Quality of in-hospital care in traumatic spinal column and cord injuries (TSC/SCI) in I.R Iran

PURPOSE

This study aimed to implement the Quality of Care (QoC) Assessment Tool from the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to map the current state of in-hospital QoC of individuals with Traumatic Spinal Column and Cord Injuries (TSCCI).

METHODS

The QoC Assessment Tool, developed from a scoping review of the literature, was implemented in NSCIR-IR. We collected the required data from two primary sources. Questions regarding health system structures and care processes were completed by the registrar nurse reviewing the hospital records. Questions regarding patient outcomes were gathered through patient interviews.

RESULTS

We registered 2812 patients with TSCCI over six years from eight referral hospitals in NSCIR-IR. The median length of stay in the general hospital and intensive care unit was four and five days, respectively. During hospitalization 4.2% of patients developed pressure ulcers, 83.5% of patients reported satisfactory pain control and none had symptomatic urinary tract infections. 100%, 80%, and 90% of SCI registration centers had 24/7 access to CT scans, MRI scans, and operating rooms, respectively. Only 18.8% of patients who needed surgery underwent a surgical operation in the first 24 h after admission. In-hospital mortality rate for patients with SCI was 19.3%.

CONCLUSION

Our study showed that the current in-hospital care of our patients with TSCCI is acceptable in terms of pain control, structure and length of stay and poor regarding in-hospital mortality rate and timeliness. We must continue to work on lowering rates of pressure sores, as well as delays in decompression surgery and fatalities.

Trinitroglycerin-loaded chitosan nanogels: Shedding light on cytotoxicity, antioxidativity, and antibacterial activities

AIM AND BACKGROUND

Trinitroglycerin (TNG) is a remarkable NO-releasing agent. Here, we synthesized TNG based on chitosan Nanogels (Ngs) for ameliorating complications associated with high-dose TNG administration.

METHOD

TNG-Ngs fabricated through ionic-gelation technique. Fourier-transformed infrared (FT-IR), zeta-potential, dynamic light scattering (DLS), and electron microscopy techniques evaluated the physicochemical properties of TNG-Ngs. MTT was used to assess the biocompatibility of TNG-Ngs, as the antioxidative properties were determined via lactate dehydrogenase (LDH), reactive oxygen species (ROS), and lipid peroxide (LPO) assays. The antibacterial activity was evaluated against Staphylococcus aureus (S. aureus), Escherichia coli (E. coli), Methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococci (VRE).

RESULTS

Physicochemical characterization reveals that TNG-Ngs with size diameter (96.2 ± 29 nm), polydispersity index (PDI, 0.732), and negative zeta potential (-1.1 mv) were fabricated. The encapsulation efficacy (EE) and loading capacity (LC) were obtained at 71.1 % and 2.3 %, respectively, with no considerable effect on particle size and morphology. The cytotoxicity assay demonstrated that HepG2 cells exposed to TNG-Ngs showed relative cell viability (RCV) of >80 % for 70 μg/ml compared to the TNG-free drug at the same concentration (P < 0.05). TNG-Ngs showed significant differences with the TNG-free drug for LDH, LPO, and ROS formation at the same concentration (P < 0.001). The antibacterial activity of the TNG-Ngs against S. aureus, E. coli, VRE, and MRSA was higher than the TNG-free drug and Ngs (P < 0.05).

CONCLUSION

TNG-Ngs with enhanced antibacterial and antioxidative activity and no obvious cytotoxicity might be afforded as novel nanoformulation for promoting NO-dependent diseases.

The Outcome of Surgical Versus Conservative Management in Old Patients With Traumatic Brain Injury

Background and Aim: It is still unclear whether the surgical or conservative approach has the best recovery and the least adverse outcomes after the treatment of patients with traumatic brain injury (TBI), especially the elderly. The use of invasive versus conservative therapies in elderly patients with TBI is controversial, and the current brain surgery procedures for the elderly require further evaluation. Methods and Materials/Patients: In this retrospective cohort study, the medical records of 238 patients with TBI (119 surgical patients and 119 patients treated with conservative methods) over the age of 65 were reviewed. The patients were compared for the degree of recovery indicated by the Glasgow outcome score (GOS) and postoperative complications. Results: No difference was found in the primary Glasgow coma scale (GCS) between surgical and conservative approaches, but after two treatment protocols, the assessment of GCS and GOS showed a significant difference between the two groups; however, after adjusting baseline parameters in a multivariable logistic regression model, the difference between the two groups in CGS and recovery state turned to insignificance. There was no difference between surgical and conservative management in the post-treatment sequels, including contusion, hydrocephalus, myocardial infarction, pulmonary infection, and death. However, the recurrence of hematoma was significantly higher in those who were treated by the conservative method even after multivariate regression modeling. Conclusion: In TBI patients aged over 65 years, surgical management can result in more favorable outcomes compared with the conservative approach.

Outcomes and Complications of Incomplete Spinal Cord Injury in the Thoracolumbar Region

Background and Aim: Improvement of neurological disorders in patients with incomplete spinal cord injury (SCI) remains an important issue worldwide. This study aimed to explore the outcomes and complications of patients with incomplete SCI in the thoracolumbar region within one year after trauma. Methods and Materials/Patients: In this longitudinal prospective study, patients with traumatic incomplete SCI were studied. The demographic and clinical variables including age, sex, site of injury, motor force, sensory disorder, and sphincter dysfunction were recorded on admission and 3, 6, 9, and 12 months after discharge. SPSS software, version 28 was used for data analysis. Results: Out of 120 patients with incomplete SCI, 100 patients were included. The mean age of the participants was 32.39±7.47 years and the mean duration of hospitalization was 14.78±3.81 days. The most common injury site was T12-L1 (43%). Over time, the average motor force of patients increased. The lowest and highest averages were observed during hospitalization and 12 months after discharge, respectively. No significant difference was observed in the paired comparison of motor force at 3, 6, 9, and 12 months after discharge. The frequency of sensory disorders decreased over time. The highest and lowest frequencies belonged to the hospitalization time (81%) and 12 months after discharge (9%). No significant difference was observed between the time intervals of 6, 9, and 12 months, as well as the time of hospitalization and discharge. Over time, the frequency of sphincter dysfunction decreased. Pulmonary infection (12%) and bed sores (9%) were the complications observed during hospitalization. Complications observed 12 months after admission were bed sores (21%) and venous thrombosis (17%). Conclusion: The highest recovery rate of motor force was recorded within the first three months. The frequency of sensory and sphincter disturbances in patients decreased over time with the highest recovery rate during the first six months after the injury.

Effect of Granulocyte Colony-Stimulating Factor (G-CSF) on Improving Impairment Scale After Acute Spinal Cord Injury: An Individual Participant Data Meta-Analysis

Background and Aim: The present study was conducted to investigate the effects of granulocyte colony-stimulating factor (G-CSF) after acute spinal cord injury on increasing a grade of improvement entitled American spinal cord injury association impairment scale (AIS) as an individual participant data (IPD) meta-regression analysis of clinical trials. Methods and Materials/Patients: According to our search strategy, four studies were selected. Multilevel ordered logistic regression modeling was used to predict AIS grade with G-CSF administration and time variable (first day and a 3-month follow-up). The IDs of the studies as well as the time series variable were imported to the random part of the model. Odds ratio (OR) and 95% confidence interval (CI) were reported. Results: A total of 277 samples were studied. A fixed effect model was performed at first. Accordingly, using G-CSF was associated with increased AIS grade (lower impairment) (OR=1.503, 95% CI=1.110-2.035) adjusted with time series (OR=1.868, 95% CI=1.378-2.532). In the mixed effect model, G-CSF was again associated with increased AIS grade (OR=1.780, 95% CI=1.301- 2.436) adjusted with time series (OR=2.152, 95% CI=1.406-3.294). Conclusion: The present meta-analysis showed the protective effect of GCS-F observed as an improvement in AIS grade. This protecting effect was further after adjusting the random effects of time series and individual studies. Although multilevel modeling could reduce our limitations, it should be regarded that the number of trials was not enough to establish strong conclusions.

Burden in caregivers of spinal cord injury patients: a systematic review and meta-analysis

BACKGROUND

Caregivers of individuals with spinal cord injury encounter high levels of physical, psychosocial, and financial burden by providing lifelong assistance. In the present study, we aimed to assess the overall burden score of caregivers in spinal cord injury by pooling different standard scores together as a review.

METHOD

Search on databases of PubMed/Medline, Web of Science and Scopus was conducted using PRISMA guidelines. Studies that assessed the burden of care using the caregiver burden inventories of CBI (caregiver burden inventory), CBS (caregiver burden scale), CG (caregiver), CSI (Caregiver Strain Index), and short- and long-form Zarit questionnaires were included in our study. The results were analyzed using the meta-analysis method and a random effect pooled estimator. All analyses were performed using STATA SE software version 14.

RESULT

A total of 23 articles out of 399 retrieved studies were added to this review study. The overall score of caregiver burden in individuals with SCI was calculated 48.68 (95% CI 42.574-54.788). The I2 heterogeneity was 11.7%, suggesting a low level of heterogeneity among the included studies. There was no systematic difference between various questionnaires added to meta-analysis (P = 0.526). In addition, the caregiver burden did not differ in less and highly developed countries (P = 0.405).

CONCLUSION

Since SCI places a considerable burden on caregivers, scoring the burden of care can help policymakers plan for essential interventions and allocate more facilities for these patients and their caregivers.

Lobectomy in traumatic brain injury patients with intracerebral hemorrhage and delayed contusion

Background:

TBI, standing for Traumatic Brain Injury, is a leading cause of death worldwide; nonetheless, data on its management has hitherto been sparse. In view of the fact that brain lobectomy is a contentious issue in the management of TBI, we set out the current study to assess the mortality rate and outcomes of TBI with delayed contusion or Intracerebral Hemorrhage (ICH) undergoing lobectomy.

Methods:

We evaluated 135 TBI patients with delayed contusion or ICH undergoing brain lobectomy from 2001 to 2013. Withal, the mortality and Glasgow Outcome Scale (GOS) and Glasgow Comma Scale (GCS) rates were assessed in these patients and the association in between was sought.

Results:

The TBI patients undergoing brain lobectomy (77% male versus 23 % female) had a mean age of 43.4±20.3 years and experienced a survival rate of 62.2% (71% in females versus 60% in males). Favorable GOS was observed in 53% of male patients, compared with 27% in the females. Age was demonstrated to significantly affect the mortality rate (p=0.0001). Initial GCS score was associated with GOS as 79.1% of the survived patients with a GCS of higher than 9 on admission were discharged with favorable GOS.

Conclusions:

The evidence from the present study indicates that lobectomy can be an acceptable surgical procedure in management of TBI patients with delayed contusion or ICH.

Lobectomy in traumatic brain injury patients with intracerebral hemorrhage and delayed contusion

BACKGROUND

TBI, standing for Traumatic Brain Injury, is a leading cause of death worldwide; nonetheless, data on its management has hitherto been sparse. In view of the fact that brain lobectomy is a contentious issue in the management of TBI, we set out the current study to assess the mortality rate and outcomes of TBI with delayed contusion or Intracerebral Hemorrhage (ICH) undergoing lobectomy.

METHODS

We evaluated 135 TBI patients with delayed contusion or ICH undergoing brain lobectomy from 2001 to 2013. Withal, the mortality and Glasgow Outcome Scale (GOS) and Glasgow Comma Scale (GCS) rates were assessed in these patients and the association in between was sought.

RESULTS

The TBI patients undergoing brain lobectomy (77% male versus 23 % female) had a mean age of 43.4±20.3 years and experienced a survival rate of 62.2% (71% in females versus 60% in males). Favorable GOS was observed in 53% of male patients, compared with 27% in the females. Age was demonstrated to significantly affect the mortality rate (p=0.0001). Initial GCS score was associated with GOS as 79.1% of the survived patients with a GCS of higher than 9 on admission were discharged with favorable GOS.

CONCLUSIONS

The evidence from the present study indicates that lobectomy can be an acceptable surgical procedure in management of TBI patients with delayed contusion or ICH.

The relationship between weight indices and injuries and mortalities caused by the motor vehicle accidents: a systematic review and meta-analysis

BACKGROUND

The relationship between weight indices and injuries and mortality in motor vehicle accidents is unknown. Systematic review studies addressing the collection and analysis of the relationship in investigations are very limited. The purpose of this systematic review is to determine the relationship between BMI, obesity and overweight with mortality and injuries and their severity and vulnerable organs after the motor vehicle accident.

METHODS

The databases (MEDLINE/PUBMED, EMBASE, Web of Science, etc) were searched for relevant abstracts using certain keywords. Of all the articles, similar ones were removed considering different filters. The collected data were entered into the STATA SE v 13.1. The heterogeneity of the data was analyzed using i2 statistics. In addition, the estimates of the study were done based on the age group (children and adults) and the impact of obesity on different regions of the body.

RESULTS

A direct relationship was observed between the overall BMI and the degrees of injuries (CI=0.503-1.139), and mortality due to motor vehicle accident (CI=1.267-1.471). A positive relationship was found between obesity and AIS+2 (CI=0.653-1.426), and AIS+3 (CI=1.184-1.741), and ISS (CI=1.086-1.589). Also, a negative relationship between overweight and injuries rates, and a direct relationship between overweight and mortality (CI=0.979-1.167), and injuries with index of AIS+2 (CI=1.178-0.768) and AIS+3 (CI=0.48-2.186) were found.

CONCLUSIONS

The prediction of injury, mortality and severity of injuries in the motor vehicle accident by the variable of obesity and overweight determines the need to design prevention programs for this vulnerable group at all levels.

Spinopelvic Alignment Parameters in Spondylolisthesis Patients Compared to Nonspondylolisthesis Patients

Objective We aimed at describing spin pelvic alignment features in patients with degenerative spondylolisthesis (DS), in comparison with other patients complaining of low back pain but no evidence of spondylolisthesis on standard standing lateral lumbosacral X-ray.

Methods In this prospective descriptive study, patients with low back pain included in two groups of DS and non-DS patients, according to preoperative lumbosacral X-ray in standard standing lateral position. Patient’s demographic characteristics, as well as spinopelvic alignment parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis, and facet joint orientation, were collected. DS patients were compared with non-DS, age-matched control group.

Results DS patients were significantly obese (p = 0.031) and had a high PI (56.39 ± 11.5), SS (38.28 ± 10.32), and PT (18.52 ± 9.11), (p = 0.00, 0.01, 0.04, respectively). Moreover, segmental lordosis at L2–L3, L3–L4, and L5–S1 levels demonstrated a significant increase (p < 0.05). Facet joints at L4–L5 level were located more sagittally (37.5 ± 7.07 vs. 40.71 ± 6.33).

Conclusion PI, SS, and PT significantly increase in DS patients compared with non-DS group. Elevated segmental lordosis at high lumbar levels and sagittal orientation of facet joints were other features observed in DS patients.

Rolipram optimizes therapeutic effect of bevacizumab by enhancing proapoptotic, antiproliferative signals in a glioblastoma heterotopic model

The unstable response to bevacizumab is a big dilemma in the antiangiogenic therapy of high-grade glioma that appears to be linked to an increase in the post-treatment intratumor levels of hypoxia-inducible factor 1 α (HIF1α) and active AKT. Particularly, a selective phosphodiesterase IV (PDE4) inhibitor, rolipram is capable of inhibiting HIF1α and AKT in cancer cells. Here, the effect of bevacizumab alone and in presence of rolipram on therapeutic efficacy, intratumor hypoxia levels, angiogenesis, apoptosis and proliferation mechanisms were evaluated. BALB/c mice bearing C6 glioma were received bevacizumab and rolipram either alone or combined for 30 days (n = 11/group). At the last day of treatments, apoptosis, proliferation and microvessel density, in xenografts (3/group) were detected by TUNEL staining, Ki67 and CD31 markers, respectively. Relative expression of target proteins was measured using western blotting. Bevacizumab initially hindered the tumor progression but its antitumor effect was weakened later despite the vascular regression and apoptosis induction. Unpredictably, bevacizumab-treated tumors exhibited the highest cell proliferation coupled with PDE4A, HIF1α and AKT upregulation and p53 downregulation and reversed by co-treatment with rolipram. Unlike a similar antivascular pattern to bevacizumab, rolipram consistently led to a more tumor growth suppression and proapoptotic effect versus bevacizumab. Co-treatment maximally hampered the tumor progression and elongated survival along with the major vascular regression, hypoxia, apoptosis induction, p53 and caspase activities. In conclusion, superior and persistent therapeutic efficacy of co-treatment provides a new insight into antiangiogenic therapy of malignant gliomas, suggesting to be a potential substitute in selected patients.

Determinants of utilization and out-of-pocket payments for psychiatric healthcare in Iran

Purpose

Mental health is an inevitable and vital dimension when it comes to providing a global definition for the appropriate health status. This highlights the importance of investigating factors influencing utilization and out-of-pocket payments (OOP) for mental health services. Thus, the purpose of this paper is to assess the determinants of the utilization and OOP for psychiatric healthcare in Iran.

Design/methodology/approach

A total of 39,864 households were included in this cross-sectional study. Data on the utilization and OOP for psychiatric healthcare as well as all their determinants (e.g. wealth index of households, geographical area, household size, etc.) were extracted from the Household Income and Expenditure Survey (HIES). The HIES was conducted by the Statistical Center of Iran in 2016. A zero-inflated Tobit model was used to identify the main factors affecting utilization and OOP for psychiatric healthcare utilization.

Findings

The average of utilization and OOP for psychiatric services was found to be 14.67 times per 1,000 households and $7.783 per month for service users, respectively. There were significant positive relationships between income and utilization (p=0.0002) and OOP (p<0.0001) for psychiatric services. Significant negative associations were found between the number of illiterate people in the household and OOP (coefficient=−1.56) and utilization (coefficient=−0.2002) for psychiatric services. Utilization and OOP for psychiatric services were statistically significantly higher among households with higher wealth status.

Originality/value

Despite the higher rate of mental disorders, the utilization of psychiatric services in Iran is very low. Due to financial barriers and insufficient insurance coverage, high socioeconomic status (SES) households utilize more psychiatric services than low-SES households. Thus, the integration of mental health services in public health programs is required to improve the utilization of psychiatric services in Iran.

Cerebral hemodynamic abnormalities of patients with ischemic stroke who are opium addicted: A study by transcranial doppler ultrasonography

Background: Ischemic stroke as the major cause of mortality and morbidity worldwide has different risk factors. One of its modifiable risk factors is opium addiction whose role is not clear yet. This study aimed at assessing the hemodynamic parameters in ischemic stroke patients addicted to opium using transcranial Doppler (TCD) ultrasonography and comparing them with non-addicted patients. Methods: This comparative cross-sectional study was conducted in an academic hospital in the north of Iran in 2016. All the patients diagnosed as ischemic stroke underwent cerebrovascular ultrasound in the first 4 days of symptoms onset. Frequency of hemodynamic abnormalities confirmed by pulsatility index (PI) and mean flow velocity (MFV) were determined and compared between the two groups. The data were analyzed by chi-square test, t-test, and multiple logistic regression models using SPSS software. Results: A total of 353 patients with ischemic stroke (92 addicted and 261 non-addicted patients) were enrolled in the study. Univariate analysis indicated that the PI and MFV differences were statistically significant between two groups of addicted and non-addicted patients (P = 0.0001). By multivariate logistic regression model, the age [odds ratio (OR) = 1.143], diabetes mellitus (DM) (OR = 3.875), hypertension (HTN) (OR = 2.557), and opium usage (OR = 9.615) had influence on PI and only opium usage (OR = 3.246) had influence on MFV. Conclusion: Opium usage affects the cerebral hemodynamic parameters and increases the chance of having abnormal PI as ten-fold and abnormal MFV as three-fold.

Spontaneous Cervical Epidural Hematoma with Stroke Manifestations

Spontaneous cervical epidural hematoma (SCEH), which is a rare disease, is manifested as by a sudden quadriplegia or paraplegia and other neurological deficits. SCEH can compress the spinal cord resulting in its clinical manifestations. The reported etiological risk factors are anticoagulants, coagulopathies, vascular malformations, infections, and herniated discs. Here, we report a 77-year-old woman with a presenting chief complaint of left hemiparesis and a history of hypertension. The medical drugs in use were aspirin and antihypertensives. The initiating presentations were hemiparesis, in favor of ischemic stroke, so the patient admitted to neurology ward and received anticoagulant therapy with the initial diagnosis of stroke. Although clinical manifestations and examinations are important in these patients due to mimicking stroke picture, imaging evaluation is paramount for a definite diagnosis, which in our case showed a SCEH, who was suspected to have an ischemic stroke during the initial assessment because its initial demonstration mimicked ischemic stroke. This patient underwent laminectomy after 3 days and showed a clinical recovery the day after. Her muscle strength improved gradually, and neurological symptoms were diminished after physiotherapy.

Comparison of Religious Teaching with Muscle Relaxation Methods on Anxiety Patients

Background: Anxiety in psychiatric patients is more prevalent than the general population. Non-pharmacological methods for the treatment of anxiety are beneficial to the health of the patient, but it is not clear which of these approaches are more appropriate. Objectives: The aim of this study is comparison of the effects religious teachings and muscle relaxation on reducing anxiety in patients hospitalized to psychiatric hospital. Materials & Methods: This is a quasi-experipsychiatric study with pre and post-test with control group that was performed on patients hospitalized to the ward of psychiatric hospital during the period from March to June, 2016. Out of 100 patients under the Spielberger anxiety screening, 60 anxious patients were diagnosed and 45 subjects who entered the study were randomly assigned to three groups of 15. Univariate analysis of Variance was used to analyze the data. Results: There was a significant difference between the post-training scores in the three groups (P=0.0001 and F=19.11). According to the Bonferroni test, there was a significant difference between the mean scores after the training in both groups of religious teachings (P=0.001 and MD=8.03, and relaxation with control group (P=0.0001 and MD=12.48). However, there is no statistically significant difference between the mean scores after training in the groups of religious teachings with relaxation (P=0.094 and MD=4.45). Conclusion: The use of the religious teaching module reduces of anxiety in psychiatric patients; religious teachings and relaxation techniques are equally effective in alleviating the anxiety of psychiatric patients. Therefore, it is suggested that these complementary and low cost methods be used to reduce anxiety instead.

Feasibility and Data Quality of the National Spinal Cord Injury Registry of Iran (NSCIR-IR): A Pilot Study

BACKGROUND

Spinal cord injury (SCI) is one of the most disabling consequences of trauma with unparalleled economic, social, and personal burden. Any attempt aimed at improving quality of care should be based on comprehensive and reliable data. This pilot investigation studied the feasibility of implementing the National Spinal Cord and Column Injury Registry of Iran (NSCIR-IR) and scrutinized the quality of the registered data.

METHODS

From October 2015 to May 2016, over an 8-month period, 65 eligible trauma patients who were admitted to hospitals in three academic centers in mainland Iran were included in this pilot study. Certified registered nurses and neurosurgeons were in charge of data collection, quality verification, and registration.

RESULTS

Sixty-five patients with vertebral column fracture dislocations were registered in the study, of whom 14 (21.5%) patients had evidence of SCI. Mechanisms of injury included mechanical falls in 30 patients (46.2%) and motor vehicle accidents in 29 (44.6%). The case identification rate i.e. clinical and radiographic confirmation of spine and SCI, ranged from 10.0% to 88.9% in different registry centers. The completion rate of all data items was 100%, except for five data elements in patients who could not provide clinical information because of their medical status. Consistency i.e. identification of the same elements by all the registrars, was 100% and accuracy of identification of the same pathology ranged from 66.6% to 100%.

CONCLUSIONS

Our pilot study showed both the feasibility and acceptable data quality of the NSCIR-IR. However, effective and successful implementation of NSCIR-IR data use requires some modifications such as presence of a dedicated registrar in each center, verification of data by a neurosurgeon, and continuous assessment of patients' neurological status and complications.

Pros and cons of the health transformation program in Iran: evidence from financial outcomes at the household level

OBJECTIVES

The health transformation program was a recent reform in the health system of Iran that was implemented in early 2014. Some of the program’s important goals were to improve the equity of payments and to reduce out-of-pocket (OOP) payments and catastrophic health expenditures (CHE). In this study, these goals were evaluated using a before-and-after analysis.

METHODS

Data on household income and expenditures in Guilan Province were gathered for the years 2013 and 2015. OOP payments for outpatient, inpatient, and drug services were calculated, and the results were compared using the propensity score matching technique after adjusting for confounding variables. Concentration indices and curves were added to quantify changes in inequity before and after the reform. The incidence of catastrophic expenditures was then calculated.

RESULTS

Overall and outpatient service OOP payments increased by approximately 10 dollars, while for other types of services, no significant changes were found. Inequity and utilization of services did not change after the reform. However, a significant reduction was observed in CHE incidence (5.75 to 3.82%).

CONCLUSIONS

The reform was successful in decreasing the incidence of CHE, but not in reducing the monetary amount of OOP payments or affecting the frequency of health service utilization.

Psycho-social and Mental Variables and Post-Traumatic Stress Disorder in Traffic Accident Survivors in Northern Iran

OBJECTIVE

To assess the psycho-social and mental variables associated with post-traumatic stress disorder (PTSD) in a series of Iranian patients.

METHODS

A total of 528 eligible accident survivors in pre-sampling of a randomized controlled trial targeting PTSD were included in this cross-sectional study. Psycho-social characteristics associated to PTSD were explored in these survivors in an outpatient clinic. They completed the questionnaires via interview between six weeks to six months after accident. Data collection tools were PSS (DSM-V version) for PTSD and BDI-II for depression and a researcher-made questionnaire for psycho-social variables.

RESULTS

There was a significant association between PTSD and the following variables; family communication, current depression, return to work, history of death of relatives, witnessed the death, length of amnesia, hospitalization, injured situation, and accident severity. Multivariate logistic regression indicated that some variables were associated with PTSD such as accident severity, (p<0.001), injured situation, (p<0.001), current depression, (p<0.001), RTW (p<0.001), and family communication (p=0.01).

CONCLUSION

Psychiatric nursing prevention efforts is best directed toward motorcycle depressed drivers with severe accident and poor family communication who do not return to work. Thus, routine assessment of PTSD, depression and psycho-social variables after traffic accidents must be taken into account.

Maternal SSRI exposure increases the risk of autistic offspring: A meta-analysis and systematic review

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressants used to preclude maternal pregnancy depression. There is a growing body of literature assessing the association of prenatal exposure to SSRIs with autism spectrum disorder (ASD). The present systematic review and meta-analysis reviewed the medical literature and pooled the results of the association of prenatal exposure to SSRIs with ASD.

METHODS

Published investigations in English by June 2016 with keywords of selective serotonin reuptake inhibitors, SSRI, autism spectrum disorder, ASD, pregnancy, childhood, children, neurodevelopment were identified using databases PubMed and PMC, MEDLINE, EMBASE, SCOPUS, and Google Scholar. Cochran's Q statistic-value (Q), degree of freedom (df), and I² indices (variation in odds ratio [OR] attributable to heterogeneity) were calculated to analyze the risk of heterogeneity of the within- and between-study variability. Pooled odds ratio (OR) and 95% confidence interval (CI) were reported by a Mantel-Haenszel test.

RESULTS

There was a non-significant heterogeneity for the included studies ([Q=3.61, df=6, P=0.730], I²=0%). The pooled results showed a significant association between prenatal SSRI exposure and ASD (OR=1.82, 95% CI=1.59-2.10, Z=8.49, P=0.00).

CONCLUSION

The evidence from the present study suggests that prenatal exposure to SSRIs is associated with a higher risk of ASD.

Comparing Pediatric Trauma, Glasgow Coma Scale and Injury Severity scores for mortality prediction in traumatic children

BACKGROUND

Trauma is a major cause of disability and death among children worldwide, particularly in developed countries. The present aim was to compare efficacies of the Pediatric Trauma score (PTS), the Glasgow Coma Scale score (GCS), and the Injury Severity Score (ISS) in the prediction of mortality in children injured by trauma.

METHODS

A total of 588 children admitted to the emergency ward of the Poursina Medical and Educational Center from 2010-2011 with trauma were included. The PTS, GCS, and ISS were calculated for all patients. Predictive efficacy of these scores was compared using receiver operating characteristic (ROC) curve with 95% confidence interval.

RESULTS

Of the patient population, 62.1% were male and 37.9% female, with a mean age of 7.31±3.8 years. Road accident (42.2%) was the most common cause of injury. Overall, 2.4% of participants died. Regarding the prediction of mortality, the best cut-off point for the GCS was ≤8, with 98.4% sensitivity and 92.3% specificity. The same point for the PTS was ≤0.5, with 100% sensitivity and 31% specificity. For the ISS it was ≥16.5, with 92.5% sensitivity and 62% specificity. All variables based on mortality prediction were statistically significant (p<0.0001).

CONCLUSION

When compared to the PTS and ISS, the GCS may be a better predictor of mortality in cases of childhood trauma.

Comparison of Revised Trauma Score, Injury Severity Score and Trauma and Injury Severity Score for mortality prediction in elderly trauma patients

BACKGROUND

Trauma is the fifth leading cause of death in patients 65 years and older. This study is a comparison of results of Revised Trauma Score (RTS), Injury Severity Score (ISS), and Trauma and Injury Severity Score (TRISS) in prediction of mortality in cases of geriatric trauma.

METHODS

This is a cross-sectional study of records of 352 elderly trauma patients who were admitted to Pour-Sina Hospital in Rasht between 2010 and 2011. Injury scoring systems were compared in terms of specificity, sensitivity, and cut-off points using receiver operating characteristic curve of patient prognosis.

RESULTS

Mean age of patients was 71.5 years. Most common mechanism of injury was traffic accident (53.7%). Of the total, 13.9% of patients died. Mean ISS was higher for patients who did not survive. Mean of TRISS and RTS scores in elderly survivors was higher than non-survivors and difference in all 3 scores was statistically significant (p<0.001). Best cut-off points for predicting mortality in elderly trauma patients in RTS, ISS, and TRISS systems were ≤6, ≥13.5, and ≤2, with sensitivity of 99%, 84%, and 95% and specificity of 62%, 62%, and 72%, respectively.

CONCLUSION

TRISS was the strongest predictor of mortality in elderly trauma patients as result of combination of both anatomical and physiological parameters.

MtDNA T4216C variation in multiple sclerosis: a systematic review and meta-analysis

MtDNA T4216C variation has frequently been investigated in Multiple Sclerosis (MS) patients; nonetheless, controversy has existed about the evidence of association of this variation with susceptibility to MS. The present systematic review and meta-analysis converge the results of the preceding publications, pertaining to association of mtDNA T4216C variation with susceptibility to MS, into a common conclusion. A computerized literature search in English was carried out to retrieve relevant publications from which required data were extracted. Using a fixed effect model, pooled odds ratio (OR), 95 % confidence interval (95 % CI), and P value were calculated for association of mtDNA T4216C variation with susceptibility to MS. The pooled results showed that there was a significant association between mtDNA T4216C variation and MS (OR = 1.38, 95 % CI = 1.13-1.67, P = 0.001). The present systematic review and meta-analysis suggest that mtDNA T4216C variation is a contributory factor in susceptibility to MS.

A Time Series Model for Assessing the Trend and Forecasting the Road Traffic Accident Mortality

Background

Road traffic accident (RTA) is one of the main causes of trauma and known as a growing public health concern worldwide, especially in developing countries. Assessing the trend of fatalities in the past years and forecasting it enables us to make the appropriate planning for prevention and control.

Objectives

This study aimed to assess the trend of RTAs and forecast it in the next years by using time series modeling.

Materials and Methods

In this historical analytical study, the RTA mortalities in Zanjan Province, Iran, were evaluated during 2007 - 2013. The time series analyses including Box-Jenkins models were used to assess the trend of accident fatalities in previous years and forecast it for the next 4 years.

Results

The mean age of the victims was 37.22 years (SD = 20.01). From a total of 2571 deaths, 77.5% (n = 1992) were males and 22.5% (n = 579) were females. The study models showed a descending trend of fatalities in the study years. The SARIMA (1, 1, 3) (0, 1, 0) 12 model was recognized as a best fit model in forecasting the trend of fatalities. Forecasting model also showed a descending trend of traffic accident mortalities in the next 4 years.

Conclusions

There was a decreasing trend in the study and the future years. It seems that implementation of some interventions in the recent decade has had a positive effect on the decline of RTA fatalities. Nevertheless, there is still a need to pay more attention in order to prevent the occurrence and the mortalities related to traffic accidents.

Prevalence of Cytomegalovirus in Patients With Multiple Sclerosis: A Case-Control Study in Northern Iran

BACKGROUND

Multiple sclerosis (MS) is a chronic debilitating disease known as one of the most common neurological dysfunctions in young adults. Recent studies suggest that infections with herpesviruses play a critical role in the pathogenesis of MS.

OBJECTIVES

The present investigation aimed to detect the presence of cytomegalovirus (CMV) in patients with MS using polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) methods.

PATIENTS AND METHODS

Plasma and peripheral blood mononuclear cells (PBMCs) were collected from MS patients (n = 82) and from blood donors as control group (n = 89). They were tested for the presence of CMV antibodies and DNA by ELISA and PCR, respectively.

RESULTS

Anti-CMV was positive in 65 (79.3%) and 69 (77.5%) of the MS patients and healthy subjects, respectively (P= 0.853). Similarly, 23 (28%) and 2 (2.2%) patients were positive for CMV DNA among the MS and control groups, respectively. Statistical analysis showed that the frequency of CMV DNA in the MS patients was significantly higher than in the healthy controls (P < 0.001).

CONCLUSIONS

The results of this study showed a possible association between CMV infection and MS. Further experimental and epidemiological studies using case-control approaches are needed to confirm this association.

The High Prevalence of the Varicella Zoster Virus in Patients With Relapsing-Remitting Multiple Sclerosis: A Case-Control Study in the North of Iran

BACKGROUND

Multiple sclerosis (MS) is the most common neurological autoimmune disease, characterized by multifocal areas of inflammatory demyelination within the central nervous system. It has been hypothesized that the stimulation of the immune system by viral infections is the leading cause of MS among susceptible individuals.

OBJECTIVES

The aim of this study was to investigate the prevalence of the varicella zoster virus (VZV) in patients with relapsing-remitting multiple sclerosis.

PATIENTS AND METHODS

Plasma and peripheral blood mononuclear cells (PBMCs) collected from MS patients (n = 82) and controls (n = 89) were screened for the presence of anti-VZV antibodies and VZV DNA by the ELISA and PCR methods. DNA was extracted from all samples, and VZV infection was examined by the PCR technique. Statistical analysis was used to investigate the frequency of the virus in MS patients and a healthy control group.

RESULTS

Of all the MS patients, 78 (95.1%) and 21 (25.6%) were positive for anti-VZV and VZV DNA, respectively. Statistical analysis of the PCR results showed a significant correlation between the abundance of VZV and MS disease (P < 0.001). However, there was no significant correlation between the abundance of anti-VZV antibodies and MS disease by the ELISA method.

CONCLUSIONS

These results support the hypothesis that VZV may contribute to MS in establishing a systemic infection process and inducing an immune response.

The role of early posttraumatic neuropsychological outcomes in the appearance of latter psychiatric disorders in adults with brain trauma

BACKGROUND

The objective was to determine the predictors of posttraumatic psychiatric disorders (PTPD) during the first 6 months following traumatic brain injury (TBI) focusing on neuroimaging, clinical and neuropsychological appraisements during acute and discharge phase of TBI.

MATERIALS AND METHODS

We designed a prospective, longitudinal study in which 150 eligible TBI patients were entered. Postresuscitation brain injury severity and discharged functional outcome were evaluated by standard clinical scales. First neuroimaging was done at a maximum of 24 h after head trauma. Early posttraumatic (PT) neuropsychological outcomes were assessed using Persian neuropsychological tasks at discharge. The standardized psychiatric assessments were carefully implemented 6 months postinjury. A total of 133 patients returned for follow-up assessment at 6 months. They were divided into two groups according to the presence of PTPD.

RESULTS

Apparently, aggression was the most prevalent type of PTPD (31.48%). There was no significant difference between groups regarding functional outcome at discharge. Diffuse axonal injury (12.96%) and hemorrhages (40.74%) within the cortex (42.59%) and sub-cortex (33.33) significantly occurred more prevalent in PTPD group than non-PTPD ones. Primary postresuscitation TBI severity, early PT lingual deficit and subcortical lesion on first scan were able to predict PTPD at 6 months follow-up.

CONCLUSION

Almost certainly, the expansive dissociation risk of cortical and subcortical pathways related to linguistic deficits due to severe intracranial lesions over a period of time can augment possibility of subsequent conscious cognitive-emotional processing deficit, which probably contributes to latter PTPD. Hence, early combined therapeutic supplies including neuroprotective pharmacotherapy and neurofeedback for neural function reorganization can dampen the lesion expansion and latter PTPD.

Prevention of drowning by community-based intervention: implications for low- and middle- income countries

Background

Drowning is a serious but neglected health problem in low-and middle-income countries.

Objectives

To describe the effectiveness of drowning prevention program on the reduction of drowning mortality rates in rural settings at the north of Iran, and guide its replication elsewhere.

Patients and Methods

This interventional design included pre- and post-intervention observations in the rural area of the Caspian Sea coastline without a comparison community. Cross-sectional data were collected at pre- and post-intervention phases. Outcome evaluation was based on a four-year period (March 2005-March 2009) utilizing drowning registry data for the north of Iran.

Results

The implementation program increased the rate of membership in an organization responsible for promoting safety in high risk areas near the Caspian Sea. Compared to a WHO standardized population, drowning incidence in rural areas of the study demonstrated a continuous decrease in age-specific drowning rate among the oldest victims with a gradual decline during the implementation. In the study area, the epidemiological aspects of the study population were exposed and contributing factors were highlighted.

Conclusions

This study showed that the promotion of passive interventions had a greater effect on drowning rate than that of active interventions.