UC and CD patients. For the first time, the present study demonstrated lower levels of CTRP3 in the UC and CD patients. Decreased serum levels of CTRP3 and its inverse relationship with inflammatory cytokines and TGF-β levels suggested a possible role for CTRP3 in the pathogenesis of UC and CD diseases.

Evaluation of a PCR assay for diagnosis of toxoplasmosis in serum and peripheral blood mononuclear cell among HIV/AIDS patients

Cerebral toxoplasmosis is one of the neurological infections with high morbidity and mortality in patients with AIDS, so the accurate method for diagnosis of cerebral toxoplasmosis seems necessary. In this study, nested PCR assay using B1 gene was evaluated in diagnosis of toxoplasmosis in serum and peripheral blood mononuclear cell (PBMC) among HIV/AIDS patients. One hundred eight blood samples from HIV/AIDS patients, including four patients with cerebral toxoplasmosis and 104 HIV/AIDS patients without cerebral toxoplasmosis were evaluated for the Toxoplasma gondii antibodies using Enzyme Linked immunosorbent Assay. DNA of serum and PBMC of these patients were extracted and nested-PCR was carried out. Of 108 participants, 95 cases (88%) were positive for Toxoplasma IgG antibodies and one patient was found positive for Toxoplasma IgM antibody. In general, four patients, including three patients with cerebral toxoplasmosis, who were positive for Toxoplasma IgG antibodies and one patient without cerebral toxoplasmosis who was positive for Toxoplasma IgM antibody were found to be PCR positive. DNA of T. gondii was detected in both serum and PBMC in two cerebral toxoplasmosis patients; however DNA was detected in only PBMC in other cerebral toxoplasmosis patient. All cases with cerebral toxoplasmosis were also diagnosed by clinical and radiological manifestations. The results of this study showed that the numbers of positive samples by PCR in PBMC were higher than serum specimens for diagnosis of toxoplasmosis. If molecular method and immunological assay are complemented with magnetic resonance imaging, the results can be useful for diagnosis of cerebral toxoplasmosis.

Governing off-label vaccine use: An environmental scan of the Global National Immunization Technical Advisory Group Network

BACKGROUND

National Regulatory Authorities approve the indications for vaccine use in the product information. Occasionally, National Immunization Technical Advisory Groups (NITAGs) make off-label recommendations for use in different age groups, populations, and dosing schedules from the product information. We sought to determine the rationale, policies and procedures for NITAG off-label recommendations.

METHODS

We conducted an environmental scan of Global NITAG Network members, immunization program managers and regulators in 38 high-, middle- and low-income countries. Participants completed an online survey regarding policies, procedures, and legislation governing development of off-label recommendations. A sub-sample of respondents met for a focus group and interviews which were analyzed qualitatively.

RESULTS

Thirty-four people responded from 26/38 (68%) countries surveyed; 76% of respondents were NITAG members or immunization program managers. Recommendations for off-label vaccine use were made in 14/26 (54%) countries; the NITAG made those recommendations in 8/14 (57%) countries. Reasons for off-label vaccine recommendations included response to disease outbreaks or vaccine shortages. Only one country had standard operating procedures for developing off-label recommendations while 6/14 (43%) countries had policies for implementing off-label recommendations. Nine respondents from 8 countries agreed to participate in a focus group (n = 6) or individual interviews (n = 3). Barriers to off-label recommendations included legal concerns, lack of standard definition for off-label use, and manufacturer reluctance to update product information. Facilitators included confidence in the decision-making process, and transparency of open communication among stakeholders.

CONCLUSIONS

Best practice guidelines are needed that define off-label use and outline a transparent, evidence-based approach to develop off-label recommendations.

Sitagliptin vs. pioglitazone as add-on treatments in patients with uncontrolled type 2 diabetes on the maximal dose of metformin plus sulfonylurea

AIMS

To compare the efficacy of sitagliptin versus pioglitazone as add-on drugs in patients with poorly controlled diabetes with metformin and sulfonylureas.

METHODS

This is a randomized, open-label, parallel assignment clinical trial. Patients who had inadequate glycemic control [7% (53 mmol/mol) ≤ A1C < 11% (97 mmol/mol)] despite a minimum 6-month period of active treatment with metformin 2000 mg/day plus gliclazide 240 mg/day were enrolled in the study. HbA1C, fasting blood glucose (FBG), fasting plasma lipid parameters [total cholesterol (TC0, low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C)], systolic and diastolic blood pressure (SBP, DBP), weight, waist circumference, and body mass index were measured at baseline and after 17, 34, and 52 weeks of treatment. Generalized estimating equation analysis was done to compare treatment groups for continuous efficacy parameters.

RESULTS

No significant difference in HbA1C reduction was observed between the treatment groups during the study course. (P = 0.149, adjusted P = 0.434; coefficient - 0.11 ± 0.08). The FBG (P = 0.032; coefficient 7.44 ± 3.48), HDL-C (P = 0.001; coefficient - 2.69 ± 0.83), TG (P = 0.027; coefficient 12.63 ± 5.71) and SBP (P < 0.001; coefficient 5.43 ± 1.26) changes from baseline, and weight gain were greater in the pioglitazone group. The mean changes in LDL-C and TC from baseline to week 52 were greater in the sitagliptin group (P = 0.034; coefficient - 7.40 ± 3.50, P = 0.013; coefficient - 7.16 ± 2.88, respectively).

CONCLUSION

Sitagliptin and pioglitazone were equally effective in improvement of HbA1C. There were some differences in terms of lipid indices, weight gain, and SBP. The current study confirmed that both sitagliptin and pioglitazone are effective treatment options and the decision should be made for each individual based on the baseline characteristics.

Budget Impact Analysis of Rotavirus Vaccine Adoption in the Childhood Immunization Schedule of Iran

OBJECTIVES

To examine the budget impact of introducing the RotaTeq® vaccine (Merck and Co Inc, West Point, PA) to the national immunization program in Iran.

METHODS

The pre- and postvaccine introduction costs were compared. The total annual costs included the vaccination and diarrhea treatment costs. The health outcome was the estimated annual cases of the disease. To evaluate the net budget impact, the annual prevaccine introduction cost was reduced from the postvaccine introduction cost. The sensitivity analysis was done to reduce the uncertainties.

RESULTS

The total cost of vaccination for 5 years would be more than $184 million. Nevertheless, the financial savings would be about $45 million and $7.5 million because of the reduction in the number of patients after vaccination in inpatient and outpatient sectors, respectively. So the incremental cost would be $131 450 210 during 5 years of immunization.

CONCLUSIONS

The results show that the inclusion of rotavirus vaccine in the national vaccination program would have a significant effect on health budgets and would raise government expenditure.

Prevalence of Intestinal Parasitic Infection in Cancer, Organ Transplant and Primary Immunodeficiency Patients in Tehran, Iran

Background:

Intestinal parasitic infection in immunodeficient patients especially those with impaired cellular immunity, like neoplasia, renal or heart transplant needs careful consideration. The objective of this study is to evaluate the prevalence of intestinal parasites in different group of patients including cancer patients; organ transplants recipients, and primary immunodeficiency patients.

Methods:

Stool samples from 190 patients including 80 patients with Primary Immunodeficiency, 85 cancer patients and 25 organ transplant recipients were collected; a direct examination with Phosphate buffered saline (PBS) and formalin ether concentration was performed. The DNA was extracted from parasitologically confirmed patients and nested PCR and sequencing was performed and new obtained sequences of Cryptosporidium parvum and Enterocytozoon bieneusi were compared with deposited ones.

Results:

In general, the prevalence of parasites was 26/80 (32.5%) in primary immunodeficiency, 22/85(25.9%) in cancer group, and 7/25 (28%) in organ transplant. The prevalence of intestinal parasitic infections in primary immunodeficiency patients were Blastocystis hominis 13 (16.2%), Giardia lamblia 10 (12.5%), Cryptosporidium 1(1.2%), Chilomastix mesnilii 1 (1.2%), Dientamoeba fragilis 1(1.2%). Of 25 organ transplants, 6 (24%) Cryptosporidium sp were found, all of which were confirmed as Cryptosporidium parvum and one case of Microspora in a heart transplant recipient was confirmed as Enterocytozoon bieneusi by PCR sequencing. The predominant intestinal parasitic infection in cancer patients was 19 (22.3%) Blastocystis hominis followed by two (2.3%) Giardia lamblia and one Dientamoeba fragilis 1 (1.1%).

Conclusion:

The high rate of infection with Blastocystis hominis was found in cancer patients especially colorectal cancer patients, so careful consideration should be given by physicians. Cryptosporidium sp was found to be the major cause of parasitic intestinal infection in patients with organ transplant compared to primary immunodeficiency patients; so transplant recipients undergoing immunosuppressive therapy should be considered as a risk group for acquiring microsporidiosis and Cryptosporidium infection.

Influenza vaccination situation in Middle-East and North Africa countries: Report of the 7th MENA Influenza Stakeholders Network (MENA-ISN)

Background

The Middle East and North Africa (MENA) region faces a dual challenge with regard to influenza infection due to severe zoonotic influenza outbreaks episodes and the circulation of Northern Hemisphere human influenza viruses among pilgrims.

Methods

The MENA Influenza Stakeholder Network (MENA-ISN) was set-up with the aim of increasing seasonal influenza vaccination coverage by (i) enhancing evidence-based exchanges, and (ii) increasing awareness on the safety and benefits of seasonal vaccination. During the 7th MENA-ISN meeting, representatives from 8 countries presented their influenza surveillance, vaccination coverage and actions achieved and provided a list of country objectives for the upcoming 3 years.

Results

MENA-ISN countries share the goal to reduce influenza related morbidity and mortality. Participants admitted that lack of knowledge about influenza, its consequences in terms of morbidity, mortality and economy are the major barrier to attaining higher influenza vaccination coverage in their countries. The cost of the vaccine is another key barrier that could contribute to low vaccination coverage. Participants drew a list of strategic interventions to bridge gaps in the knowledge of influenza burden in this region.

Conclusions

Participating countries concluded that despite an increase in vaccine uptake observed during the last few years, influenza vaccination coverage remains relatively low. Priority areas should be identified and action plans tailored to each country situation set-up to investigate the best way to move forward.

Retinal nerve fibre layer thickness is reduced in metabolic syndrome

AIMS

To investigate retinal nerve fibre layer (RNFL) thickness in people with metabolic syndrome (MetS) and healthy controls.

METHODS

A cross-sectional study was performed from March 2014 to January 2016. All participants underwent anthropometric and serological biochemical measurements, ophthalmological examination, and spectral-domain optical coherence tomography (SD-OCT). Individuals with elevated intraocular pressure, glaucoma, diabetic retinopathy and other ocular disorders were excluded. T-test, Chi square and general linear models were used to analyse the data.

RESULTS

In total, 278 eyes from 139 participants were investigated [median (interquartile range) age: 37 (32-43) years]. RNFL thickness was lower in the nasal superior (107.8 ± 19.5μm) and temporal superior (135.7 ± 18.9μm) sectors in MetS group compared with the control group (114.6 ± 22.4 μm, P = 0.013 and 140.7 ± 18.2 μm, P = 0.027, respectively). After multiple adjustments for age, gender and the side of the examined [right (OD)/left (OS)] eye, MetS was independently associated with a lower RFNL thickness in the nasal superior (β = 0.20, P = 0.009) and temporal superior (β = 0.14, P = 0.048) sectors. RNFL thickness was significantly reduced in participants with higher numbers of metabolic abnormalities, independent of age, gender and the side of the examined eye (P = 0.043).

CONCLUSION

Our findings demonstrate that MetS is independently associated with reduced RNFL thickness, suggesting that neurodegeneration is implicated in pathogenesis of MetS.

The Effect of Coenzyme Q10 Supplementation on Circulating Levels of Novel Adipokine Adipolin/CTRP12 in Overweight and Obese Patients with Type 2 Diabetes

Background: Adipolin, the novel adipokine that is proposed to be reduced in diabetes, obesity and inflammation, may improve glycemic control. It is known that coenzyme Q10 could improve insulin sensitivity. The aim of the current study was to investigate the effect of Q10 supplementation on adipolin concentration and glucose metabolism in overweight and obese diabetic patients. Material & Methods: Sixty four patients with type 2 diabetes and 25<BMI<35 kg/m² were randomly divided to receive 200 mg Q10 or placebo daily for 12 weeks. Fasting serum levels of adipolin, glucose, insulin, HbA1c and HOMA-IR were measured before and after supplementation. Results: Following supplementation, adipolin levels decreased significantly in Q10 group (38.19±32.02 to 29.03±34.23 ng/ml;P=0.001). HbA1c decreased dramatically following supplementation only in Q10 group (8.6±2.2% to 7.9±2.1%, P<0.001). It was also marginally lower in Q10 compared to placebo group at the end of study (P=0.056). Moreover, weight (P=0.003), BMI (P=0.003) and waist circumference (P=0.016) decreased significantly in Q10 group. No significant alterations were observed in FBS, fasting insulin and HOMA-IR within or between Q10 and placebo groups. Conclusions: Coenzyme Q10 reduced HbA1c considerably in overweight and obese patients with diabetes, although interestingly adipolin levels declined simultaneously. In this study, Q10 modulated glucose homeostasis, which was expected to be mediated by increasing adipolin. The similar mechanisms of action of Q10 and adipolin may justify lowering effect of Q10 on adipolin. In addition, the possible anti-adipogenic effect of Q10 might explain the significant reduction in weight and waist circumference and hence the adipolin decrease. Further studies are required to evaluate the precise role of adipolin in glucose metabolism as well as the probable effects of coenzyme Q10 on adipose tissue and adipokines.

Hypertension and mortality in the Golestan Cohort Study: A prospective study of 50 000 adults in Iran

High blood pressure has been the second most important determinant of disease burden in Iran since the 1990s. Despite well-recognized evidence on the association of high blood pressure and mortality in other countries, this relationship has not been fully investigated in the demographic setting of Iran. The current study is the first large-scale longitudinal study of this association in Iran. Briefly, 50 045 subjects between 40 and 75 years of age have been recruited and followed. Blood pressure measurements were carried out at baseline. Causes of death were reported and verified by verbal autopsy throughout the follow-up period. The outcomes of interest were all-cause deaths and deaths due to ischemic heart disease (IHD) or stroke. Cox proportional hazards regression models were used to estimate hazard ratios (HRs). A total of 46 674 subjects free from cardiovascular disease at baseline were analyzed. Absolute mortality rates increased along with increasing systolic or diastolic blood pressure above 120 and 80 mm Hg, respectively. Adjusted HRs (95% confidence intervals) for each 20 mm Hg increase in systolic blood pressure in all age groups were 1.18 (1.13-1.23) for all-cause mortality, 1.21 (1.13-1.31) for deaths due to IHD and 1.50 (1.39-1.63) for deaths due to stroke. Unadjusted and adjusted HRs were higher in younger subjects and decreased with increasing age of the participants. High blood pressure is a serious threat to the health of Iranians. The entire health-care system of Iran should be involved in a comprehensive action plan for controlling blood pressure.

Reduction in asymmetric dimethylarginine plasma levels by coenzyme Q10 supplementation in patients with type 2 diabetes mellitus

AIM

According to many studies, supplementation with Coenzyme Q10 (CoQ10) yields beneficial results in terms of endothelial function in type 2 diabetes mellitus. Despite these promising results, data elucidating the effect of CoQ10 on plasma levels of asymmetric dimethylarginine (ADMA), as a recently discussed cardiovascular risk factor, is lacking. This study was designed to investigate the effect of CoQ10 supplementation on endothelial function, specifically by evaluating plasma ADMA levels.

METHODS

Sixty-four type 2 diabetic patients were randomly assigned to two groups; either receiving 200mg/d oral dose of CoQ10 (N.=31) or receiving placebo (N.=33) for 12 weeks. Clinical and biochemical assessments were performed before and after the trial for evaluating ADMA, serum nitrite and nitrate (NOx), hemoglobin A1c and lipid profile.

RESULTS

The intervention resulted in a significant improvement in ADMA, NOx , low-density lipoprotein and hemoglobin A1c levels in CoQ10 compared to placebo group. Interestingly, difference in changes of these parameters were also significant (P=0.01, 0.03, 0.04 and 0.03, respectively).

CONCLUSION

Supplementation with CoQ10 yields beneficial effects on ADMA levels, leading to decreased diabetic cardiovascular events.

Cost-Effectiveness of Rotavirus Vaccination for Under-Five Children in Iran

Background:

Rotavirus diarrhea is one of the most important causes of death among under-five children. Anti-rotavirus vaccination of these children may have a reducing effect on the disease.

Objectives:

this study is intended to contribute to health policy-makers of the country about the optimal decision and policy development in this area, by performing cost-effectiveness and cost-utility analysis on anti-rotavirus vaccination for under-5 children.

Patients and Methods:

A cost-effectiveness analysis was performed using a decision tree model to analyze rotavirus vaccination, which was compared with no vaccination with Iran’s ministry of health perspective in a 5-year time horizon. Epidemiological data were collected from published and unpublished sources. Four different assumptions were considered to the extent of the disease episode. To analyze costs, the costs of implementing the vaccination program were calculated with 98% coverage and the cost of USD 7 per dose. Medical and social costs of the disease were evaluated by sampling patients with rotavirus diarrhea, and sensitivity analysis was also performed for different episode rates and vaccine price per dose.

Results:

For the most optimistic assumption for the episode of illness (10.2 per year), the cost per DALY averted is 12,760 and 7,404 for RotaTeq and Rotarix vaccines, respectively, while assuming the episode of illness is 300%, they will be equal to 2,395 and 354, respectively, which will be highly cost-effective. Number of life-years gained is equal to 3,533 years.

Conclusions:

Assuming that the illness episodes are 100% and 300% for Rotarix and 300% for Rota Teq, the ratio of cost per DALY averted is highly cost-effective, based on the threshold of the world health organization (< 1 GDP per capita = 4526 USD). The implementation of a national rotavirus vaccination program is suggested.

Vitamin D deficiency is associated with insulin resistance in nondiabetics and reduced insulin production in type 2 diabetics

It is not known whether the association of serum 25-hydroxyvitamin D [25(OH)D] with glycemic measurements of individuals without diabetes is similar to those with diabetes or not. This study is aimed to investigate the association of serum 25(OH)D with glycemic markers of diabetics, nondiabetics, and prediabetics. A case-control study was conducted on age and sex matched 1,195 patients with type 2 DM, 121 prediabetics, and 209 healthy controls. Anthropometric variables, lipid profile, glycemic measurements, and serum 25(OH)D levels were recorded. Serum insulin and C-peptide levels were also measured. All glycemic measurements were compared between diabetics and nondiabetics and prediabetics at different vitamin D status. Patients with DM had lower serum 25(OH)D compared to prediabetics and healthy controls. Endogenous insulin production in response to food intake and in fasting was significantly lower in vitamin D deficient patients with DM compared to those with serum 25(OH)D>40 ng/ml. Diabetic women with serum 25(OH)D<20 ng/ml had lower beta cell function as estimated by lower HOMA-B compared to their counterparts with serum 25(OH)D>40 ng/ml. Healthy individuals with serum 25(OH)D<20 ng/ml had signs of insulin resistance as estimated by significant increase of HOMA-IR, HbA1c, and fasting plasma glucose (FPG). In addition, we found that serum 25(OH)D was inversely associated with insulin resistance. Vitamin D deficiency is associated with insulin resistance in nondiabetics, which is independent of obesity. Furthermore, vitamin D deficiency is associated with reduced insulin production in type 2 diabetics, which was mainly observed in men. Accordingly, a gender disparity also exists in association of serum 25(OH)D with glycemic measurements.

The comparative effect of pioglitazone and metformin on serum osteoprotegerin, adiponectin and intercellular adhesion molecule concentrations in patients with newly diagnosed type 2 diabetes: a randomized clinical trial

AIM

The etiologic role of inflammatory pathways in the development of diabetic complications, especially cardiovascular events, has been established. The anti-inflammatory role of metformin and pioglitazone has been described; however, no study to date has compared the efficacy of these common oral agents in this regard. In this study, the authors aimed to compare the anti-inflammatory properties of pioglitazone and metformin, with respect to their effect on serum concentrations of highly sensitive C-reactive protein (hsCRP), osteoprotegerin (OPG), intercellular adhesion molecule-1 (ICAM-1) and adiponectin.

METHODS

In an open-label randomized clinical trial, 117 patients with newly diagnosed type 2 diabetes mellitus were visited; 84 fulfilled the inclusion criteria, and were randomly allocated to 2 arms receiving either 1,000 mg/d metformin or 30 mg/d pioglitazone, respectively. Biochemical assessments were made at baseline and the end of the 3 months trial.

RESULTS

Significant reduction in FPG, insulin and HbA1c in women and men of both arms were observed. Log-hsCRP values significantly decreased in both arms. A decreasing, but non-significant trend in log-OPG levels was observed in women of the metformin arm (p=0.063). A greater reduction in log-ICAM levels was identifiable in men receiving pioglitazone compared to the other arm (p=0.008); in addition, the same trend was observed in log-OPG values (p=0.029). Nonetheless, reduction in log-ICAM and log-OPG levels was comparable between the 2 arms. A significant increase in adiponectin was observed in both men and women in the pioglitazone arm (p<0.001), whereas changes were non-significant in the metformin arm.

CONCLUSION

Remarkably, patients receiving pioglitazone revealed more significant reduction in inflammatory markers.

Comparative effects of metformin and pioglitazone on YKL-40 in type 2 diabetes: a randomized clinical trial

PURPOSE

Metformin and pioglitazone are believed to exert their long-term benefits by means of amelioration of chronic low-grade inflammation, a key event in development of diabetes and its long-term complications. The present trial was designed to investigate the comparative efficacy of the two anti-diabetes medications on serum concentrations of YKL-40, a novel marker of inflammation.

METHODS

In a parallel-group, open-label, randomized trial setting (ClinicalTrials.gov Identifier No. NCT01521624), 84 newly diagnosed, medication-naïve type 2 diabetes patients were assigned to metformin 1,000 mg daily (n = 42) or pioglitazone 30 mg daily (n = 42). Serum concentrations of YKL-40, along with highly sensitive C-reactive protein, indices of glycemic control and lipid profile were measured at baseline and after 3 months.

RESULTS

In the analyzed sample (metformin = 40, pioglitazone = 42), both medications were equally effective with regard to control of hyperglycemia, and hsCRP reduction (p > 0.05). However, metformin caused a significant decline in weight (p = 0.005), BMI (p = 0.004), and total cholesterol levels (p = 0.028) of the patients. Metformin also significantly reduced YKL-40 concentrations after 3 months (1.90 ± 17 vs. 1.66 ± 0.15 µg/L, p = 0.019). The amount of change in the pioglitazone arm did not reach statistical significance (2.18 ± 0.14 vs. 2.25 ± 0.16 µg/L, p = 0.687). When compared, metformin was significantly more effective than pioglitazone with respect to YKL-40 reduction in both univariate (p = 0.020, effect size = 6.7%) and multivariate models (p = 0.047, effect size = 5.7%).

CONCLUSIONS

Metformin is more effective in reduction of YKL-40 concentration in short term and the effect seems to be independent of degree of glycemic control, or hsCRP reduction.

The role of metabolic syndrome and related clinical variables in determining CEA levels

OBJECTIVES

The aim of the study was to investigate how metabolic syndrome (MetS) and related clinical variables correlate with high levels of carcinoembryonic antigen (CEA).

MATERIAL AND METHODS

Variables related to MetS as well as the serum CEA levels of 366 subjects were assayed. Logistic regression analyses were used to determine the associations between various clinical variables and high CEA levels, which were defined as values greater than the median (i.e., 1.4 ng/mL).

RESULTS

MetS, as an entity, and diabetes were more prevalent in subjects with high CEA levels (for MetS: 64.2% in subjects with CEA≥1.4 vs. 51.1% in subjects with CEA<1.4 ng/mL, p<0.05; for diabetes: 72.6% vs. 59.1% respectively, p<0.05). Waist circumference, triglycerides, fasting plasma glucose (FPG), homeostasis-model assessment of insulin resistance index (HOMA-IR), and HbA1c as well as systolic and diastolic blood pressures were directly associated with CEA levels, after adjusting for age and sex (p<0.05). Subjects with a greater number of MetS components tended to have high CEA levels. Multivariate regression analysis revealed that the association of waist circumference and FPG with CEA is independent of other MetS components, age and sex.

CONCLUSIONS

MetS and related clinical variables contribute to CEA values. Thus, the reference interval of CEA may differ according to the clinical status of the subjects.

Rotavirus Infection in Children with Acute Gastroenteritis in Iran: A Systematic Review and Meta-analysis

BACKGROUND

The recent studies show that Rotavirus is important cause of the acute gastroenteritis. The aim of this review is to estimate the number of Rotavirus infection among Iranian children by performing a systematic review and estimating a pooled data.

METHODS

We performed a systematic literature review in relevant databases including PUBMED, MEDLINE, OVID, SID, MAGIRAN, and IRANMEDEX. Search in databases was done in October 10, 2013. Meta-analysis was performed using the STATA statistical package version 11. We assessed heterogeneity by Q-test and used random model for pooling measures of proportion of Rotavirus infection among Iranian children with diarrhea (and 95% confidence intervals [CI]). Sub group analysis between in-patient and outpatient group were done and publication bias was assessed by Egger and Begg tests.

RESULTS

A total of 154 records were identified in our searching. There were 36 studies including a total of 15,368 children with diarrhea. Out of 15,368 children, 6,338 were positive for Rotavirus gastroenteritis. Overall pooled estimate of infection with Rotavirus among cases of gastroenteritis was 0.35 (95% CI, 0.28-0.41). Pooled estimates for hospitalized children and outpatient subgroups were 0.39 (95% CI, 0.30-0.48), and 0.31 (95% CI, 0.23-0.38), respectively.

CONCLUSIONS

This study supports the importance of Rotavirus in the Iranian population such as common cause of diarrhea among children. Therefore, decision to adopt immunization programs to prevent Rotavirus infection might be helpful in Iran.

Differences in vitamin D concentration between metabolically healthy and unhealthy obese adults: associations with inflammatory and cardiometabolic markers in 4391 subjects

AIM

This study aimed to compare concentrations of serum 25-hydroxy vitamin D and inflammatory markers in metabolically healthy obesity (MHO) and metabolically unhealthy obesity (MUO), and to determine whether the relationship between vitamin D levels and both cardiometabolic and inflammatory markers differs between MHO and MUO.

METHODS

This cross-sectional study comprised 4391 obese subjects aged>18 years. A panel of cardiometabolic and inflammatory markers, including anthropometric variables, glycaemic indices, lipid profiles, liver enzymes, homocysteine, C-reactive protein (CRP), fibrinogen and serum 25-hydroxy vitamin D levels, was investigated. All cardiometabolic and inflammatory markers in MHO and MUO as well as in vitamin D deficiency were compared.

RESULTS

Prevalence of MHO was 41.9% in our obese subjects using International Diabetes Federation criteria. Considering insulin resistance and inflammation, the prevalence of MHO was 38.4%. Individuals with MHO had significantly higher vitamin D concentrations compared with MUO, and this difference in vitamin D status persisted after accounting for BMI and waist circumference. Subjects with MHO had significantly better metabolic status, lower liver enzymes, lower inflammatory markers and higher serum 25-hydroxy vitamin D than those with MUO. Associations between vitamin D levels and inflammatory and cardiometabolic markers differed according to MHO/MUO status. Among MUO subjects, vitamin D deficiency was associated with higher liver marker and homocysteine levels. Serum vitamin D was negatively associated with fasting plasma glucose and HbA1c in MHO only.

CONCLUSION

Serum 25-hydroxy vitamin D levels were lower in MUO vs MHO, and reduced vitamin D concentrations were more strongly associated with cardiometabolic and inflammatory markers in MUO than in MHO subjects. These findings suggest that a deficiency in vitamin D could be a key component of MUO.

National Immunization Program in Iran: whys and why nots

The national immunization program of Iran has played an important role in achievements toward the control, elimination and eradication of some important infectious diseases. However, there are challenges regarding both diseases covered by the program and the type of vaccine or route of delivery, which are discussed in this Commentary. The current immunization program does not provide vaccines for rotavirus, Haemophilus influenzae type b (Hib), varicella, pneumococcal and influenza. There are also issues regarding use of oral poliovirus vaccine (OPV) instead of inactivated vaccine (IPV) and whole cell pertussis (wP) instead of acellular pertussis vaccine (aP). We have reviewed the evidence regarding these immunization issues; it seems that at least for rotavirus and Hib, there is sufficient evidence regarding the efficiency of vaccination in Iran. OPV is currently preferred because of the endemic situation of polio in Afghanistan and Pakistan (eastern neighbors) and considerations of efficiency. More data are needed for the analysis of policies on pneumococcal and influenza vaccines and aP vaccine.

Visit-to-visit blood pressure variability is related to albuminuria variability and progression in patients with type 2 diabetes

Recent studies have suggested that visit-to-visit variability of blood pressure (BP) is correlated with microalbuminuria in patients with diabetes, independent of mean pressure. We investigated the contribution of BP variability to albuminuria progression in normoalbuminuric type 2 diabetes patients. BP and urinary albumin excretion of patients were assessed in each visit during a median follow-up of 31 months. Variability was assessed using standard deviation, coefficient of variation, standard deviation independent of mean, peak, average real variability, and average real variability independent of mean. Of 194 patients enrolled, 31 subjects (16.0%) developed microalbuminuria. Systolic blood pressure (SBP) variability indices (except for coefficient of variation and average real variability) were significant predictors of microalbuminuria in multivariate Cox regression models (hazard ratio ranging from 2.02 to 2.76). The same was not observed for diastolic blood pressure. Using linear regression, SBP variability significantly correlated with some but not all indices of albuminuria variability. Peak SBP was the strongest predictor of albuminuria variability in multivariate models (standardized beta ranging from 0.216 to 0.339). In conclusion, visit-to-visit variability of SBP is an independent risk factor for development of microalbuminuria in patients with diabetes, and is associated with an increased variability in albuminuria.

Comparison of osteoprotegerin and vascular endothelial growth factor in normoalbuminuric Type 1 diabetic and control subjects

BACKGROUND

The aim of the current study was to evaluate the association of osteoprotegerin and vascular endothelial growth factor (VEGF) with glycemic indices and diabetes status.

METHODS

A total of 44 normoalbuminuric Type 1 diabetic patients and 44 healthy control subjects, matched for age, body mass index, sex ratio, and lipid measures were enrolled. Univariate and multivariate logistic regression analyses were used to determine the association of osteoprotegerin and VEGF with diabetes status. Further, linear regression analysis was performed to investigate the roles of osteoprotegerin and VEGF as determinants of glycated hemoglobin (HbA1c).

RESULTS

Osteoprotegerin and VEGF were significantly elevated in diabetic subjects (2.76±0.85 vs 2.26±0.75 pmol/l and 187.1±92.7 vs 125.9±52.3 pg/ml, respectively, p<0.01) and were positively correlated with glycemic indices (i.e. fasting plasma glucose and HbA1c, p<0.001). After controlling for possible confounding factors, odds ratios (confidence interval) of osteoprotegerin and VEGF for diabetes were 2.532 (1.003-6.392) and 1.021 (1.002-1.041), respectively (p<0.05). Further, linear regression analysis revealed that the association of osteoprotegerin with HbA1c is independent of VEGF and vice versa (p<0.001).

CONCLUSION

Osteoprotegerin and VEGF are elevated in normoalbuminuric Type 1 diabetic subjects and are independently associated with glycemic indices and diabetes status.

The effect of coenzyme Q10 supplementation on metabolic status of type 2 diabetic patients

AIM

Increased oxidative stress and impaired antioxidant defense contribute to pathogenesis and progression of type 2 diabetes. Consistent with this fact, it has been shown that diabetic patients have reduced coenzyme Q10 level. In this study we sought to compare the effect of coenzyme Q10 versus placebo on glycemic control and lipid profile in type 2 diabetic patients.

METHODS

In a randomized double-blind placebo-controlled trial, 64 type 2 diabetic patients were randomly assigned to receive either 200 mg Q10 or placebo daily for 12 weeks. Fasting blood samples were obtained and fasting plasma glucose (FPG), HbA1c, total cholesterol (TC), triglycerides (TG), LDL-C and HDL-C were measured.

RESULTS

In this study no significant differences considering age, body mass index (BMI), diabetes duration, FPG, HbA1c, TC, TG, LDL-C and HDL-C were shown between two groups. Serum HbA1C concentration decreased in the Q10 treated group (8 ± 2.28 vs. 8.61 ± 2.47%) with no significant effect in the placebo group. Following intervention no differences have been shown regarding FPG, TG and HDL-C in Q10 treated group. Furthermore, mean differences of TC and LDL-C level were statistically altered between two groups (P value=0.027 and 0.039 respectively).

CONCLUSION

In this study, Q10 treatment improved glycemic control, total and LDL cholesterol but these differences were associated with no favourable effects on TG and HDL-C.

The inverse relation of CA-125 to diabetes, metabolic syndrome, and associated clinical variables

OBJECTIVE

We aimed to evaluate the association of carbohydrate antigen 125 (CA-125; also known as cancer antigen 125) with various anthropometric and metabolic measures and also with diabetes and metabolic syndrome.

METHODS

A total of 357 diabetic and nondiabetic subjects were enrolled. CA-125, anthropometric parameters, lipids, blood pressure, as well as glycemic and insulin resistance measures were assessed. Metabolic syndrome was defined according to the International Diabetes Federation (IDF) criteria.

RESULTS

CA-125 was lower in subjects with diabetes and/or metabolic syndrome [median (interquartile range) of 8.20 (5.70-11.57) and 9.55 (6.50-16.25) U/mL for diabetic and nondiabetic subjects, respectively, P<0.05; 8.11 (5.90-11.45) and 9.50 (6.34-14.76) U/mL for subjects with metabolic syndrome and those without metabolic syndrome, respectively, P<0.05]. Anthropometric measures, dyslipidemia, insulin resistance, and blood pressure were inversely associated with CA-125 (P<0.05); waist circumference and body mass index were also identified as the strongest determinants of CA-125 (P<0.001). Using multiple linear regression models, waist circumference (β=-0.088, P<0.01), apolipoprotein B (β=-0.027, P<0.05), and systolic blood pressure (β=-0.054, P<0.05) were independently associated with CA-125. However, none of insulin resistance measures remained in the model after adjusting for other clinical variables.

CONCLUSION

CA-125 is inversely correlated with diabetes status, metabolic syndrome, and their associated anthropometric and metabolic measures. Furthermore, CA-125 is independently associated with waist circumference, apolipoprotein B, and systolic blood pressure, but not with any insulin resistance measures.

Gender-dependent effects of metformin on vaspin and adiponectin in type 2 diabetes patients: a randomized clinical trial

The aim of the study was to assess the effects of metformin on serum concentrations of vaspin and adiponectin in diabetes. Randomized clinical trial of 99 newly diagnosed, medication-naïve, type 2 diabetes patients (NCT01521624) was carried out. Patients were randomly assigned to either metformin 1 000 mg daily plus advice for exercise and lifestyle modification (n=50) or modification alone (n=49). A third group of 50 normoglycemic subjects were also enrolled to compare adipokine concentrations between healthy and diabetes subjects. Serum concentrations of adipokines were measured at baseline and after 12 weeks using ELISA method. Healthy subjects had significantly higher adiponectin levels, but lower concentrations of serum vaspin (p<0.001 in all cases). Vaspin and adiponectin concentrations were 23% and 26% higher in women compared with men. Vaspin dropped significantly after 3-month metformin therapy only in women (1.36 vs. 0.98, p=0.003 in women and 1.31 vs. 1.20, p=0.335 in men). Metformin therapy did not change adiponectin concentration in neither women nor men of the case group (12.66 vs. 12.44 p=0.699 in women and 10.13 vs. 10.94 p=0.253 in men). Comparing case and control groups, metformin decreased vaspin levels more significantly than lifestyle modification in the final multivariate model after controlling for potential confounders only in women (p=0.002) but not men (p=0.896). Conversely, adiponectin levels increased more significantly in the control group, again only in women (p=0.012 and 0.579 for women and men, respectively). Our findings suggest that metformin therapy reduces vaspin concentration in a gender-specific manner. Metformin exerts little benefit in increasing adiponectin levels in diabetes patients.

Patient-to-Patient Transmission of Hepatitis C at Iranian Thalassemia Centers Shown by Genetic Characterization of Viral Strains

BACKGROUND

Hepatitis C is prevalent among thalassemia patients in Iran. It is mainly transfusion mediated, in particular among patients treated before 1996 when blood screening was introduced.

OBJECTIVES

The current study aimed to investigate why patients still seroconvert to anti-HCV in Iranian thalassemia centers.

PATIENTS AND METHODS

During 2006-2007 sera were sampled from 217 anti-HCV positive thalassemia patients at nine thalassemia centers in Tehran and Amol city, where 34 (16%) patients had been infected after 1996. The HCV subtype could be determined by sequencing and phylogenetic analysis of partial NS5B and/or 5׳NCR-core region in 130 strains.

RESULTS

1a (53%) was predominant followed by 3a (30%), 1b (15%), and one strain each of 2k, 3k and 4a. Phylogenetic analysis revealed 19 clades with up to five strains diverging with less than six nucleotides from each other within subtypes 1a and 3a. Strains in seven clades were from nine patients infected between 1999 and 2005 and similar to strains from eight patients infected before 1996, indicating ongoing transmission at the centers. Further epidemiological investigation revealed that 28 patients infected with strains within the same clade had frequently been transfused at the same shift sitting on the same bed. An additional eight patients with related strains had frequently been transfused simultaneously in the same room.

CONCLUSIONS

The results suggest nosocomial transmission at these thalassemia centers both before and after the introduction of blood screening. Further training of staff and strict adherence to preventive measures are thus essential to reduce the incidence of new HCV infections.

Immunization against Haemophilus Influenzae Type b in Iran; Cost-utility and Cost-benefit Analyses

BACKGROUND

Haemophilus Influenzae type b (Hib) is an important cause of morbidity and mortality in children. Although its burden is considerably preventable by vaccine, routine vaccination against Hib has not been defined in the National Immunization Program of Iran. This study was performed to assess the cost-benefit and cost-utility of running an Hib vaccination program in Iran.

METHODS

Based on a previous systematic review and meta-analysis for vaccine efficacy, we estimated the averted DALYs (Disability adjusted life years) and cost-benefit of vaccination. Different acute invasive forms of Hib infection and the permanent sequels were considered for estimating the attributed DALYs. We used a societal perspective for economic evaluation and included both direct and indirect costs of alternative options about vaccination. An annual discount rate of 3% and standard age-weighting were used for estimation. To assess the robustness of the results, a sensitivity analysis was performed.

RESULTS

The incidence of Hib infection was estimated 43.0 per 100000, which can be reduced to 6.7 by vaccination. Total costs of vaccination were estimated at US$ 15,538,129. Routine vaccination of the 2008 birth cohort would prevent 4079 DALYs at a cost per averted-DALY of US$ 4535. If we consider parents' loss of income and future productivity loss of children, it would save US$ 8,991,141, with a benefit-cost ratio of 2.14 in the base-case analysis. Sensitivity analysis showed a range of 0.78 to 3.14 for benefit-to-cost ratios.

CONCLUSION

Considering costs per averted DALY, vaccination against Hib is a cost-effective health intervention in Iran, and allocating resources for routine vaccination against Hib seems logical.

Apolipoproteins a-I and B as components of metabolic syndrome with respect to diabetes status: a factor analysis

BACKGROUND

The aim of the current study was to elucidate the clustering pattern of metabolic syndrome components along with apolipoproteins (Apo) A-I and B in diabetic and nondiabetic subjects.

METHODS

Factor analysis of conventional variables of metabolic syndrome [i.e., waist circumference, homeostasis model assessment of insulin resistance (HOMA-IR), triglycerides (TG), high-density lipoprotein-cholesterol (HDL-C), and systolic blood pressure (SBP)] with or without addition of Apo A-I and B was performed on 567 and 327 diabetic and nondiabetic subjects, respectively. Thereafter, analyses were repeated after substitution of TG and HDL-C by the TG-to-HDL-C ratio (TG/HDL-C).

RESULTS

Regarding conventional variables of metabolic syndrome, one or two underlying factors were identified, depending on whether lipid measures were entered as two distinct variables or as a composite measure. Apolipoproteins were consistent with a one-factor structure model of metabolic syndrome and did not change the loading pattern remarkably in nondiabetics. TG and HDL-C tended to cluster with Apo B and A-I, respectively, in different models.

CONCLUSION

The current study confirms that addition of Apo A-I and B is consistent with the one-factor model of metabolic syndrome and does not modify the loading pattern remarkably in nondiabetic subjects.

Adverse reactions following immunization with MMR vaccine in children at selected provinces of Iran

BACKGROUND

Several adverse events following immunization (AEFI) have been attributed to immunization with live attenuated measles, mumps, and rubella (MMR) vaccines. The MMR vaccine was introduced into the routine infant immunization schedule in 2003, followed by a second dose of vaccine at school-entry for children 4 to 6 years of age. The objective of this study was to characterize adverse reactions following MMR vaccination in Iran.

METHODS

Children who received the MMR vaccine and resided in five selected provinces of Iran were examined weekly for four weeks to detect well-known AEFIs that included: parotitis, fever and convulsions, convulsions without fever, encephalopathy, and anaphylactic reactions. Incidence of AEFIs were calculated and compared among recipients in both age groups.

RESULTS

During the follow-up period, trained providers reported 792 AEFIs. Parotitis was the most frequent event occurring in 1.8% of recipients. Of 14,109 children vaccinated at 12 months of age the following AEFIs occurred: parotitis (147), fever and convulsions (8), convulsions (7), encephalopathy (1), and anaphylactic reactions (1). Of 29,338 children vaccinated at 4 to 6 years of age, parotitis, fever and convulsions, encephalopathy, and anaphylaxis occurred in 626, 5, 1, and 1 child, respectively; no convulsions without fever were reported in this age group.

CONCLUSION

Parotitis is the most frequent AEFI among MMR vaccine recipients in Iran. Incidence rates of AEFIs following MMR vaccination in Iran are similar to rates of AEFIs reported in other studies.

Immunogenicity and efficacy of Hoshino strain of mumps vaccine in Iran; two years study

This report describes the immunogenicity and efficacy and long term immunity of Hoshino strain of Mumps (included in MMR Vaccine) in shahr-e-kord, Islamic Republic of Iran (I.R.Iran). A total of 338 Children aged 3-18 years were tested for Mumps IgG using enzyme-linked immunosorbent assay (ELISA). The proportion of susceptible, mumps IgG negative, children was 19.8% (67 subjects). Of the 67 susceptible children, 36 received the MMR vaccination and successfully completed the study. Blood was collected by venipuncture 3, 12, and 24 months after vaccination and serum samples were tested by ELISA for detection of Mumps IgM and IgG. The overall seroconversion rate was 86.1%, 77.7% and 75% at 3, 12, and 24 months after vaccination respectively.

Molecular Epidemiology of Measles Virus before and after the 2003 Mass Vaccination Campaign for Measles/Rubella in Iran

BACKGROUND

Molecular epidemiology of measles virus (MV) is important, not only to measure the success of measles vaccination programs but also to monitor the circulation and elimination of the virus worldwide. In this study, we compared MV obtained from patients before the 2003 mass vaccination MR campaign and viruses detected after 2003 until 2008 in Iran.

METHODS

The nucleoprotein (N) gene of 29 MV strains circulating in Iran between 2002 and 2008 were amplified by RT-PCR and subjected to sequence and phylogenetic analysis.

RESULTS

Molecular characterization of MV studied here revealed that although the outbreaks in Iran were associated with MV genotype D4, the isolated viruses clearly belonged to several different lineages. Maximum and minimum homology within the 29 Iranian strains in our study was100% and 94.9% within the carboxyl terminus of the N gene, respectively. Using ClustalX program, the alignment of Iranian MV sequences showed nine lineages.

CONCLUSION

This study provides the usefulness of MV sequence analysis for the demonstration of local interruption of indigenous strain transmission as well as providing a valuable means for monitoring the elimination processes of MV control.