Association between metabolic syndrome and prevalent skin diseases: A systematic review and meta-analysis of case-control studies

Background and Aim

Metabolic syndrome (MetS) is a well-known noncommunicable disease that plays a significant role in emerging other chronic disorders and following complications. MetS is also involved in the pathophysiology of numerous dermatological diseases. We aim to evaluate the association of MetS with the most prevalent dermatological diseases.

Methods

A systematic search was carried out on PubMed, Science Direct, Web of Science, Cochrane, as well as the Google Scholar search engine. Only English case-control studies regarding MetS and any skin disease from the beginning of 2010 up to November 15, 2022, were selected. The study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

Results

A total of 37 studies (13,830 participants) met the inclusion criteria. According to our result, patients with psoriasis, hidradenitis suppurativa (HS), vitiligo, androgenetic alopecia (AGA), and lichen planus (LP) have a higher chance of having MetS compared to the general population. Furthermore, people with seborrheic dermatitis (SED) and rosacea are more prone to insulin resistance, high blood pressure (BP), and higher blood lipids. After pooling data, the meta-analysis revealed a significant association between MetS and skin diseases (pooled odds ratio [OR]: 3.28, 95% confidence interval: 2.62-4.10). Concerning the type of disease, MetS has been correlated with AGA (OR: 11.86), HS (OR: 4.46), LP (OR: 3.79), and SED (OR: 2.45). Psoriasis also showed a significant association but with high heterogeneity (OR: 2.89). Moreover, skin diseases and MetS are strongly associated in Spain (OR: 5.25) and Thailand (OR: 11.86). Regarding the metaregression model, the effect size was reduced with increasing age (OR: 0.965), while the size increased with AGA (OR: 3.064).

Conclusions

MetS is closely associated with skin complications. Dermatologists and other multidisciplinary teams should be cautious while treating these patients to prevent severe complications resulting from MetS.

MRI Detection of Carotid Intraplaque Hemorrhage and Postintervention Cognition

BACKGROUND AND PURPOSE

Cognitive improvement has been reported after carotid revascularization and attributed to treating stenosis and correcting hypoperfusion. This study investigated the effect of carotid intraplaque hemorrhage on postintervention cognition.

MATERIALS AND METHODS

In this institutional review board-approved single-center study, consecutive patients scheduled for carotid surgery were recruited for preoperative carotid MR imaging (MPRAGE) and pre- and postintervention cognitive testing using the Repeatable Battery for the Assessment of Neuropsychological Status. Pre- and postintervention scores were compared using t tests and multivariable linear regression.

RESULTS

Twenty-three participants were included, with endarterectomy performed in 20 (87%) and angioplasty/stent placement, in 3 (13%). Overall, statistically significant improvements occurred in the pre- versus postintervention mean Total Scale score (92.1 [SD, 15.5] versus 96.1 [SD, 15.8], P = .04), immediate memory index (89.4 [SD, 18.2] versus 97.7 [SD, 14.9], P < .001), and verbal index (96.1 [SD, 14.1] versus 103.0 [SD, 12.0], P = .002). Intraplaque hemorrhage (+) participants (n = 11) had no significant improvement in any category, and the attention index significantly decreased (99.4 [SD, 18.0] versus 93.5 [SD, 19.4], P = .045). Intraplaque hemorrhage (-) participants (n = 12) significantly improved in the Total Scale score (86.4 [SD, 11.8] versus 95.5 [SD, 12.4], P = .004), immediate memory index (82.3 [SD, 14.6] versus 96.2 [SD, 14.1], P = .002), delayed memory index (94.3 [SD, 14.9] versus 102.4 [SD, 8.0], P = .03), and verbal index (94.3 [SD, 13.2] versus 101.5 [SD, 107.4], P = .009). Postintervention minus preintervention scores for intraplaque hemorrhage (+) versus (-) groups showed statistically significant differences in the Total Scale score (-0.4 [SD, 6.8] versus 8.0 [SD, 8.5], P = .02), attention index (-5.9 [SD, 8.5] versus 4.3 [SD, 11.9], P = .03), and immediate memory index (4.2 [SD, 6.7] versus 12.2 [SD, 10.2], P = .04).

CONCLUSIONS

Cognitive improvement was observed after carotid intervention, and this was attributable to intraplaque hemorrhage (-) plaque. MR imaging detection of intraplaque hemorrhage status may be an important determinant of cognitive change after intervention.

Carotid Vessel Wall Imaging on CTA

Vessel wall imaging has been increasingly used to characterize plaque beyond luminal narrowing to identify patients who may be at the highest risk of cerebrovascular ischemia. Although detailed plaque information can be obtained from many imaging modalities, CTA is particularly appealing for carotid plaque imaging due to its relatively low cost, wide availability, operator independence, and ability to discern high-risk features. The present Review Article describes the current understanding of plaque characteristics on CTA by describing commonly encountered plaque features, including calcified and soft plaque, surface irregularities, neovascularization, and inflammation. The goal of this Review Article was to provide a more robust understanding of clinically relevant plaque features detectable on routine CTA of the carotid arteries.

Association between Carotid Plaque Features on CTA and Cerebrovascular Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

CTA is a widely available imaging examination that may allow the evaluation of high-risk carotid plaque features.

PURPOSE

Our aim was to evaluate the association between specific carotid plaque features on CTA and ipsilateral cerebrovascular ischemia.

DATA SOURCES

We performed a systematic review of Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library from inception to March 2016 for articles that evaluated the relationship between CTA-detected carotid plaque features and ischemic events, defined as ipsilateral ischemic stroke or transient ischemic attack.

STUDY SELECTION

Sixteen studies were ultimately included after screening 12,557.

DATA ANALYSIS

Two readers recorded data from each study and assessed the study quality with all disagreements resolved by a third reader. A random-effects OR was used to evaluate the association between cerebrovascular ischemia and each of the evaluated plaque features.

DATA SYNTHESIS

We found significant positive relationships with cerebrovascular ischemia for the presence of soft plaque (OR, 2.9; 95% CI, 1.4-6.0), plaque ulceration (OR, 2.2; 95% CI, 1.4-3.4), and increased common carotid artery wall thickness (OR, 6.2; 95% CI, 2.5-15.6). We found a significant negative relationship between calcified plaque and ipsilateral ischemia (OR, 0.5; 95% CI, 0.4-0.7).

LIMITATIONS

We found heterogeneity in the existing literature secondary to lack of standardized plaque features and clinical definitions.

CONCLUSIONS

Soft plaque, plaque ulceration, and increased common carotid artery wall thickness on CTA are associated with ipsilateral cerebrovascular ischemia, while calcified plaque is negatively associated with downstream ischemic events.

Association between Intracranial Atherosclerotic Calcium Burden and Angiographic Luminal Stenosis Measurements

BACKGROUND AND PURPOSE

Calcification of the intracranial vasculature is an independent risk factor for stroke. The relationship between luminal stenosis and calcium burden in the intracranial circulation is incompletely understood. We evaluated the relationship between atherosclerotic calcification and luminal stenosis in the intracranial ICAs.

MATERIALS AND METHODS

Using a prospective stroke registry, we identified patients who had both NCCT and CTA or MRA examinations as part of a diagnostic evaluation for ischemic stroke. We used NCCTs to qualitatively (modified Woodcock Visual Score) and quantitatively (Agatston-Janowitz Calcium Score) measure ICA calcium burden and used angiography to measure arterial stenosis. We calculated correlation coefficients between the degree of narrowing and calcium burden measures.

RESULTS

In 470 unique carotid arteries (235 patients), 372 (79.1%) had atherosclerotic calcification detectable on CT compared with 160 (34%) with measurable arterial stenosis on CTA or MRA (P < .001). We found a weak linear correlation between qualitative (R = 0.48) and quantitative (R = 0.42) measures of calcium burden and the degree of luminal stenosis (P < .001 for both). Of 310 ICAs with 0% luminal stenosis, 216 (69.7%) had measurable calcium scores.

CONCLUSIONS

There is a weak correlation between intracranial atherosclerotic calcium scores and luminal narrowing, which may be explained by the greater sensitivity of CT than angiography in detecting the presence of measurable atherosclerotic disease. Future studies are warranted to evaluate the relationship between stenosis and calcium burden in predicting stroke risk.

Quantifying Intracranial Internal Carotid Artery Stenosis on MR Angiography

BACKGROUND AND PURPOSE

Intracranial atherosclerosis is a common cause of ischemic stroke. Intracranial stenosis is most commonly quantified by the Warfarin-Aspirin Symptomatic Intracranial Disease method, which involves calculating a ratio of luminal diameter measurements on conventional angiography. Our purpose was to determine whether a single linear measurement of the narrowest caliber of the intracranial ICA on MRA can accurately predict Warfarin-Aspirin Symptomatic Intracranial Disease stenosis measurements.

MATERIALS AND METHODS

We identified patients from a prospective stroke registry who had undergone head MRAs to quantitatively evaluate the degree of Warfarin-Aspirin Symptomatic Intracranial Disease-derived stenosis in each intracranial ICA. We also made a single linear millimeter measurement at the site of maximal narrowing of the ICA. We calculated a correlation coefficient between the lumen diameter in millimeters and percentage Warfarin-Aspirin Symptomatic Intracranial Disease stenosis. We performed receiver operating characteristic analysis to determine optimal luminal diameter cutoff values.

RESULTS

In 386 unique intracranial ICAs, we found a strong linear relationship between single lumen measurements and Warfarin-Aspirin Symptomatic Intracranial Disease-style stenosis measurements (R = -0.84, P < .0001). We found that ICA lumen diameters of ≤2.1 and ≤1.3 mm were optimal cutoffs for identifying patients with ≥50% stenosis and ≥70% stenosis, respectively (area under the curve = 0.96 and 0.99, respectively).

CONCLUSIONS

There is a strong linear relationship between the narrowest lumen diameter of the intracranial ICA and percentage stenosis. Our results suggest that a single lumen diameter measurement on MRA allows accurate estimation of Warfarin-Aspirin Symptomatic Intracranial Disease stenosis, which may affect risk stratification and treatment decisions.

Evaluating Permeability Surface-Area Product as a Measure of Blood-Brain Barrier Permeability in a Murine Model

BACKGROUND AND PURPOSE

Permeability surface-area product has been suggested as a marker for BBB permeability with potential applications in clinical care and research. However, few studies have demonstrated its correlation with actual quantitative measurements of BBB permeability. Our aim was to demonstrate the correlation of quantitative permeability surface-area product and BBB permeability in a murine model by histologic confirmation.

MATERIALS AND METHODS

Coronal MR imaging was performed on mice treated with mannitol (n = 6) for disruption of the BBB and controls treated with saline (n = 5). Permeability surface-area product was determined by ROI placement and was compared between saline- and mannitol-treated mice. Correlation was made with contrast-enhancement measurements and immunohistologic-stained sections of tripeptidyl peptidase-1 distribution in mice treated with mannitol and saline followed by injection of a viral vector containing the CLN2 gene, which directs production of tripeptidyl peptidase-1.

RESULTS

Significantly increased permeability surface-area product was seen in mannitol- compared with saline-treated mice in the whole brain (P = .008), MCA territory (P = .014), and mixed vascular territories (P = .008). These findings were compared with contrast-enhancement measurements of BBB permeability and were correlated with immunohistologic-stained sections demonstrating BBB permeability to a large vector.

CONCLUSIONS

Permeability surface-area product is increased in situations with known disruptions of the BBB, as evidenced by immunologic staining of large-vector passage through the BBB and concordance with contrast-enhancement measurements in a murine model. Quantitative permeability surface-area product has potential as an imaging marker of BBB permeability.

Application of Blood-Brain Barrier Permeability Imaging in Global Cerebral Edema

BACKGROUND AND PURPOSE

Blood-brain barrier permeability is not routinely evaluated in the clinical setting. Global cerebral edema occurs after SAH and is associated with BBB disruption. Detection of global cerebral edema using current imaging techniques is challenging. Our purpose was to apply blood-brain barrier permeability imaging in patients with global cerebral edema by using extended CT perfusion.

MATERIALS AND METHODS

Patients with SAH underwent CTP in the early phase after aneurysmal rupture (days 0-3) and were classified as having global cerebral edema or nonglobal cerebral edema using established noncontrast CT criteria. CTP data were postprocessed into blood-brain barrier permeability quantitative maps of PS (permeability surface-area product), K(trans) (volume transfer constant from blood plasma to extravascular extracellular space), Kep (washout rate constant of the contrast agent from extravascular extracellular space to intravascular space), VE (extravascular extracellular space volume per unit of tissue volume), VP (plasmatic volume per unit of tissue volume), and F (plasma flow) by using Olea Sphere software. Mean values were compared using t tests.

RESULTS

Twenty-two patients were included in the analysis. Kep (1.32 versus 1.52, P < .0001), K(trans) (0.15 versus 0.19, P < .0001), VP (0.51 versus 0.57, P = .0007), and F (1176 versus 1329, P = .0001) were decreased in global cerebral edema compared with nonglobal cerebral edema while VE (0.81 versus 0.39, P < .0001) was increased.

CONCLUSIONS

Extended CTP was used to evaluate blood-brain barrier permeability in patients with SAH with and without global cerebral edema. Kep is an important indicator of altered blood-brain barrier permeability in patients with decreased blood flow, as Kep is flow-independent. Further study of blood-brain barrier permeability is needed to improve diagnosis and monitoring of global cerebral edema.

Hemispheric Differences in Leukoaraiosis in Patients with Carotid Artery Stenosis: A Systematic Review

PURPOSE

Despite the prevalence of leukoaraiosis in neuroimaging and its link to dementia, stroke, and death, the exact pathogenesis is still unclear. While some have postulated a link between carotid artery disease and leukoaraiosis, the exact relationship between the two common clinical findings is unknown. To determine the link between carotid disease and leukoaraiosis, we performed a systematic review of interhemispheric differences in white matter disease in patients with carotid artery disease.

METHODS

We performed a comprehensive literature search in multiple electronic databases evaluating the association of carotid artery and white matter disease using both subjective and volumetric assessment of white matter burden. The included studies examined patients with at least 30 % carotid artery stenosis for white matter burden both ipsilateral and contralateral to the site of carotid artery disease.

RESULTS

Of the 2920 manuscripts screened, five were included in the systematic review. One study used a volumetric analysis of the white matter burden and the others used various subjective methods. Four studies found no statistically significant relationship between carotid artery disease and ipsilateral white matter burden and one study found a significantly higher amount of white matter disease ipsilateral to carotid artery stenosis.

CONCLUSIONS

The mixed results in degree of hemispheric leukoaraiosis in patients with carotid artery disease indicate that no definite relationship can be established based on the existing literature. Given the complex nature of carotid artery disease, including increased risk with certain plaque components, the exact relationship requires further investigation with more rigorous research design.

Automated calcium burden measurement in internal carotid artery plaque with CT: a hierarchical adaptive approach

AIM

Calcium burden measurement in internal carotid artery (ICA) plaque could play an important role in assessing stroke risk and stenosis quantification in the ICA. We propose an automatic method for labelling calcified plaques in ICA in CT images.

METHODS

Our approach builds upon the mean shift paradigm via an adaptive thresholding strategy. The data consists of single CT slices from 75 patients, with variety of plaque sizes and number of calcium regions. The manual measurements were carried out by a neuroradiologist for benchmarking. The calcium burden was measured as the area of the labelled plaque. Various metrics were employed to compare manual and automated measurements including correlation coefficient (CC), dice similarity (DS), Jacard Index (JI), polyline distance metric (PDM) and precision of merit (PoM).

RESULTS

We found that our automated method of calcium area characterization performed accurately compared to manual measurements with CC=0.978, and PoM=0.915. The PDM, DS, and JI, also indicate a good performance with a mean DS=0.85 (SD=0.085), a mean JI=0.747 (SD=0.12), and a mean PDM=0.195 (SD=0.177).

CONCLUSION

The proposed approach for calcium burden measurement, yields reasonably accurate labelling of calcified plaque when benchmarked against manual measurements. The approach is independent of the number and size of calcium regions, and the prototype design shows encouraging results to be adaptable to clinical practice.

Evaluating CT Perfusion Deficits in Global Cerebral Edema after Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Global cerebral edema is an independent predictor of mortality and poor outcomes after aneurysmal SAH. Global cerebral edema, a complex disease process, is thought to be associated with an altered cerebral autoregulatory response. We studied the association between cerebral hemodynamics and early global cerebral edema by using CTP.

MATERIALS AND METHODS

We retrospectively studied consecutive patients with aneurysmal SAH with admission CTP performed at days 0-3. Two neuroradiologists classified global cerebral edema and hydrocephalus on NCCT performed concurrently with CTP. Global cerebral edema was defined as diffuse effacement of the sulci and/or basal cisterns or diffuse disruption of the cerebral gray-white matter junction. CTP was postprocessed into CBF and MTT maps by using a standardized method. Quantitative analysis of CTP was performed by using standard protocol with ROI sampling of the cerebral cortex. The Fisher exact test, Mann-Whitney test, and independent-samples t test were used to determine statistical associations.

RESULTS

Of the 45 patients included, 42% (19/45) had global cerebral edema and 58% (26/45) did not. Patient groups with and without global cerebral edema were well-matched for demographic and clinical data. Patients with global cerebral edema were more likely to have qualitative global CTP deficits than those without global cerebral edema (P = .001) with an OR = 13.3 (95% CI, 2.09-138.63). Patients with global cerebral edema also had a very strong trend toward statistical significance, with reduced quantitative CBF compared with patients without global cerebral edema (P = .064).

CONCLUSIONS

Global perfusion deficits are significantly associated with global cerebral edema in the early phase after aneurysmal SAH, supporting the theory that hemodynamic disturbances occur in global cerebral edema.

Evaluating blood-brain barrier permeability in delayed cerebral infarction after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Patients with SAH are at increased risk of delayed infarction. Early detection and treatment of delayed infarction remain challenging. We assessed blood-brain barrier permeability, measured as permeability surface area product, by using CTP in patients with SAH with delayed infarction.

MATERIALS AND METHODS

We performed a retrospective study of patients with SAH with delayed infarction on follow-up NCCT. CTP was performed before the development of delayed infarction. CTP data were postprocessed into permeability surface area product, CBF, and MTT maps. Coregistration was performed to align the infarcted region on the follow-up NCCT with the corresponding location on the CTP maps obtained before infarction. Permeability surface area product, CBF, and MTT values were then obtained in the location of the subsequent infarction. The contralateral noninfarcted region was compared with the affected side in each patient. Wilcoxon signed rank tests were performed to determine statistical significance. Clinical data were collected at the time of CTP and at the time of follow-up NCCT.

RESULTS

Twenty-one patients with SAH were included in the study. There was a statistically significant increase in permeability surface area product in the regions of subsequent infarction compared with the contralateral control regions (P < .0001). However, CBF and MTT values were not significantly different in these 2 regions. Subsequent follow-up NCCT demonstrated new delayed infarction in all 21 patients, at which time 38% of patients had new focal neurologic deficits.

CONCLUSIONS

Our study reveals a statistically significant increase in permeability surface area product preceding delayed infarction in patients with SAH. Further investigation of early permeability changes in SAH may provide new insights into the prediction of delayed infarction.

CT angiographic features of symptom-producing plaque in moderate-grade carotid artery stenosis

BACKGROUND AND PURPOSE

Emerging evidence indicates that plaque imaging can improve stroke risk stratification in patients with carotid artery atherosclerosis. We studied the association between soft and hard (calcified) plaque thickness measurements on CTA and symptomatic disease status (ipsilateral stroke or TIA) in patients with moderate-grade carotid artery stenosis.

MATERIALS AND METHODS

We measured soft-plaque and hard-plaque thickness on CTA axial source images in each carotid artery plaque in subjects with NASCET 50%-69% ICA stenosis. We used logistic regression and receiver operating characteristic analyses to assess the strength of the association between thickness measurements and prior stroke or TIA.

RESULTS

Twenty of 72 vessels studied (27.7%) had ischemic symptoms ipsilateral to the side of moderate-grade carotid stenosis. Each 1-mm increase in soft plaque resulted in a 3.7 times greater odds of a prior ipsilateral ischemic event (95% CI, 1.9-7.2). Conversely, for each 1-mm increase in hard plaque, the odds of being symptomatic decreased by approximately 80% (OR, 0.22; 95% CI, 0.10%-0.48%). Receiver operating characteristic analysis showed an area under the curve of 0.88 by using soft-plaque thickness measurements to discriminate between asymptomatic and symptomatic plaques. Sensitivity and specificity were optimized by using a maximum soft-plaque thickness of 2.2 mm, which provided a sensitivity of 85% and a specificity of 83%.

CONCLUSIONS

Simple CTA plaque-thickness measurements might differentiate symptomatic and asymptomatic moderate-grade carotid artery plaque. With further prospective validation, CTA plaque measures could function as an easily implementable tool for risk stratification in carotid artery disease.

Oxygen extraction fraction and stroke risk in patients with carotid stenosis or occlusion: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Increased oxygen extraction fraction on PET has been considered a risk factor for stroke in patients with carotid stenosis or occlusion, though the strength of this association has recently been questioned. We performed a systematic review and meta-analysis to summarize the association between increased oxygen extraction fraction and ipsilateral stroke risk.

MATERIALS AND METHODS

A comprehensive literature search was performed. We included studies with baseline PET oxygen extraction fraction testing, ipsilateral stroke as the primary outcome, and at least 1 year of follow-up. A meta-analysis was performed by use of a random-effects model.

RESULTS

After screening 2158 studies, 7 studies with 430 total patients with mean 30-month follow-up met inclusion criteria. We found that 6 of 7 studies were amenable to meta-analysis. Although 4 of the 6 studies independently did not reach statistical significance, meta-analysis revealed a significant positive relationship between abnormal oxygen extraction fraction and future ipsilateral stroke, with a pooled OR of 6.04 (95% CI, 2.58-14.12). There was no statistically significant difference in OR in the subgroup analyses according to testing method or disease site.

CONCLUSIONS

Abnormal oxygen extraction fraction remains a powerful predictor of stroke in carotid stenosis or occlusion and is a valuable reference standard to compare and validate MR imaging-based measures of brain oxygen metabolism. However, there is a need for further evaluation of oxygen extraction fraction testing in patients with high-grade but asymptomatic carotid disease.

Intraplaque high-intensity signal on 3D time-of-flight MR angiography is strongly associated with symptomatic carotid artery stenosis

BACKGROUND AND PURPOSE

Intraplaque hemorrhage in carotid artery atherosclerotic plaque has been shown to be a marker of risk, associated with prior and future ischemic events, and has been associated with regions of intraplaque high-intensity signal on 3D-TOF MRA. We assessed the association of intraplaque high-intensity signal determined on 3D-TOF MRA with the incidence of prior ipsilateral stroke or TIA.

MATERIALS AND METHODS

We assessed intraplaque hemorrhage by evaluating for intraplaque high-intensity signal adapting a recently validated technique on 3D-TOF source images in participants with high-grade (≥ 70%) extracranial carotid stenosis. Logistic regression analyses were used to assess the strength of association between the presence of intraplaque high-intensity signal on routine MRA sequences and prior stroke or TIA.

RESULTS

Intraplaque high-intensity signal was present in 22 (41.5%) of 53 carotid arteries studied in 51 patients. Ipsilateral ischemic events occurred in 15 (68.1%) of 22 in the intraplaque high-intensity signal-positive group (10 strokes, 5 TIAs) and in 4 (12.9%) of 31 in the intraplaque high-intensity signal-negative group (3 strokes, 1 TIA). Ischemic events occurred within the 6-month period preceding imaging in 18 (94.7%) of 19 cases. The univariate odds ratio of the association of intraplaque high-intensity signal with any prior ischemic event was 14.5 (95% CI, 3.6-57.6), and the multivariate age- and sex-adjusted odds ratio was 14.2 (95% CI, 3.3-60.5). The association remained present across 1.5 T and 3T magnet field strengths.

CONCLUSIONS

Intraplaque high-intensity signal determined from MRA sequences already in place to measure luminal stenosis is strongly associated with prior ipsilateral ischemic events. Prospective validation of these findings to predict outcome in carotid artery stenosis could provide a valuable and widely accessible stroke risk stratification tool.

Effects of a structured self-monitoring of blood glucose method on patient self-management behavior and metabolic outcomes in type 2 diabetes mellitus

BACKGROUND

The purpose of this study was to evaluate the effect of structured self-monitoring of blood glucose (SMBG) on patient self-management behavior and metabolic outcomes in patients with type 2 diabetes mellitus (T2DM).

METHODS

From January to June 2009, 30 patients with basic diabetes education were followed for a period of 90 days. To provide assessment of glycemic control and frequency of dysglycemia, patients, underwent 3 consecutive days of seven-point SMBG during each month for 3 consecutive months, using the ACCU-CHEK 360° View tool. Glucose profiles of the first and third month were used for comparison.

RESULTS

Hemoglobin A1c (HbA1c) improved significantly during the 90-day period in all patients [confidence interval (CI) 95%, 0.32-1.64%, p < .05] and those with poor metabolic control (group B; CI 95%, 0.86-2.64%, p < .05). Mean blood glucose (MBG) values decreased significantly in group B (CI 95%, 0.56-24.78 mg/dl, p < .05) and all cases (CI 95%, 1.61-19.73 mg/dl, p < .05). Meanwhile, there was an average decrease of 15.7 mg/dl in fasting blood sugar (FBS) levels in the whole subjects. Mean postprandial blood glucose levels (MPP) decreased by 19.3 and 11.3 mg/dl in group B and in all cases, respectively. However, there were no significant changes in HbA1c, MBG, FBS, and MPP in people with good metabolic control.

CONCLUSION

A structured SMBG program improves HbA1c, FBS, MPP, and MBG in people with poorly controlled diabetes. This improvement shows the importance of patient self-management behavior on metabolic outcomes in T2DM.

A comparison of answer retrieval through four evidence-based textbooks (ACP PIER, Essential Evidence Plus, First Consult, and UpToDate): a randomized controlled trial

BACKGROUND

The efficacy of bedside information products has not been properly evaluated, particularly in developing countries.

AIM

To compare four evidence-based textbooks by comparing efficacy of their use by clinical residents, as measured by the proportion of questions for which relevant answers could be obtained within 20 min, the time to reach the answer and user satisfaction.

METHODS

One hundred and twelve residents were taught information mastery basics and were randomly allocated to four groups to use: (1) ACP PIER, (2) Essential Evidence Plus (formerly InfoRetriever), (3) First Consult, and (4) UpToDate. Participants received 3 of 24 questions randomly to retrieve the answers from the assigned textbook. Retrieved answers and time-to-answers were recorded by special designed software, and the researchers determined if each recorded answer was relevant.

RESULTS

The rate of answer retrieval was 86% in UpToDate, 69% in First Consult, 49% in ACP PIER, and 45% in Essential Evidence Plus (p < 0.001). The mean time-to-answer was 14.6 min using UpToDate, 15.9 min using First Consult, 16.3 min using Essential Evidence Plus, and 17.3 min using ACP PIER (p < 0.001).

CONCLUSION

UpToDate seems more comprehensive in content and also faster than the other three evidence-based textbooks. Thus, it may be considered as one of the best sources for answering clinicians' questions at the point of care.

Effect of membrane sweeping at term pregnancy on duration of pregnancy and labor induction: a randomized trial

AIM

To evaluate the efficacy of sweeping of fetal membranes for induction of labor in uncomplicated term pregnancies.

METHODS

A randomized controlled trial was performed in 122 pregnant women beyond 39 weeks of gestation with no complications. The women were assigned to have their membranes swept or not (controls) for labor induction. The main outcome measures included duration of pregnancy and possible complications of sweeping of membranes, including rupture of membranes, postpartum infections, and vaginal bleeding.

RESULTS

Twenty-one patients did not give birth in our hospital and were, therefore, excluded from the study; 101 women completed the study (51 patients in the control group and 50 women in the study group). There were no statistically significant differences in maternal age, parity, birth weight, and Bishop score in the two groups. The mean interval between sweeping (stripping) and vaginal examination until delivery was 7.7 +/- (SD) 6.9 and 7.1 +/- 5.6 days in the sweeping and in the control group, respectively (p = 0.61). Of the 101 pregnant women, only 6 patients had premature rupture of membranes (2 in the sweeping group and 4 in the control group). There were no statistically significant differences between these individuals (p = 0.68). Significant vaginal bleeding was not observed in the two groups. Meconium-stained amniotic fluid was seen in 13 women: 8 in the sweeping group and 5 in the control group. There were no statistically significant differences among the women who had meconium-stained fluid in case and control groups (p = 0.39). There were no differences between women who had puerperal fever (3 in the sweeping group and 2 in the control group; p = 0.68). 12 of the 101 women (6 in each group) had cesarean section performed, but there was no difference between the two groups.

CONCLUSION

Sweeping of membranes at 39 weeks of gestation has no significant clinical effect on the duration of pregnancy.

Pregnancy outcome following a previous spontaneous abortion (miscarriage)

OBJECTIVE

To determine the pregnancy outcome following a previous spontaneous abortion (miscarriage).

METHOD

A prospective cohort study was done on 300 gravida-2 patients: 200 patients (case group) whose previous pregnancy was spontaneously aborted (early abortion), and 100 patients (control group) whose previous pregnancy went to term and a live fetus was delivered. All the patients were followed until delivery, and then the pregnancy outcomes, neonatal complications and delivery routes were determined and compared between the 2 groups. Pregnancy outcomes included: maternal complications (e.g. placenta previa, placental abruption, premature rupture of the membranes, preeclampsia and eclampsia, abortion, breech presentation, preterm labor, intrauterine fetal death); neonatal complications (low birth weight, gross congenital malformations, low Apgar score at 1 min), and delivery routes (cesarean delivery or instrumental delivery, e.g. forceps or vacuum). Statistical analysis was performed using the Statistical Package for Social Science.

RESULTS

Statistical analysis showed that the pregnancy complications following a previous spontaneous miscarriage were no different from those of the control group, except for abortion (16.5 vs. 11%, p < 0.003, RR = 1.15, CI 95% = 0.95-1.39), fetal deaths (1.5 vs. 0%, p < 0.004, RR = 1.51, CI 95% = 1.39-1.63), and vaginal bleeding during the first trimester (19 vs. 1%, p < 0.001, RR = 1.57, CI 95% = 1.41-1.75), which were more than those of the control group. Also, the rate of cesarean delivery (28.14 vs. 13.48%) was increased (p = 0.026, RR = 1.25, CI 95% = 1.07-1.47). Neonatal complications were not statistically significantly different in comparison with the control group.

CONCLUSION

A prior spontaneous miscarriage is a risk for the next pregnancy, and the risk of abortion and intrauterine fetal death will increase. Therefore, careful prenatal care is mandatory.

Clinical teachers' attitudes toward the efficacy of evidence-based medicine workshop and self-reported ability in evidence-based practice in Iran

INTRODUCTION

Evidence-based medicine (EBM) has been introduced in medical schools worldwide, but there is little known about effective methods for teaching EBM skills, particularly in developing countries. This study assesses the impact of an EBM workshop on clinical teachers' attitudes and use of EBM skills.

METHODS

Seventy-two clinical teachers attended two half-day workshops on EBM. Participants completed precourse and postcourse questionnaires using a 5-point Likert scale. Nonparametric 2-sample Wilcoxon rank-sum tests were performed to compare responses.

RESULTS

Attitudes about EBM improved (3.2 precourse vs 3.4 postcourse), as did self-reported EBM skills (3.1 vs 4.4, p < .0001).

DISCUSSION

An EBM workshop may improve clinical teachers' abilities and skills in using EBM. However, carefully designed studies are required to evaluate the long-term effects of EBM curricula in changing behaviors, practice patterns, and patient care outcomes.

High seroprotection rate induced by intradermal administration of a recombinant hepatitis B vaccine in young healthy adults: comparison with standard intramuscular vaccination

Intradermal (ID) vaccination has been proposed as a cost-saving alternative for administration of Hepatitis B (HB) vaccine to implement of mass vaccination of high-risk groups, particularly in developing countries. Therefore, the effectiveness of ID vaccination needs to be evaluated and verified in different ethnic backgrounds. The present study is a randomized trail using a recombinant vaccine (Heberbiovac) to compare immunogenecity and safety of an intradermal low-dose (4 microg) with standard dose (20 microg) of intramuscular (IM) vaccination in healthy Iranian population. Participants were 143 healthy Iranian medical and nursing students randomly allocated to ID or IM vaccination group. The vaccine was inoculated at 0, 1 and 6 months intervals. Serum samples were collected 1 month after the last vaccination and the anti-HBs response was determined using ELISA. The overall seroprotection rate (anti-HBs level > or = 10 IU/L) was 97.3% for ID vaccination group, which was not different from that of IM vaccination group (98.55%) (p = 0.99). Similarly, geometric mean titers (GMT) of anti-HBs were not significantly different between ID (1164.1 IU/L) and IM (1071.8 IU/L) vaccination groups (p = 0.4). There was no significant difference in seroprotection rate and GMT of anti-HBs between sexes. Although induration and hyperpigmentation at the site of injection were more frequently observed in ID vaccination group, no other clinically adverse effects were observed in both vaccination groups. We conclude that the ID route, which would require one-fifth of the standard dose, would be suitable for use in certain groups such as high-risk adults when the cost of vaccine is the inhibiting factor for mass vaccination.

Psychological distress among Bam earthquake survivors in Iran: a population-based study

Background

An earthquake measuring 6.3 on the Richter scale struck the city of Bam in Iran on the 26th of December 2003 at 5.26 A.M. It was devastating, and left over 40,000 dead and around 30,000 injured. The profound tragedy of thousands killed has caused emotional and psychological trauma for tens of thousands of people who have survived. A study was carried out to assess psychological distress among Bam earthquake survivors and factors associated with severe mental health in those who survived the tragedy.

Methods

This was a population-based study measuring psychological distress among the survivors of Bam earthquake in Iran. Using a multi-stage stratified sampling method a random sample of individuals aged 15 years and over living in Bam were interviewed. Psychological distress was measured using the 12-item General Health Questionnaire (GHQ-12).

Results

In all 916 survivors were interviewed. The mean age of the respondents was 32.9 years (SD = 12.4), mostly were males (53%), married (66%) and had secondary school education (50%). Forty-one percent reported they lost 3 to 5 members of their family in the earthquake. In addition the findings showed that 58% of the respondents suffered from severe mental health as measured by the GHQ-12 and this was three times higher than reported psychological distress among the general population. There were significant differences between sub-groups of the study sample with regard to their psychological distress. The results of the logistic regression analysis also indicated that female gender; lower education, unemployment, and loss of family members were associated with severe psychological distress among earthquake victims.

Conclusion

The study findings indicated that the amount of psychological distress among earthquake survivors was high and there is an urgent need to deliver mental health care to disaster victims in local medical settings and to reduce negative health impacts of the earthquake adequate psychological counseling is needed for those who survived the tragedy.

Albendazole versus placebo in treatment of echinococcosis

Echinococcus granulosus infection can have multiorgan involvement, and is common in Third-World countries. Uncontrolled studies show that albendazole can be effective in its treatment, but there are also reports of spontaneous resolutions. We therefore undertook a placebo-controlled double-blind parallel-group randomized study in Iran to evaluate the effect of albendazole on hydatid cysts. Twenty-nine patients with 240 cysts entered the study in 1994-95 and received either albendazole (400 mg twice a day, in 3 cycles of 6 weeks with 2 weeks between cycles) or placebo. At study completion, 172 and 31 cysts in the albendazole and placebo groups, respectively, were evaluable. In the treatment arm, 134 cysts showed improvement or cure compared to 4 in the placebo group (P < 0.001). Eighteen (82%) of 22 patients in the treatment arm showed either cure (8 patients) or improvement (10 patients); in the placebo group only 1 (14%) of 7 showed spontaneous improvement but no cure. Some patients with liver cysts after treatment showed increasing heterogeneity and density suggestive of inactive cysts. Patients with larger cysts and those with pulmonary involvement were better responders. Age and gender had no effect on outcome. The observed results are encouraging, showing albendazole has good effect on hydatid cysts and should be offered to patients before surgical treatment is considered.

A placebo controlled study of albendazole in the treatment of pulmonary echinococcosis

Infection with Echinococcus granulosus is endemic in Middle Eastern countries. Some patients are noted to undergo spontaneous resolution, but many require surgical removal with its associated risks. Although, there are studies showing favourable responses to medical treatment, there is no controlled study on the effect of albendazole. In this study, 20 patients with 179 E. granulosus cysts affecting the lungs were entered into a triple blind parallel randomized clinical trial comparing the effects of albendazole versus placebo. Fifteen patients (150 cysts) completed 6 months of treatment; four patients (26 cysts) were in the placebo group and 11 patients (124 cysts) in the treatment group receiving 800 mg albendazole daily in three cycles of 6 weeks with 2 weeks between cycles. Ten of 11 patients (91%) in the treatment group showed either cure (five patients) or improvement (five patients); in the placebo group, only one of four (25%) showed spontaneous improvement but no cure. In the treatment group, 88 of 124 cysts (71%) showed improvement compared to four of 26 (15.4%) in the placebo group (p=0.000). Complication from therapy was insignificant; one case had recurrent disease, which responded to further therapy. It is suggested that patients suffering from uncomplicated hydatid disease should be given a trial of albendazole before surgery is considered.