Exploring the clinical benefit of ventilation therapy across various patient groups with COVID-19 using real-world data

Scarcity of ventilators during COVID-19 pandemic has urged public health authorities to develop prioritization recommendations and guidelines with the real-time decision-making process based on the resources and contexts. Nevertheless, patients with COVID-19 who will benefit the most from ventilation therapy have not been well-defined yet. Thus, the objective of this study was to investigate the benefit of ventilation therapy among various patient groups with COVID-19 admitted to hospitals, based on the real-world data of hospitalized adult patients. Data used in the longitudinal study included 599,340 records of hospitalized patients who were admitted from February 2020 to June 2021. All participants were categorized based on sex, age, city of residence, the hospitals' affiliated university, and their date of hospitalization. Age groups were defined as 18-39, 40-64, and more than 65-year-old participants. Two models were used in this study: in the first model, participants were assessed by their probability of receiving ventilation therapy during hospitalization based on demographic and clinical factors using mixed-effects logistic regression. In the second model, the clinical benefit of receiving ventilation therapy among various patient groups was quantified while considering the probability of receiving ventilation therapy during hospital admission, as estimated in the first model. The interaction coefficient in the second model indicated the difference in the slope of the logit probability of recovery for a one-unit increase in the probability of receiving ventilation therapy between the patients who received ventilation compared to those who did not while considering other factors constant. The interaction coefficient was used as an indicator to quantify the benefit of ventilation reception and possibly be used as a criterion for comparison among various patient groups. Among participants, 60,113 (10.0%) cases received ventilation therapy, 85,158 (14.2%) passed away due to COVID-19, and 514,182 (85.8%) recovered. The mean (SD) age was 58.5 (18.3) [range = 18-114, being 58.3 (18.2) among women, and 58.6 (18.4) among men]. Among all groups with sufficient data for analysis, patients aged 40-64 years who had chronic respiratory diseases (CRD) and malignancy benefitted the most from ventilation therapy; followed by patients aged 65 + years who had malignancy, cardiovascular diseases (CVD), and diabetes (DM); and patients aged 18-39 years who had malignancy. Patients aged 65 + who had CRD and CVD gained the least benefit from ventilation therapy. Among patients with DM, patients aged 65 + years benefited from ventilation therapy, followed by 40-64 years. Among patients with CVD, patients aged 18-39 years benefited the most from ventilation therapy, followed by patients aged 40-64 years and 65 + years. Among patients with DM and CVD, patients aged 40-64 years benefited from ventilation therapy, followed by 65 + years. Among patients with no history of CRD, malignancy, CVD, or DM, patients aged 18-39 years benefited the most from ventilation therapy, followed by patients aged 40-64 years and 65 + years. This study promotes a new aspect of treating patients for ventilators as a scarce medical resource, considering whether ventilation therapy would improve the patient's clinical outcome. Should the prioritization guidelines for ventilators allocation take no notice of the real-world data, patients might end up being deprived of ventilation therapy, who could benefit the most from it. It could be suggested that rather than focusing on the scarcity of ventilators, guidelines focus on evidence-based decision-making algorithms to also take the usefulness of the intervention into account, whose beneficial effect is dependent on the selection of the right time in the right patient.

The protection quest is a primary key to sharing the neutralizing antibody response to cover against all emerging VOCs based on BIV1-CovIran studies

Over time, the antigenic evolution of emerging variants of SARS-CoV-2 has demanded the development of potential protective vaccines. Administration of additional doses of current vaccines based on the WT spike protein may boost immunity, but their effectiveness has dwindled for patients with more recent variants. Here, we studied the neutralization activity of post-WT strain-based vaccination and a structural simulation in-silico based on the interactions of the RBD-hACE2 as the key to initiating infection among the VOCs of SARS-CoV-2. Our data display shows that WT sera showed a markedly greater reduction in Delta and Omicron, suggesting that the Wuhan-based vaccines may be more susceptible to breakthrough and new VOCs. According to the MD simulation, mutations of Omicron result in a significant change in the variant charge distribution throughout the binding interface that consequently alters the critical interface electrostatic potential in comparison to other variants. This observation provides new insights into immunization policy and next-generation vaccine development.

Assessment of BIV1-CovIran inactivated vaccine-elicited neutralizing antibody against the emerging SARS-CoV-2 variants of concern

OBJECTIVES

The BIV1-CovIran vaccine is highly effective against COVID-19. The neutralizing potency of all SARS-CoV-2 vaccines seems to be decreased against variants of concern. We assessed the sensitivity of the Alpha (B.1.1.7), Beta (B.1.351), and Delta (B.1.617.2) variants to neutralizing antibodies (NAbs) present in sera from individuals who had received the BIV1-CovIran candidate vaccine compared with an original Wuhan-related strain.

METHODS

The ability of vaccine serum to neutralize the variants was measured using the conventional virus neutralization test. The correlation of spike (S) protein antibody and anti-receptor binding domain with neutralizing activity was investigated.

RESULTS

The current study demonstrated that 29 of 32 (90.6%; 95% CI: 75.0-98.0) of the vaccinees developed NAbs against a Wuhan-related strain. It is noteworthy that 28 (87.50%) and 24 of 32 (75%) of the recipients were able to produce NAbs against Alpha, Beta, and Delta variants, respectively. Serum virus-neutralizing titres for different SARS-CoV-2 strains were weakly correlated with anti-receptor binding domain antibodies (Spearman r = 36-42, p < 0.05), but not S-binding antibodies (p > 0.05).

DISCUSSION

Although there was a reduction in neutralization titres against the Alpha, Beta, and Delta variants compared with the Wuhan strain, BIV1-CovIran still exhibited potent neutralizing activity against the SARS-CoV-2 variants of concern.

Protective Effect of Mito-TEMPO on Sodium Valproate-Induced Hepatotoxicity in Mice

Valproic acid is a broad-spectrum anticonvulsant drug that is also useful for other diseases such as bipolar disorder and migraines. The most important side effect of this drug is hepatotoxicity. Oxidative stress and mitochondrial dysfunction play a role in the pathogenesis of liver toxicity of valproic acid. Mito-TEMPO is an antioxidant-based compound, which is selectively accumulated in mitochondria. The effects of its mitochondrial protection against oxidative damage in various pathologies, such as liver damage, have been observed. The aim of this study was to evaluate the protective effect of Mito-TEMPO on liver toxicity induced by sodium valproate in mice. Animals were divided into five groups and treated intraperitoneally over a 4-week period. Group 1 received normal saline, served as vehicle control, group 2 treated with 12.5 mg/kg of sodium valproate, group 3 was treated with 1 mg/kg of Mito-TEMPO, group 4 received both sodium valproate (12.5 mg/kg) and Mito-TEMPO (1 mg/kg), and group 5 received sodium valproate (12.5 mg/kg), and vitamin E (5 mg/kg) served as a positive control. At the end of the experiment, blood samples were collected by cardiac puncture, and all the animals were killed under ether anesthesia. Biochemical parameters including AST, ALT, ALP, and GGT in serum samples and glutathione (GSH) and malondialdehyde (MDA) contents in liver homogenates were determined. The findings of this study showed that the activity of AST and ALT were significantly lower in the sodium valproate+Mito-TEMPO treated animals as compared to the sodium valproate group (group 2). Furthermore, Mito-TEMPO was able to recover glutathione content (GSH) of liver tissue. The effect of Mito-TEMPO on the activity of ALP and GGT and serum level of MDA was not significant. Taken collectively, Mito-TEMPO has a protective role in sodium valproate hepatotoxicity. Considering the present results, further studies, in view of the potential therapeutic properties of Mito-TEMPO in improving liver damage caused by the use of valproic acid, may lead to the clinical applications of Mito-TEMPO in the treatment of liver disease.

Evolution and Comparison Effects of Fludrocortisone and Betamethasone on Glucose and Lipid Profile in Rats

Hyperglycemia may associate with improper use of glucocorticoids, impaired insulin function, or both, and is associated with many complications such as hyperlipidemia and Hyperglycemia. Researches suggest that proper use of glucocorticoids can delay the onset and progression of complications of hyperglycemia and hyperlipidemia. In the present study, we compare two of these compounds on glucose and lipid profile level. We use 40 male Wistar rats from the Yazd Animal infertility center. Initially, the rats were randomly divided into 2 groups, and then each group was divided into 4 groups. Subsequently, fludrocortisone doses of 12, 24 and 36 mg/kg were administered to rats, and dosages of 6, 12 and 18 mg/kg for betamethasone administered to rats on a daily basis at 1 o'clock for 21 days by intraperitoneal injection. Betamethasone and Fludrocortisone increased blood glucose and AST, ALT, TG, LDL, VLDL, and decreased HDL, causing red pigmentation in the skin, and obesity and puffiness of the rats. In all of the measured factors, fludrocortisone changes were more than betamethasone. Fludrocortisone and betamethasone also had significant effects on weight, which was more pronounced with fludrocortisone. As the dose increased, the levels of AST, ALT, and cholesterol, TG, VLDL and LDL in the blood increased significantly and HDL levels decreased more in the blood, but fludrocortisone showed a stronger effect than betamethasone. Therefore, it can be expected that the use of Betamethasone would be logical due to fewer side effects than fludrocortisone. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(8):478-483.

Iran in transition

Being the second-largest country in the Middle East, Iran has a long history of civilisation during which several dynasties have been overthrown and established and health-related structures have been reorganised. Iran has had the replacement of traditional practices with modern medical treatments, emergence of multiple pioneer scientists and physicians with great contributions to the advancement of science, environmental and ecological changes in addition to large-scale natural disasters, epidemics of multiple communicable diseases, and the shift towards non-communicable diseases in recent decades. Given the lessons learnt from political instabilities in the past centuries and the approaches undertaken to overcome health challenges at the time, Iran has emerged as it is today. Iran is now a country with a population exceeding 80 million, mainly inhabiting urban regions, and has an increasing burden of non-communicable diseases, including cardiovascular diseases, hypertension, diabetes, malignancies, mental disorders, substance abuse, and road injuries.

National and Subnational Patterns of Cause of Death in Iran 1990-2015: Applied Methods

BACKGROUND

Causes of death statistics provide crucial health intelligence in national and international communities. An efficient death registration system provides reliable information for health policy system. In many developing countries, death registration systems face a degree of misclassification and incompleteness. There are many impediments to putting an estimate of cause-specific death rates. Addressing those challenges could prevent misleading results.

METHODS

Our data was collected by Ministry of Health and Medical Education, Tehran and Isfahan cemeteries from 1995 to 2010. After converting ICD codes of Iran's death registration into GBD codes, 170 underlying causes of deaths were recognized in the available data. A wide range of methods were applied for preparing the data. We used several statistical models to estimate mortality rates in age-sex-province groups for all causes of deaths. The considerable number of combinations for age, sex, cause of death, year, and province variables made further complicated model selection and evaluation of the results.

RESULTS

Totally, 58.91% of deaths were related to males. The majority of cases of death were classified as NCDs (77.83%) and injuries (14.80%). We extrapolated 71.76% and 14.71% of causes of death by mixed effect model, spline model with parameter 0.9 and 0.6, respectively.

CONCLUSION

A comprehensive and unique registration system is able to solve many DRS issues. It is necessary to assess the quality and validity of cause of death data. Scientific methods like analyzing mortality level and cause-of-death data are used to provide an overview for better decisions.

Birth seasonality in rural areas of Iran, analysis of 5,536,262 births from 1992 to 2007

PURPOSE

We conducted this study to investigate birth seasonality in rural parts of Iran.

METHODS

In this study, patterns of 5,536,262 live births in rural parts of Iran between 1992 and 2007 were studied. Information about birth numbers, environmental factors, and sociocultural status of participants was obtained from previous works. Visually inspecting the seasonal variation of birth, studying its trend using autocorrelation analysis, examining the trend of birth seasonality using the seasonality coefficient, a newly introduced index, studying correlations between birth seasonality and possible associated factors, and analyzing associations between these variables and birth seasonality using multiple regression model were performed in this study.

RESULTS

In this study, we showed birth seasonality in rural parts of Iran, with the highest births in the first two seasons, winter and spring, mostly before the year of 2002. Latitude and mean temperature of districts, wealth status of families, education of women, and mothers' ages were associated with birth seasonality. However, latitude, temperature, and mothers' ages lost their associations after adjusting for sociocultural factors in the regression model.

CONCLUSIONS

Birth numbers in rural areas of Iran follow a rhythmic seasonal pattern; however, the ordering of seasons changes in the last years of the study period.

Burden of Cancers in Iran from 1990 to 2010: findings from the Global Burden of Disease study 2010

BACKGROUND

Cancer is one of the most common non-communicable diseases in both sexes and a major cause of disability and death around the world, as well as in Iran. The aim of the present manuscript is to report the results of the Global Burden of Disease study 2010 (the GBD 2010) to compare the results with the other similar findings. The paper also discusses the existing deficiencies of the GBD study. Our aim was to describe and criticize the attributed burden of cancers according to the GBD results by sex and age.

METHODS

The GBD 2010 has profited from 100 collaborators worldwide and provides a vast network of data on health outcomes, vital registries, and population surveys. The GBD has used various scientific-approved methods to estimate important health statuses like death rates, life expectancy, and healthy adjusted life expectancy, disability-adjusted life years, years of living lost due to premature death and years of life with disabilities. In the present study, we extracted and graphed the GBD results for Iran in order to present a better scheme for readers.

RESULTS

The mortality rate of cancers in Iranians has increased by about 8.5%, the disability-adjusted life year rates have declined by about 9%, and years lost due to premature death have also decreased by about 10% from 1990 to 2010 compared to an 85% increase in years of life with disabilities in the same time period.

CONCLUSION

The burden of all non-communicable diseases (NCDs) including cancers showed decrease during the past two decades. However, these diseases still remain worldwide health challenge. Prevention should be considered as an important priority and responsibility. The health authorities also need to determine the burden of cancers at the national and sub-national levels for implementation of effective preventive strategies.

Burden of Hepatitis C in Iran Between 1990 and 2010: findings from the Global Burden of Disease Study 2010

BACKGROUND

Hepatitis C virus (HCV) is the foremost cause of deaths attributable to cirrhosis and hepatocellular carcinoma. The Global Burden of Disease study 2010 (GBD 2010) quantifies and compares the degree of health loss as a result of diseases, injuries, and risk factors by age, sex, and geography overtime. This study aimed to present and critique the burden of hepatitis C and its trend in Iran between 1990 and 2010 by using the GBD study 2010.

METHODS

We used the results of GBD 2010 for Iran to measure rates and trends of mortality, causes of deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability adjusted life years (DALYs) due to hepatitis C. Hepatitis C was defined as the presence of hepatitis C virus in the serum. Data were presented in three categories: acute hepatitis C, cirrhosis secondary to hepatitis C, and liver cancer secondary to hepatitis C.

RESULTS

HCV infection (including the three categories of the study) led to 57.29, 59.92, and 66.45 DALYs (per 100,000 population) in 1990, 2000, and 2010, respectively. DALYs and death rates showed a slight decreasing trend for HCV cirrhosis; however, DALYs and death rates increased for acute hepatitis and liver cancer due to patients with HCV. The majority of deaths and DALYs were in individuals aged 70 years and above in all three categories of HCV. YLLs made the greatest contributions to DALYs.

CONCLUSION

DALYs due to HCV infection are increasing in Iran according to GBD 2010; however, the estimations of DALYs using GBD 2010 are mostly from model-based data and there are significant uncertainties for extrapolated data. In this regard, a comprehensive study such as the National and Subnational Burden of Diseases (NASBOD) study would be needed to estimate and calculate precisely prevalence and burden of HCV-related diseases at national and subnational levels.

Burden of Drug and Alcohol Use Disorders in Iran: findings from the Global Burden of Disease Study 2010

BACKGROUND

Due to its specific socio-cultural and geographical situation, Iran has a major public health problem in terms of drug and alcohol use. The aim of this study is to report and critique the burden of drug and alcohol use disorders in Iran, and to compare these measurements with similar findings.

METHODS

This study used data for Iran for the years 1990, 2005, and 2010 derived from the Global Burden of Disease study (GBD 2010) conducted by the Institute for Health Metrics and Evaluation (IHME) in 2010. The burden of drug and alcohol use disorders was evaluated in terms of disability adjusted life years (DALYs), years of life lost to premature mortality (YLLs), and years lived with disability (YLDs).

RESULTS

All rates were reported per 100,000 individuals. Death rates attributed to drug and alcohol use disorders were 7.7 and 0.16 for men, and 0.62 and 0.02 for women, respectively. YLL rates regarding drug use disorders were 351.8 and 24.8 for men and women, while these figures were 5.8 and 1.0 for alcohol use disorders for men and women, respectively. YLD rates of drug use disorders were 452.6 for men and 202.1 for women, and 105.8 for men and 23.7 for women for alcohol use disorders. DALY rates attributed to drug use disorders were 804.5 for men and 227 for women, while these rates were 111.7 for men and 24.7 for women, related to alcohol use disorders.

CONCLUSION

Similar to the cases in many other countries, the burden of both drug and alcohol use disorders is higher for men than women in Iran. Although prevention policies and programs for drug and alcohol use are required for both genders, the need for drug and alcohol use intervention seems more urgent for men in Iran.

Tobacco Smoking Status and the Contribution to Burden of Diseases in Iran, 1990-2010: findings from the Global Burden of Disease Study 2010

BACKGROUND

Tobacco smoking and exposure to second-hand smoke in the indoor environment are major public health risks worldwide. The aim of this paper is to report and critique a global assessment of smoking prevalence, smoking-attributable deaths, and disability adjusted life years (DALYs) extracted from GBD study 2010, by sex and age in Iran from 1990 to 2010.

METHODS

The Global Burden of Disease (GBD) Study 2010 estimated the distributions of exposure and relative risks per unit of exposure by systematically reviewing and analyzing published and unpublished data. These assessments were used, together with estimates of death and DALYs due to specific risk factors, to calculate the attributed burden for each risk factor exposure compared with the theoretical-minimum-risk exposure. Uncertainties in the distribution of exposure, relative risks, and relevant outcomes were incorporated into estimates of attributable mortality and burden. In this study, our aim was to reformulate the GBD data, produce new graphs, and explain the results for Iran in greater detail.

RESULTS

Between 1990 and 2010, the prevalence of tobacco smoking at all ages increased by 1% in men and declined by 2% in women in Iran, but the overall prevalence in the general population was unchanged (12%). A reduction was observed in the age-standardized death and DALY rates (per 100,000 population) attributed to tobacco smoking, including second-hand smoke. The attributed DALY rate was greater for Iranian men than for Iranian women. The highest rates of DALYs because of tobacco smoking were found in smoker men and women aged 70+, but exposure to second-hand smoke had the most significant burden in children under 5 years old. In 1990, the three leading disease burdens attributed to tobacco smoking, including second-hand smoke, were ischemic heart disease; communicable, maternal, neonatal, and nutritional disorders; and chronic respiratory diseases. In 2010, three leading burden of diseases attributed to tobacco smoking belonged to ischemic heart disease, chronic respiratory disease, and, and cerebrovascular disease, respectively.

CONCLUSION

Despite a reduction in the rate of tobacco smoking, including second-hand smoke, since 1990, smoking exposure remained the fifth leading risk factor for deaths and DALYs in Iran in 2010. Overall, our data clearly show the need for new efforts in Iran to reduce the mortality and burden attributed to tobacco smoking.

The Most Prevalent Causes of Deaths, DALYs, and Geriatric Syndromes in Iranian Elderly People Between 1990 and 2010: findings from the Global Burden of Disease study 2010

BACKGROUND

The substantial increase in life expectancy during recent decades has left all countries with a high number of elderly people that have particular health needs. Health policy-makers must be aware of the most prevalent causes of deaths and DALYs in this age group, as well as geriatric syndromes, in order to provide appropriate care and allocate resources in an equitable manner.

METHODS

The Global Burden of Disease study 2010 (GBD 2010), conducted by the institute for Health Metrics and Evaluation team, estimated the worldwide burden of diseases from 1990 to 2010. Its estimations were conducted on the basis of the proportion of deaths, the duration of symptoms and disability weights for sequelae, years lived with disability (YLDs), years of life lost (YLLs), and disability adjusted life years (DALYs) attributable to different diseases. In the present study, we extracted the data regarding the top five most prevalent causes of deaths, DALYs, and geriatric syndromes in the elderly based on the aforementioned GBD 2010, discussed the results using some tables and figures, reviewed the results, described the limitations of GBD 2010, and finally provided some recommendations as potential solutions.

RESULTS

According to GBD 2010, the total number of deaths in Iran in 1990 was 321,627, of which 116,100 were in elderly people (those aged 60 years and above), meaning that 36.10% of all deaths occurred in the elderly. Among all diseases in this year, the first to third ranked causes of death were ischemic heart disease (IHD; 29.44%), neoplasms (13.52%), and stroke (7.24%). In comparison, the total number of deaths in Iran increased to 351,814 in 2010, with 213,116 of these occurring in the elderly (60.58% of deaths), but the most prevalent causes of death remained the same as in 1990. The highest 1990 DALYs rates were the result of IHD (21.56%), neoplasms (10.70%), and stroke (4.85%). IHD (22.77%), neoplasms (9.48%), and low back pain (LBP; 5.72%) were the most prevalent causes of DALYs in older Iranian adults in 2010. The fourth and fifth ranked causes of deaths and DALYs in both 1990 and 2010, both in Iran and globally, were different diseases and geriatric syndromes in the elderly Iranian population.

CONCLUSION

The aged population of Iran is growing steadily, and there is a need for health policy-makers to create appropriate programs to meet the health needs of elderly people. Although GBD 2010 results are useful in providing burden estimations at regional and national levels, each individual country should estimate its burden of diseases, injuries, and risk factors at a sub-national level to obtain further details regarding the health status of its people. As no comprehensive study regarding elderly people in Iran has previously been conducted, our study will be a major source for identifying the important causes of deaths, DALYs, and geriatric syndromes among this population.

Using drug sales data to evaluate the epidemiology of cardiometabolic risk factors and their inequality: an ecological study on atorvastatin and total cholesterol in Iran

BACKGROUND

Statins have been effective medications in lowering serum total cholesterol (TC) concentrations across populations over time. The aim of this study was to estimate national and provincial trends in atorvastatin sales in Iran, to systematically quantify its relationship with socioeconomic indicators, and changes in TC level.

METHODS

In this retrospective ecological study, conducted in Iran, we examined trends in atorvastatin sales, the wealth index (WI) as a validly-available socio-economic indicator, and TC level between 2004 and 2011. The main outcome variable was mean atorvastatin sold in defined daily dose per 100,000 people per day (DPD). We analyzed the relationship between WI and DPD and between DPD and mean TC across time and space.

RESULTS

At national level, both mean WI and mean DPD showed increasing trend over time, while we observed decreasing trend for TC. Mean WI and DPD in 2011 was nearly 5 and 50 time that of their respective figures in 2004, while the mean TC decreased for nearly 10%. Increases in both WI and DPD had happened in every province, but with different patterns. The maximum and minimum changes in DPD versus WI were seen in Gilan and North Khorasan respectively.

CONCLUSION

A striking increase occurred in the sales for atorvastatin in Iran from 2004-2012 in most provinces examined. The wealthier a province became, the more sales were seen for atorvastatin. TC optimistically decreased from 2005 to 2011 and its decrease was positively correlated with increasing sales for atorvastatin.

National and sub-national burden of breast cancer in Iran; 1990-2013

BACKGROUND

Estimating the burden of diseases, injuries and major risk factors is necessary for adopting appropriate health policies in every country, and this paper aims to explain the study protocol of national and sub-national burden of breast cancer in Iran from 1990 to 2013.

METHODS

We will perform a systematic review of the confirmed databases and literature to gather data on breast cancer epidemiology in Iran. The definitions, data sources, organizing the team, methods of data gathering and data generating will be explained in this paper. The methodology of estimating the trend of prevalence, years of life lost due to premature death (YLLs), years of life lost due to disability (YLDs) and disability-adjusted life years lost (DALYs) of breast cancer by age groups, provinces and probable inequalities will be explained. We will tackle possible data problems due to the lack of data points on provinces and years and also geographical misalignment by using two advanced statistical methods, namely Bayesian autoregressive multilevel and Spatio-temporal models. Trend estimation will be reported using these two models together with uncertainty intervals.

CONCLUSION

This study provides a comprehensive assessment of breast cancer and its specific pattern in Iran. The results will help policy makers to know the trend of prevalence, the distribution, and the inequalities of breast cancer in Iran to allocate resources in a better way.

National and sub-national prevalence, trend, and burden of end stage renal diseases (ESRD) in Iran 1990-2013; the study protocol

BACKGROUND

End Stage Renal Diseases (ESRD) imposes a huge economic burden on the health system; however, there is a serious lack of data related to ESRD, especially at Sub-national level, in Iran. Calculating the burden of ESRD at National and Sub-national level provides an opportunity to apply cost-effective interventions for the purpose of prevention and treatment. The current study protocol aims to explain the general structure and methods that will be used in the burden of ESRD study in Iran from 1990 to 2013.

METHODS

The prevalence, incidence, mortality and geographical and socioeconomic inequality trend of ESRD will be calculated through a comprehensive systematic review of published and unpublished data. Years of Life Lost due to premature mortality, and Years Lived with Disability and Disability-Adjusted Life Years (DALYs) will be quantified for ESRD by gender, age group, and province with their uncertainly intervals. "Spatio-Temporal" and "Bayesian multilevel autoregressive" will be applied to deal with data scarcity and misalignment problem which exist in the data sources.

DISCUSSION

The findings of the burden of ESRD study will be useful to organize preventive, treatment also research priorities at national and sub-national levels in Iran. Better understanding of the magnitude of ESRD burden is essential to prevent the progression of chronic kidney diseases to the end stage phase which is considered as a devastating illness.

National and sub-national burden of chronic diseases attributable to lifestyle risk factors in Iran 1990 - 2013; study protocol

BACKGROUND

Non-communicable diseases, as the major public health problem, are caused by different risk factors. The main leading lifestyle risk factors for most diseases burden in Iran are unhealthy diet, physical inactivity, and smoking. The aim of this study is to provide data collection and methodology processes for estimating the trends of exposures to the selected lifestyle risk factors and their attributed burden at national and sub-national levels.

METHODS

Systematic review will be performed through PubMed/MEDLINE, Scopus and ISI/Web of Science as well as Iranian databases such as IranMedex, Irandoc and Scientific Information Database (SID). In addition, hand searching of unpublished data sources will be used to identify relevant population-based studies. The searched studies will be included only if it is reasonably population-based and representative, and exposure data has been reported or could be plausibly obtained from the study. For risk factors with no surveys identified, other sources of potential data will be considered. The target population is healthy Iranian adult population living within Iran from 1990 to 2013. Other data sources include national censuses, national registration systems, and national and sub-national surveys. Spatio-temporal Bayesian hierarchical model and Bayesian multilevel autoregressive model will be used to overcome the problem of data gaps in provinces, and in some age or sex groups or in urban/rural areas. The problem of misaligned areal units will be also addressed in these models.

CONCLUSION

National and sub-national assessment of major lifestyle risk factors such as unhealthy diet, physical inactivity, and smoking is necessary for priority setting and policy making in different regions of Iran.

National and sub-national trend and burden of injuries in Iran, 1990 - 2013: a study protocol

BACKGROUND

Worldwide, injuries are a major public health concern and make a considerable contribution to the disease burden. The present study is a component of the National and Subnational Burden of Diseases, Injuries, and Risk Factors from 1990 to 2013 (NASBOD) study in Iran, which was designed to investigate the burden of most important injuries (road traffic injuries, falls, burns, poisonings and drownings) at the national and sub-national levels in Iran. In this paper we explain definitions, organization, injuries selection process, data sources, data gathering methods, and data analyses of the national and sub-national burden of injuries study in Iran.

METHODS

The burden of most important injuries in current metric of DALYs at the national and sub-national levels in Iran over 1990-2013 will be estimated through comprehensive reviews of either published or national data sources. Statistical modeling will be used to impute the missing data on the burden of selected important injuries for each district-year.

CONCLUSION

The results of present study can help health policy makers to plan more comprehensive and cost-effective strategies at national and sub-national level for prevention and control of burden caused by injuries.

Costs of Treatment after Renal Transplantation: Is it Worth to Pay More?

The primary aim of the study was to estimate costs of treatment for the first year after renal transplantation from the perspective of health insurance organizations in Iran. An Excel-based and a Monte Carlo model were developed to determine the treatment costs of current clinical practice in renal transplantation therapy (RTT). Inputs were derived from Ministry of Health and insurance organizations database, hospital and pharmacy records, clinical trials and local and international literature. According to the model, there were almost 17,000 patients receiving RTT in Iran, out of which about 2,200 patients underwent the operation within the study year (2011 - 2012; n = 2,200) The estimated first year total treatment cost after renal transplantation was almost $14,000,000. These costs corresponded to annual total cost per patient of almost $6500 for the payers. Renal transplantation therapy is almost fully reimbursed by government in Iran. However, regarding new expensive medicines, cost of medical expenditure is rapidly growing and becoming quite unaffordable for the government; therefore, out-of-pocket (OOP) payments are dramatically increasing over time. In order to improve reimbursement policy making under pressure of current budget constraints, the present study is providing decision makers with practical tools make it possible for them to easily compare budgetary impact of the current therapy strategy with the future financial consequences of purchasing newly proposed medicines. In other words having estimation of the current budget spending on RTT would help policy makers in making efficient resource allocation and decrease quite high OOP expenditures.

"Budget impact analyses": a practical policy making tool for drug reimbursement decisions

In the present article, Budget Impact Analysis as an effective, practical financial tool has been introduced to the policy makers for improving drug formulary and reimbursement decision making. In Iran, Ministry of Health (MOH), health insurance organizations, and health care providers such as hospitals could take the most advantage of the BIAs reports.

Socioeconomic inequality in infant mortality in Iran and across its provinces

OBJECTIVE

To measure the socioeconomic inequality in infant mortality in Iran (the Islamic Republic of Iran).

METHODS

We analysed data from the provincially representative Demographic and Health Survey, which was done in Iran in 2000. We used a dichotomous hierarchical ordered probit model to develop an indicator of socioeconomic status of households. We assessed the inequality in infant mortality by using the odds ratio of infant mortality between the lowest and highest socioeconomic quintiles at both the provincial and national levels, and the concentration index, an inequality measure based on the entire socioeconomic distribution.

RESULTS

We found a decreasing trend in the infant mortality rate in relation to socioeconomic quintiles. The poorest to richest odds ratio was 2.34 (95% CI = 1.78-3.09). The concentration index of infant mortality in Iran was -0.1789 (95% CI = -0.2193--0.1386). Furthermore, the inequality of infant mortality between the lowest and highest quintiles was significant and favoured the better-off in most of the provinces. However, this inequality varied between provinces.

CONCLUSION

Socioeconomic inequality in infant mortality favours the better-off in the country as a whole and in most of its provinces, but the degree of this inequality varies between the provinces. As well as its national average, it is important to consider the provincial distribution of this indicator of population health.

Pre-marriage prevention of thalassaemia: report of a 100,000 case experience in Isfahan

BACKGROUND

Iran like other middle east countries has a large number of major thalassaemics. Due to religious restrictions on abortion, the routine prevention of the birth of thalassaemic children by this means is not possible. The aim of this study is to describe an alternative means to prevent the birth of thalassaemic children.

METHODS

From January 1993 to January 1996, 10,000 people preparing for marriage were screened for the thalassaemia trait, using CBC and HbA2 level measurement. High risk couples were referred for further consultation regarding the disease and the means of its prevention. The proposed actions of the couples regarding thalassaemia prevention were evaluated immediately after consultation and then re-evaluated three months later.

RESULT

After the project had been running for three years the average of high risk couple initially deciding not to marry was 90% and no new cases of thalassemia were detected in the children of the screened population.

CONCLUSION

Where both members of the couple were trait-positive their preferred choice was not to marry, rather than to marry and use other or no methods of preventing a thalassemia affected child being born to them. Cultural and religious ideas can affect such decisions and in some Islamic countries the establishment and use of a genetic counselling centre can help prevent most of new thalassaemia cases.