Oral regimen for high dose methotrexate urine alkalinization: a systematic review and meta-analysis

OBJECTIVE

Urine alkalinization prevents nephrotoxicity in patients receiving high-dose methotrexate (HDMTX). While the standard approach involves IV sodium bicarbonate, alternative oral bicarbonate regimens are crucial in drug shortages and outpatient settings. This study aims to review the efficacy and safety of such regimens.

METHODS

PubMed, WOS, and Scopus were systematically searched using the PRISMA protocol for relevant studies involving human subjects, including randomized clinical trials, retrospective, prospective, cohort, case reports, and case series studies. There were no restrictions on language, time, or age group. Qualified and eligible papers were used to extract data on efficacy and safety indicators, and the final relevant records were assessed for quality using the Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) assessment tool.

RESULTS

12 studies with 1212 participants were included in the systematic review, with pooled data from 8 studies used for meta-analysis. No significant differences in mean differences (MDs) or odds ratio (OR) were found after the oral bicarbonate regimen, except for when urine pH fell to < 7 (MD: 0.91, 95% CI: 0.32, 1.5, P < 0.05) and the incidence of diarrhea (OR: 2.92, 95% CI: 1.69, 5.05, P < 0.05).

CONCLUSION

An oral bicarbonate regimen is a safe and effective way to alkalize HDMTX urine, providing a viable and cost-effective alternative to IV protocols. Further prospective multicenter studies are necessary. Systematic review registration identifier: CRD42023379666.

Genetic and Lifestyle Risk Factors of Metabolic Dysfunction-Associated Fatty Liver Disease and Its Relationship with Premature Coronary Artery Disease: A Study on the Pars Cohort

BACKGROUND

The main objective of this study is to identify the risk factors of metabolic dysfunction-associated fatty liver disease (MAFLD) in coronary artery disease (CAD) patients.

METHODS

The present retrospective cohort study is part of the Pars Cohort Study (PCS). The participants were categorized as having MAFLD or not. The pattern of independent variables in patients was compared with those who did not have MAFLD. All variables were retained in the multivariable logistic regression model.

RESULTS

Totally, 1862 participants with CAD were enrolled in this study. MAFLD was diagnosed in 647 (40.1%) participants. Gender, diabetes, hypertension, tobacco, opium, alcohol, age, weight, waist circumference, cholesterol, HDL, triglyceride, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were significantly different in MAFLD and non-MAFLD patients. Also, the results of multivariable logistic regression show male gender (OR=0.651, 95% CI: 0.470‒0.902, P value=0.01) and opium consumption (OR=0.563, 95% CI: 0.328‒0.968, P value<0.001) to be negative risk factors of MAFLD occurrence in CAD patients. Having diabetes (OR=2.414, 95% CI: 1.740-3.349, P value<0.001), high waist circumference (OR=1.078, 95% CI: 1.055‒1.102, P value<0.01), high triglyceride (OR=1.005, 95% CI: 1.001‒1.008, P value=0.006), and high ALT (OR=1.039, 95% CI: 1.026‒1.051, P value<0.01) were positive risk factors of MAFLD in CAD patients.

CONCLUSION

Our study found that consuming opium decreases the likelihood of MAFLD in CAD patients, since these patients have decreased appetite and lower body mass index (BMI). On the other hand, female gender, having diabetes, high waist circumference, high triglyceride levels, and high ALT levels increase the probability of MAFLD in CAD patients.

Graft failure after allogeneic hematopoietic stem cell transplantation in pediatric patients with acute leukemia: autologous reconstitution or second transplant?

BACKGROUND

Graft failure (GF) is a rare but serious complication after allogeneic hematopoietic stem cell transplantation (HSCT). Prevention of graft failure remains the most advisable approach as there is no clear recommendation for the best strategies for reversing this complication. Administration of growth factor, additional hematopoietic progenitor boost, or a salvage HSCT are current modalities recommended for the treatment of GF. Autologous recovery without evidence of disease relapse occurs rarely in patients with GF, and in the absence of autologous recovery, further salvage transplantation following a second conditioning regimen is a potential treatment option that offers the best chances of long-term disease-free survival. The preconditioning regimens of second HSCT have a significant impact on engraftment and outcome, however, currently there is no consensus on optimal conditioning regimen for second HSCT in patients who have developed GF. Furthermore, a second transplant from a different donor or the same donor is still a matter of debate.

OBSERVATIONS

We present our experience in managing pediatric patients with acute leukemia who encountered graft failure following stem cell transplantation.

CONCLUSIONS AND RELEVANCE

Although a second transplantation is almost the only salvage method, we illustrate that some pediatric patients with acute leukemia who experience graft failure after an allogeneic stem cell transplant using Myeloablative conditioning (MAC) regimen may achieve long-term disease-free survival through autologous hematopoiesis recovery.

Clinical Phenotype and Disease Course of Inflammatory Bowel Disease in Iran: Results of the Iranian Registry of Crohn's and Colitis (IRCC)

BACKGROUND

Data on the epidemiology of inflammatory bowel disease (IBD) in the Middle East are scarce. We aimed to describe the clinical phenotype, disease course, and medication usage of IBD cases from Iran in the Middle East.

METHODS

We conducted a cross-sectional study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) from 2017 until 2022. We collected information on demographic characteristics, past medical history, family history, disease extent and location, extra-intestinal manifestations, IBD medications, and activity using the IBD-control-8 questionnaire and the Manitoba IBD index, admissions history, history of colon cancer, and IBD-related surgeries.

RESULTS

In total, 9746 patients with ulcerative colitis (UC) (n=7793), and Crohn's disease (CD) (n=1953) were reported. The UC to CD ratio was 3.99. The median age at diagnosis was 29.2 (IQR: 22.6,37.6) and 27.6 (IQR: 20.6,37.6) for patients with UC and CD, respectively. The male-to-female ratio was 1.28 in CD patients. A positive family history was observed in 17.9% of UC patients. The majority of UC patients had pancolitis (47%). Ileocolonic involvement was the most common type of involvement in CD patients (43.7%), and the prevalence of stricturing behavior was 4.6%. A prevalence of 0.3% was observed for colorectal cancer among patients with UC. Moreover,15.2% of UC patients and 38.4% of CD patients had been treated with anti-tumor necrosis factor (anti-TNF).

CONCLUSION

In this national registry-based study, there are significant differences in some clinical phenotypes such as the prevalence of extra-intestinal manifestations and treatment strategies such as biological use in different geographical locations.

Aspirin is as effective as low molecular weight heparins in preventing symptomatic venous thromboembolism following arthroscopic anterior cruciate ligament reconstruction

OBJECTIVE

The optimal agent for thromboprophylaxis following arthroscopic anterior cruciate ligament reconstruction (ACLR) remains unclear, particularly in patients with a low baseline risk for venous thromboembolism (VTE). This retrospective cohort study aims to compare the effectiveness and safety of aspirin versus low molecular weight heparins (LMWHs) in this specific patient population.

METHODS

We analyzed data from patients who underwent ACLR between March 2016 and March 2021, focusing on those with a low risk for VTE. High-risk individuals, identified by factors such as cardiac disease, pulmonary disease, diabetes mellitus, previous VTE, inflammatory bowel disease, active cancer, and a BMI > 40, were excluded (n = 33). Our approach included a thorough review of medical charts, surgical reports, and pre-operative assessments, complemented by telephone follow-up conducted over a 3-month period by a single investigator. We assessed the incidence of symptomatic VTE, including deep vein thrombosis and pulmonary thromboembolism, as the primary outcome. The secondary outcomes included to complications related to the surgery and thromboprophylaxis. Statistical analysis included descriptive statistics, univariate logistic regression models, and calculations of incidence rates.

RESULT

In our study, 761 patients (761 knees) were included, with 458 (60.18%) receiving aspirin and 303 (39.82%) receiving LMWH. The two groups showed no significant differences in demographic factors except for age. The incidence of VTE was reported at 1.31% (10 individuals). Specifically, five patients in the aspirin group (1.09%) and five patients in the LMWH group (1.65%) developed a symptomatic VTE event (p = 0.53). Additionally, the two groups did not significantly differ in terms of other complications, such as hemarthrosis or surgical site infection (p > 0.05). Logistic regression analysis revealed no statistically significant difference in VTE risk between the two groups.

CONCLUSION

This study, focusing on isolated ACLR in patients with a low baseline risk for venous thromboembolism, demonstrated that aspirin is equally effective as low molecular weight heparins for VTE prophylaxis following this surgery.

LEVEL OF EVIDENCE

III.

Evaluation of core decompression outcome in systemic lupus erythematosus with hip osteonecrosis: a retrospective cohort study

BACKGROUND

Osteonecrosis is a major cause of morbidity for patients with systemic lupus erythematosus (SLE). Although core decompression is an approved and trusted technique to prevent further joint deterioration, this surgical method seems to be less beneficial for SLE patients. We aimed to evaluate the outcomes of core decompression in SLE patients with primary stages of femoral head osteonecrosis.

METHODS

In this study, 23 patients (39 affected hip joints) with osteonecrosis of the femoral head with stage II of the disease, based on the Ficat-Arlet classification system, underwent core decompression. Also, patients demographic characteristics, clinical data, medication history, comorbidities, immunological findings, hip plain radiographs, history of total hip arthroplasty after core decompression, and patients satisfaction with joint function according to the Oxford hip score questionnaire were obtained.

RESULTS

In the study, 53.8% of affected joints showed signs of radiographic deterioration in follow-up imaging. Sixty-one and a half percent (61.5%) of patients had unsatisfactory joint performance. A third (33.3%) of affected hip joints underwent total hip arthroplasty up to 5 years from core decompression. SLE patients with a history of receiving bisphosphonate were 83.2% less dissatisfied with their joint function than patients without a history of bisphosphonate use (P < 0.02). Of the 23 studied cases, the mean cumulative dose of prednisolone before and after core decompression surgery was 46.41 mg and 14.74 mg respectively. Besides, one case (2.6%) that had a high anti-phospholipid antibodies level during follow-up did not have any radiographic deterioration, and 9 cases (23.1%) had some degrees of radiographic deterioration.

CONCLUSIONS

The patients group that used bis-phosphonate, had a higher level of satisfaction with joint function after core decompression. Patients with high-level anti-phospholipid antibodies are related to a poor prognosis after core decompression.

Hematopoietic Stem Cell Transplantation in Sickle Cell Disease: A Multidimentional Review

While exagamglogene autotemcel (Casgevy) and lovotibeglogene autotemcel (Lyfgenia) have been approved by the US Food and Drug Administration (FDA) as the first cell-based gene therapies for the treatment of patients 12 years of age and older with sickle cell disease (SCD), this treatment is not universally accessible. Allogeneic hematopoietic stem cell transplant (HSCT) has the potential to eradicate the symptoms of patients with SCD, but a significant obstacle in HSCT for SCD is the availability of suitable donors, particularly human leukocyte antigen (HLA)-matched related donors. Furthermore, individuals with SCD face an elevated risk of complications during stem cell transplantation due to SCD-related tissue damage, endothelial activation, and inflammation. Therefore, it is imperative to consider optimal conditioning regimens and investigate HSCT from alternative donors. This review encompasses information on the use of HSCT in patients with SCD, including the indications for HSCT, conditioning regimens, alternative donors, and posttransplant outcomes.

Efficacy and safety of immune checkpoint inhibitors for patients with prostate cancer: a systematic review and meta-analysis

Immunotherapy has revolutionized the treatment paradigm of many cancers, however, its effectiveness in prostate cancer patients is still under question. In the present systematic review and meta-analysis, we sought for assessing the efficacy and safety of Immune checkpoint inhibitors (ICIs) in patients with prostate cancer. PubMed, Scopus, Web of Science, and EMBASE databases were searched on Aguste 19, 2022. Thirty five studies met the eligibility criteria. The median overall survival (mOS) of all treatments was 14.1 months, with the longest and shortest mOS was seen among patients who received anti-CTLA-4 monotherapy and anti-PD-1/PD-L1+anti-CTLA-4 regimen at 24.9 and 9.2 months, respectively. Noteworthy, all types of adverse events had the lowest incidence in the anti-PD-1/PD-L1 monotherapy group. Considering the ICI monotherapy regimens, we found that fatigue, diarrhea, and infusion reaction had the highest incidence rates. Future studies evaluating the efficacy and safety of novel combination therapies with ICIs are warranted.

Comparison of Disease Phenotype and Course among Elderly- and Early-Onset Inflammatory Bowel Diseases in the Middle East

BACKGROUND

It is unknown if the clinical manifestations and phenotype of disease are comparable between early- and elderly-onset inflammatory bowel disease (IBD). We aimed to seek differences in disease phenotype, course, complications, and treatment between early- and elderly-onset IBD patients.

METHODS

This retrospective cohort study on registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) compared demographics, disease phenotype, disease activity, IBD-related surgery and medications between early- and elderly-onset IBD. A generalized linear regression model was used to investigate the relative risk of age at diagnosis adjusted for gender and disease duration for the outcomes.

RESULTS

From 10048 IBD patients, 749 with early-onset (7.5%), and 472 (4.7%) elderly-onset IBD were enrolled: 855 (63.1%) ulcerative colitis (UC) and 366 (26.9%) Crohn's disease (CD). Left-sided colitis was more frequent among elderly-onset UC patients (P<0.001). Ileum and ileocolonic locations were the most common types in elderly-onset and early-onset CD patients, respectively. In comparison with elderly-onset UC, early-onset cases more often used prednisolone (22.1% vs. 11.4%, P=0.001), immunomodulators (44.9% vs 25.2%, P<0.001) and anti-tumor necrosis factors (TNF) (20.1% vs 11.9%, P=0.002). Elderly-onset UC patients had 0.7 times lower risk of aggressive phenotype (95%CI:0.6‒0.9, P=0.005). Early-onset CD was associated with higher use of prednisolone (27.7% vs 8.1%, P<0.001), immunomodulators (58.7% vs 41.8%, P=0.005) and anti-TNF (49.6% vs 35.4%, P=0.006).

CONCLUSION

Early-onset IBD was associated with a more aggressive phenotype and higher prednisolone, immunomodulators, and anti-TNF use.

The levels and trends of diabetes prevalence at national and sub-national levels in Iran (1990 - 2016)

Background

The increasing trends in Diabetes prevalence and its attributed burden emphasized as an important issue that needs serious and urgent attention, all over the word. We estimated the mean Fasting Plasma Glucose (FPG) and the prevalence of Diabetes in aged 25 years or older Iranian adults, by sex, age, province, and year through the time period of 1990 to 2016.

Methods

In order to access the most comprehensive relevant data at the same time the systematic data searched added to the data of 5 national surveys and 7 sub-national population based investigations. Two round of modeling, including the Age-Spatio-Temporal and Gaussian Process Regression were used for estimation of mean FPG trend and uncertainties. To estimate Diabetes estimations in target groups, a crosswalk model was applies to the FPG estimates. The model reiterated separately for women and men. All of estimations standardized based on the Iran national census population of 2016 by year, age groups and sexes at national and sub-national levels.

Results

In 2016, the number of the diabetic population was 4.43 (3.93-4.99) million (2.38 million women). Between 1990 and 2016, the age-standardized mean of FPG increased from 84.69 mg/dl (79.8-89.8) to 100.5 mg/dl (97.9-103.3) in women and from 82.7 mg/dl (78.3-87.5) to 98.8 mg/dl (96.2-101.4) in men. Simultaneously, with considerable difference, the Diabetes prevalence, has increased from 6.1% (4.7-7.8) to 9.8% (8.7-11.1) in women and from 5.0% 18 (3.8-6.3) to 8.1% (7.2-9.2) in men (75% attributed to population growth). Considering the geographical patterns, the greatest increment in the prevalence of Diabetes detected in the northwestern and the central provinces.

Conclusion

Significant increasing trends of Diabetes led to alarming threat, which can make the strategies and goals of our prevention programs out of control. We should plan for more effective communicative interventions for prevention and management of Diabetes, to be designed, implemented and monitored based on the updated scientific evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01197-2.

Incidence of hemorrhagic cystitis following unmanipulated peripheral blood stem cell transplantation in acute Leukemia: A retrospective single-center risk factor analysis

BACKGROUND

Hemorrhagic cystitis (HC) is an important adverse event experienced after hematopoietic stem cell transplantation (HSCT). Severe HC could lead to significant morbidity, prolonged hospitalization with increased health-care costs, and may cause considerable mortality.

OBJECTIVES

In order to investigate the influence of different contributing factors other than BK viruria on HC occurrence in a homogenous population, we retrospectively analyzed the potential risk factors.

STUDY DESIGN

We conducted a retrospective study among 200 patients (median age 12.4 years, IQR: 7.9-16.1) with acute leukemia who received peripheral blood allogenic HSCT after radiation-free myeloablative conditioning regimen, in pediatric cell therapy department of Research Institute for Oncology, Hematology and Cell Therapy (RIOHCT), Tehran, Iran, between December 2014 and December 2021. Associations between risk factors and outcomes were examined by univariable and multivariable logistic regression models.

RESULTS

A total of 46 patients (23%) had developed HC during the study period. The median onset of HC was 29 (IQR: 24-37) days post-transplant, and it persisted for a median of 33 (7-270) days. The incidence of HC in our patients was estimated to be 3 in 1000 cases (95% CI: 2-4). The results of multivariable logistic model shows that the chance of HC in T-cell acute lymphoblastic leukemia (ALL) compared to B-cell All is nearly five times more (OR = 4.88; 95%CI: (1.51-15.78), P = 0.008). The incidence of HC in patients who underwent HSCT from haploidentical donors was significantly higher than full matched donors (P < 0.001). Undergoing transplant from a matched unrelated and haploidentical donor both augment the chance of HC in about six times more than matched related donors (OR = 6.36; 95%CI: (1.58-25.49), P = 0.009 and OR = 5.7; 95%CI: (1.83-17.75), P = 0.003, respectively). In patients who developed HC compared to non-HC group, overall survival was much worse (P < 0.001).

DISCUSSION

Most studies have failed to demonstrate any relationship between late-onset HC and the dose of cyclophosphamide. In our study, although the dose of cyclophosphamide was similar in HSCT from MRD and MUD, the hazard of HC incidence was significantly higher in the latter group. This could be accredited to ATG, as in patients in the MRD group who had not received any ATG, the incidence of HC was much lower than the patients who had underwent HSCT from MUD or haploidentical donor group.

CONCLUSIONS

Patients with T-cell ALL and those who under haploidentical HSCT had the highest incidence of HC.

Comparable Outcomes of Pre- Versus Post-Tyrosine Kinase Inhibitor Era Treatment in Chronic Myeloid Leukemia: A Retrospective Cohort Study With Long-term Follow-up

Imatinib, a selective BCR-ABL tyrosine kinase inhibitor (TKI), was introduced after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with chronic myeloid leukemia (CML). However, the long-term effects of allo-HSCT in chronic phase CML patients are mostly unknown. We retrospectively analyzed the outcomes of 204 patients with sibling donors who received peripheral stem cells and underwent allo-HSCT of chronic phase I (CP1) in the pre- and post-TKI era at Shariati Hospital in Tehran, Iran, from 1998 to 2017 and followed up till the end of 2021. The median follow-up time for all patients was 8.7 (SD = 0.54) years. Fifteen-year overall survival (OS), disease-free survival (DFS), graft-versus-host disease-free relapse-free survival (GRFS), relapse, and non-relapse mortality (NRM) incidence were 65.70%, 57.83%, 17.56%, 13.17%, and 28.98%, respectively. Using multivariable analyses, the only risk factor increasing the hazard of death was the time between diagnosis to allo-HSCT greater than 1 year compared to this time less than 1 year by 74% [hazard ratio (HR) = 1.74, P = 0.039]. Also, age is a significant risk factor for DFS (HR = 1.03, P = 0.031). Our findings suggested that allo-HSCT is still an important treatment option for CP1 patients, especially those resistant to TKI treatment. TKI consumption can have a desirable effect on NRM after allo-HSCT for CP1 CML.

The effects of antioxidants on knee osteoarthritis: A systematic review and meta-analysis

Objective

Knee osteoarthritis (KOA) is one of the growing health problems with a considerable burden. With recent research on the possible effectiveness of antioxidants in the remission of KOA symptoms, a systematic review and meta-analysis was required to confirm this hypothesis.

Design

Literature studies were searched on the most comprehensive databases such as PubMed, International Scientific Indexing, and Scopus, with no language and time restrictions. On 17 July 2021, a search strategy was developed based on the roots of "osteoarthritis (OA)" and "antioxidants," with no time or language limitations. As the primary outcome, pain was evaluated based on all indicators for evaluating pain [e.g., Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores, the visual analog scale (VAS), and the numerical rating scale (NRS)]. The symptoms and functions of KOA and quality of life (QOL) were also considered as secondary outcomes, each of which was measured and reported by the corresponding instrument in the studies. To measure the changes in pain, symptoms, and functions of participants, we included randomized controlled trials with a placebo control or other medical therapeutic interventions. Publication bias was assessed using Begg's funnel plot and Egger's regression test, which was deemed to be statistically significant at 0.1, and the results were checked by the trim-and-fill test.

Results

After refinement, data were extracted from 31 documents from 7,698 primary searched papers. Using the VAS as a reliable psychometric measuring instrument, the present study revealed that a significant difference in the characteristics of disease-related symptoms of patients with KOA was reached after antioxidant therapy (standardized mean difference (SMD): 0.467, 95% confidence interval (CI): 0.303-0.632, p < 0.0001). The results reported by WOMAC confirmed no significant difference in the combined score, difficulty score, pain score, and stiffness score.

Conclusion

As the first comprehensive systematic review of the association between antioxidant supplementation and KOA, this study showed that antioxidants can decrease disease-related symptoms in patients with KOA. The results can be useful for health policy decisions and future related studies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351060, identifier: CRD42022351060.

Modified combination of anti-thymocyte globulin (ATG) and post-transplant cyclophosphamide (PTCy) as compared with standard ATG protocol in haploidentical peripheral blood stem cell transplantation for acute leukemia

In haploidentical peripheral blood stem cell transplantation (haplo-PBSCT), the combination of anti-thymocyte globulin and post-transplant cyclophosphamide (ATG/PTCy) has a synergistic impact in preventing graft-versus-host disease (GvHD). However, little is known about the long-term consequences of the new combination approach. Our goal is to evaluate the efficacy of ATG/PTCy versus a standard ATG regimen by focusing at long-term outcomes in a more homogeneous group of patients. We retrospectively included 118 adult patients up to 60 years with acute leukemia who underwent haplo-PBSCT at our single institution, following the same myeloablative conditioning regimen. From 2010 to 2020, 78 patients received a modified combination of ATG (2.5 mg/kg/day, on days −3, −2, and −1) and PTCy (40 mg/kg/day on days +3 and +4) compared to 40 patients who had a standard ATG-based regimen (2.5 mg/kg/day from days −4 to −1) from 2008 to 2015. The median follow-up time for all patients was 5.36 years, respectively. The cumulative incidence (CI) of neutrophil and platelet engraftment, as well as CMV reactivation, did not differ statistically between the two groups. The CI of the acute GvHD of grades II–IV and III–IV and extensive chronic GvHD were considerably lower in the ATG/PTCy (34.6%, 8.97%, and 13.63%) than in the ATG cohort (57.5%, 30%, and 38.23%) as validated by multivariable modeling. Additionally, compared to the ATG arm, the ATG/PTCy was a hazard factor associated with a higher risk of relapse (HR = 2.23, p = 0.039). The probability of 5-year overall survival, disease-free survival, and GvHD-free relapse-free survival in the ATG/PTCy group (53.34%, 49.77%, and 36.04%) was comparable with the ATG group (47.5%, 42.5%, and 22.5%), respectively. Our finding suggested that a modified ATG/PTCy combination resulted in a lower risk of acute and chronic GvHD and a higher risk of relapse than the standard ATG-based protocol but had no effect on long-term outcomes. However, certain adjustments in the immunosuppression protocol are warranted to improve the outcome.

Socioeconomic inequality in violent behaviors, life dissatisfaction, and self-rated health in pediatric population: the CASPIAN-V study

BACKGROUND

Bullying, being a victim of violent behaviors, life satisfaction (LS) and self-rated health (SRH) in children and adolescents, all have consistently been recognized as vital factors in school performance and future individual life.

METHODS

This cross-sectional data secondary study was a part of the fifth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable disease (CASPIAN-V) in 2015. A total of 14,400 students 7-18 years and their parents living in 30 provinces in Iran were studied. A validated questionnaire of the World Health Organization on Global School-based Health Survey (WHO-GSHS) was used to measure the outcomes and socioeconomic variables. Family's socioeconomic status (SES) was determined using principal component analysis (PCA). The crude and adjusted odds ratios (95% confidence interval (CI)) were estimated using multiple logistic regressions for each outcome.

RESULTS

A total of 14,274 students completed the study, of whom 50.6% were boys. Overall, the prevalence of bullying, being a victim, life dissatisfaction (LDS), and poor SRH among students was 35.6, 21.4, 21.1, and 19.0%, respectively. In multiple-logistic regression analysis (Adjusted OR, (95%CI), students with an illiterate father and mother (1.60, (1.25-2.04), 1.28, (1.03-1.61), unemployed father (1.58, (1.29-1.81)), and one-parent family (1.32, (1.05 - 1.64) had a higher odd of Poor-SRH. Besides, a family size larger than four members (1.14, (1.03-1.25), and low-SES (1.35, (1.15-1.56), and illiteracy of the mother (1.64, (1.30-2.08) had a direct association with LDS. Mother illiteracy also increased the odds of bullying (1.77, (1.45-2.16) and being a victim (1.58, (1.26-1.98).

CONCLUSIONS

Some socioeconomic variables can be proposed as the statistically significant attribution of bullying and being a victim, LDS, and Poor-SRH in children and adolescents.

Outcomes of haploidentical peripheral stem cell transplantation with combination of post-transplant cyclophosphamide (PTCy) and anti-thymocyte globulin (ATG) compared to unrelated donor transplantation in acute myeloid leukemia: A retrospective 10-year experience

In the evolution of haploidentical hematopoietic stem cell transplantation (haplo-HSCT), In vivo T-cell modulation with concomitant use of anti-thymocyte globulin (ATG) and high-dose post-transplant cyclophosphamide (PTCy) provides a novel promising method on transplant outcomes; however, the long-term effects of this therapy are mostly unknown. We retrospectively compared the long-term outcomes of adult acute myeloid leukemia (AML) patients undergoing a haplo-HSCT (n = 92) with a new modified combination of ATG and PTCy in the context of peripheral blood stem cell (PBSC) and myeloablative conditioning (MAC) with an otherwise similar group of AML patients who received an unrelated donor (URD) HSCT (n = 57) with ATG protocol from February 2010 to December 2020 at our single-center (HORCSCT). Median follow-up was 3.73 and 4.28 years for haploidentical and URD-HSCT, respectively. In haplo-HSCT, the cumulative incidence of grades II-IV and III-IV acute graft versus host disease (aGvHD) and extensive chronic GvHD (cGvHD) was much lower than in URD (27% versus 56% for grades II-IV, 8.7% versus 24.5% for grades III-IV, and 15.4% versus 34.7% for extensive cGvHD, respectively). Five-year overall survival (OS) was 54.03% for haplo and 54.48% for URD (p = 0.927); GvHD-free relapse-free survival (GRFS) was 44.1% and 29.86% (p = 0.149); relapse incidence was 15.79% and 26.95% (p = 0.72); and non-relapse mortality (NRM) was 29.48% and 26.32% (p = 0.73), respectively. Using multivariable analyses, when compared to Haplo, URD was a significant predictor of relapse (HR=1.80, p = 0.039); however, no difference in OS, GRFS, and NRM was noted between haplo and URD. Therefore, given the favorable results with haplo-HSCT and considering donor availability promptly with low cost, it conservatively suggested that haplo-HSCT with the introduced protocol could be viewed as the first alternative for patients with AML in the absence of matched sibling donors.

Estimates, trends, and drivers of the global burden of type 2 diabetes attributable to PM2·5 air pollution, 1990-2019: an analysis of data from the Global Burden of Disease Study 2019

BACKGROUND

Experimental and epidemiological studies indicate an association between exposure to particulate matter (PM) air pollution and increased risk of type 2 diabetes. In view of the high and increasing prevalence of diabetes, we aimed to quantify the burden of type 2 diabetes attributable to PM2·5 originating from ambient and household air pollution.

METHODS

We systematically compiled all relevant cohort and case-control studies assessing the effect of exposure to household and ambient fine particulate matter (PM2·5) air pollution on type 2 diabetes incidence and mortality. We derived an exposure-response curve from the extracted relative risk estimates using the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. The estimated curve was linked to ambient and household PM2·5 exposures from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, and estimates of the attributable burden (population attributable fractions and rates per 100 000 population of deaths and disability-adjusted life-years) for 204 countries from 1990 to 2019 were calculated. We also assessed the role of changes in exposure, population size, age, and type 2 diabetes incidence in the observed trend in PM2·5-attributable type 2 diabetes burden. All estimates are presented with 95% uncertainty intervals.

FINDINGS

In 2019, approximately a fifth of the global burden of type 2 diabetes was attributable to PM2·5 exposure, with an estimated 3·78 (95% uncertainty interval 2·68-4·83) deaths per 100 000 population and 167 (117-223) disability-adjusted life-years (DALYs) per 100 000 population. Approximately 13·4% (9·49-17·5) of deaths and 13·6% (9·73-17·9) of DALYs due to type 2 diabetes were contributed by ambient PM2·5, and 6·50% (4·22-9·53) of deaths and 5·92% (3·81-8·64) of DALYs by household air pollution. High burdens, in terms of numbers as well as rates, were estimated in Asia, sub-Saharan Africa, and South America. Since 1990, the attributable burden has increased by 50%, driven largely by population growth and ageing. Globally, the impact of reductions in household air pollution was largely offset by increased ambient PM2·5.

INTERPRETATION

Air pollution is a major risk factor for diabetes. We estimated that about a fifth of the global burden of type 2 diabetes is attributable PM2·5 pollution. Air pollution mitigation therefore might have an essential role in reducing the global disease burden resulting from type 2 diabetes.

FUNDING

Bill & Melinda Gates Foundation.

Clinical Phenotype and Disease Course of Inflammatory Bowel Disease: A Comparison Between Sporadic and Familial Cases

BACKGROUND

The role of genetic and environmental factors in inflammatory bowel disease's (IBD) clinical course is not fully clear. We aimed to assess the clinical phenotype, disease course, and prognosis of familial IBD in comparison with sporadic cases.

METHODS

We conducted a prospective national matched case-control study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) recruited from 2017 until 2020. Sporadic and familial IBD patients were matched based on age, sex, and disease duration. Data on demographics, past medical disease, family history of IBD, disease type, clinical phenotype, extraintestinal manifestations, IBD medications, IBD activity using the IBD-control-8 questionnaire and the Manitoba IBD index, emergency visits in the past 12 months, admissions in the past 3 months, history of colon cancer, IBD-related surgeries, and aggressive phenotype were gathered. Variable distributions were compared between sporadic and familial cases.

RESULTS

Overall, 5231 patients with ulcerative colitis (UC, 18.3% familial) and 1438 patients with Crohn's disease (CD, 16.7% familial) were registered in the IRCC. Age at diagnosis was similar between familial and sporadic cases. After matching, 3523 UC patients and 908 CD patients were enrolled in the study. Extraintestinal manifestations, UC extent, CD location and behavior, anti-TNF use, disease activity, colon cancer, IBD-related surgeries and the aggressive phenotype were similar between these sporadic and familial cases.

CONCLUSIONS

The prevalence of familial UC and CD cases in Iran was more similar to western countries, and family history did not show a predictive value for disease phenotype, course, and outcomes in our study.

Does Adding a Cardia Biopsy Improve Gastric Intestinal Metaplasia Detection Rate by the Sydney System Protocol?

BACKGROUND

The Sydney system offers a standard biopsy protocol for detection and follow-up of gastric preneoplastic lesions such as intestinal metaplasia (IM). The highest frequency of cardia-type gastric adenocarcinoma (GA) in Iran has been documented in the north-western part of the country. This study aims to investigate the effect of the addition of mucosal biopsies of gastric cardia to the standard Sydney protocol on the rate of detection of IM in the asymptomatic residents of this high-risk region for proximal gastric cancer.

METHODS

A retrospective new analysis was performed on the previous data obtained in cross-sectional endoscopic screening in 2000 as well as a biopsy study of 508 asymptomatic volunteer residents in Meshkinshahr district, Ardabil province. The screening study was conducted in a group of residents aged 40 years and older who did not have any previous GI or hemodynamic problems.

RESULTS

Intestinal metaplasia at the Sydney protocol sampling sites was detected in 107 samples belonging to 76 of the 508 (14.99%) volunteers. Twenty-one patients had IM at the cardia. Of these, five patients had IM-cardia (IM only at the cardia). Therefore, adding a cardia biopsy to the set of biopsies diagnosed five more IM cases which were not diagnosed on the standard Sydney protocol (P=0.062).

CONCLUSION

The addition of a biopsy from the cardia to the Sydney protocol biopsy set does not seem to improve the frequency of detection of IM in the residents of this high-risk geographic area for proximal gastric carcinoma.

Incidence and Prognostic Impact of WT-1 Gene Exon7 and 9 Mutations in Acute Promyelocytic Leukemia

Background: Wilms’ tumor suppressor gene 1 (WT1) gene mutation has been reported to be a prognostic factor in normal-cytogenetic acute myeloid leukemia (AML) patients. Higher rates of mutation in the WT1 gene have been reported in several tumors including normal-cytogenetic AML patients. Data regarding WT1 mutations in acute promyelocytic leukemia (APL) is very scarce. In this study, we evaluated the incidence and impact of WT1 mutation on the outcome of APL patients.

Materials and Methods: A total of 92 patients diagnosed with APL were studied in three distinct groups: early mortality, relapsed, and persistent complete remission. Genomic DNA of bone marrow samples of patients was analyzed. For quantification of expression levels of the WT1 gene, real-time quantitative PCR (rqPCR) was performed by a real-time PCR system. WT1 mutation and its impact on prognosis were considered the primary endpoint of the study. Statistical analysis was performed with STATA.

Results: WT1 mutation frequency was 6.25% in the early mortality group (1/16 patients), 13.16% in the relapse group (5/38 patients), and 7.89% in the persistent complete remission group (3/38 patients). 8 mutations were in exon 7 and one mutation in exon 9. WT1 mutation in the relapse group was associated with a trend toward worse disease-free survival (DFS) while overall survival (OS) was not affected by WT1 mutation in univariate analysis. Patients with no mutations in WT1 and FLT3/ITD had better overall survival and disease-free survival compared to patients with mutations in the WT1 gene or FLT3/ITD in the relapse group.

Conclusion: The frequency of WT1 gene mutations does not differ significantly between patients with early mortality, relapse, and persistent complete remission. The presence of WT1 mutation is associated with higher relapse and lower survival rates in relapse group patients.

Endoscopic or surgical treatment for necrotizing pancreatitis: Comprehensive systematic review and meta-analysis

Background and study aims  Treatment of necrotizing pancreatitis is changed over the past two decades with the availability of endoscopic, and minimally invasive surgical approaches. The aim of this systematic review was to assess outcomes of endoscopic drainage, and different types of surgical drainage approaches in necrotizing pancreatitis. Methods  Medline, Embase, Scopus, and Web of Science were searched from 1998 to 2020 to assess outcomes in endoscopic drainage and various surgical drainage procedures. The assessed variables consisted of mortality, development of pancreatic or enteric fistula, new onset diabetes mellitus, and exocrine pancreatic insufficiency. Results  One hundred seventy studies comprising 11,807 patients were included in the final analysis. The pooled mortality rate was 22 % (95 % confidence interval [CI]: 19%-26 %) in the open surgery (OS), 8 % (95 %CI:5 %-11 %) in minimally invasive surgery (MIS), 13 % (95 %CI: 9 %-18 %) in step-up approach, and 3 % (95 %CI:2 %-4 %) in the endoscopic drainage (ED). The pooled rate of fistula formation was 35 % (95 %CI:28 %-41 %) in the OS, 17 % (95 %CI: 12%-23 %) in MIS, 17 % (95 %CI: 9 %-27 %) in step-up approach, and 2 % (95 %CI: 0 %-4 %) in ED. There were 17 comparative studies comparing various surgical drainage methods with ED. The mortality rate was significantly lower in ED compared to OS (risk ratio [RR]: 30; 95 %CI: 0.20-0.45), and compared to MIS (RR: 0.40; 95 %CI: 0.26-0.6). Also, the rate of fistula formation was lower in ED compared to all other surgical drainage approaches. Conclusions  This systematic review demonstrated lower rate of fistula formation with ED compared to various surgical drainage methods. A lower rate of mortality with ED was also observed in observational studies. PROSPERO Identifier: CRD42020139354.

Susceptibility of Patients with Inflammatory Bowel Disease to COVID-19 Compared with Their Households

BACKGROUND: Immunosuppressive agents used in the treatment of inflammatory bowel diseases (IBDs) could potentially increase the risk of coronavirus disease 2019 (COVID-19). We aimed to compare COVID-19 frequency in patients with IBD with their households and identify the related risk factors. METHODS: Firstly, a multi-centered, observational study on 2110 patients with IBD and 2110 age-matched household members was conducted to compare COVID-19 frequency. Secondly, the data of patients with IBD and COVID-19 who had called the COVID-19 hotline were added. Multivariable logistic regression was used to evaluate the effect of age, type and severity of IBD, the number of comorbidities, and medications on the frequency of COVID-19 among the patients with IBD. RESULTS: The prevalence of COVID-19 in patients with IBD and household groups was similar (34 [1.61%] versus 35 [1.65%]; P = 0.995). The prevalence of COVID-19 increased from 2.1% to 7.1% in those with three or more comorbidities (P = 0.015) and it was significantly higher in those with severe IBD (P = 0.026). The multivariable analysis only showed a significant association with anti-TNF monotherapy (OR: 2.5, CI: 0.97-6.71, P = 0.05), and other medications were not associated with COVID-19. CONCLUSION: The prevalence of COVID-19 in patients with IBD was similar to the household members. Only patients with IBD receiving anti-TNF monotherapy had a higher risk of COVID-19 susceptibility. This finding could be attributed to the higher exposure to the virus during administration in health care facilities.

A Comparison of Dexamethasone plus Vincristine versus Standard Regimen in Induction Therapy of Adult Acute Lymphoblastic Leukemia Patients Undergoing Hematopoietic Stem Cell Transplantation

Background: Current treatment options of acute lymphoblastic leukemia(ALL) include chemotherapy alone or hematopoietic stem cell transplantation (HSCT) following induction chemotherapy both along with CNS prophylaxis. The usual and standard induction regimens currently administered could have severe complications and mortality. Materials and Methods: To lessen induction regimen complications in ALL patients who undergo HSCT, we used a cytoreduction induction regimen including dexamethasone (8 mg, IV, three times a day, for 28 days) and vincristine(1.4 mg/m2, IV, on days 1,8,15 and 22) for 49 newly diagnosed adult ALL patients followed by an early sibling donor HSCT within two months. The results were matched with outcomes of HSCT in 172 ALL patients inducted by standard induction regimen. Results: Median follow-up time was 5.41 years in the standard group and 5.27 years in the other. All patients of the case group (100%) achieved complete remission. Landmark analyses were performed to scrutinize the effect of treatments on different time intervals: first two years and 2nd to end years. Type of treatment had no significant effect on the hazard of death in the first landmark (HR=0.87, P=0.64). Cytoreduction regimen amplified the hazard of death 3.43 times more than the standard regimen in the second landmark (HR=3.43 P=0.035). Multivariate analysis showed that the cytoreduction regimen reduced the hazard of relapse about 22%, but not statistically significant (HR=0.78, P-value=0.24). Conclusion: Overall, it seems despite achieving complete remission in induction therapy, depth of response is a critical predictor for long-term outcomes of HSCT in ALL patients, and the use of multiple agents may be necessary to decrease tumor cell burden and minimal residual disease(MRD).  

Outcomes of COVID-19 in Patients with Inflammatory Bowel Disease: Comparison with Household Members and the Role of IBD Medications

BACKGROUND

Most data on the effect of inflammatory bowel disease (IBD) and its treatments on coronavirus disease 2019 (COVID-19) outcomes have not had non-IBD comparators. Hence, we aimed to describe COVID-19 outcomes in IBD compared to non-IBD patients.

METHODS

We conducted a prospective cohort study of registered IBD patients with confirmed COVID-19 from six provinces in Iran from February to April 2020. Proven COVID-19 patients were followed up at four weeks and the frequency of outcomes was assessed. Multivariable logistic regression was used to assess associations between demographics, clinical characteristics and COVID-19 outcomes.

RESULTS

Overall, 2159 IBD patients and 4721 household members were enrolled, with 84 (3.9%) and 49 (1.1%) participants having confirmed COVID-19, respectively. Household spread of COVID-19 was not common in this cohort (1.2%). While hospitalization was significantly more frequent in IBD patients compared with non-IBD household members (27.1% vs. 6.0%, P=0.002), there was no significant difference in the frequency of severe cases. Age and presence of IBD were positively associated with hospitalization in IBD compared with non-IBD household members (OR: 1.06, 95% CI: 1.03-1.10; OR: 5.7, 95% CI: 2.02- 16.07, respectively). Age, presence of new gastrointestinal symptoms, and 5-aminosalicylic acid (5-ASA) use were associated with higher hospitalization rate in IBD patients (OR: 1.13, 95% CI: 1.05-1.23; OR: 6.49, 95% CI: 1.87-22.54; OR: 6.22, 95% CI: 1.90-20.36, respectively). Anti-tumor necrosis factor (TNF) was not associated with more severe outcomes.

CONCLUSION

Age, presence of new gastrointestinal symptoms and use of 5-ASA were associated with increased hospitalization rate among IBD patients, while anti-TNF therapy had no statistical association.

Influential factors on survival in gastric cancer: A single-center study

Background:

Gastric cancer (GC) is one of the conspicuous causes of cancer-related death worldwide. Considering the mounting incidence of this cancer in developing countries such as Iran, determining the influential factors on the survival of involved patients is noteworthy. Hence, we aimed to ascertain the survival rates and the prognostic factors in our GC patients.

Materials and Methods:

In this retrospective cohort study, data of 314 patients with GC in a referral cancer center in Hamadan province of Iran were studied. The outcome of our study was survival time and the influential factors were gender, age at diagnosis, tumor history, tumor grade, surgery history, radiotherapy history, stage of disease, metastasis history, and lymph node involvement. Kaplan − Meier method and log-rank test were used for the calculation and comparing the survival curves and Cox-proportional hazard model was used for the multivariable analysis of prognostic factors.

Results:

In a total of 314 GC patients, the median age at the diagnosis was 63 years (range: 21–92) with most patients (74.84%) being males. The median follow-up time was 2.42 years, and the median survival time was 2 years. The multivariable cox analysis of overall survival (OS) indicated that having distant metastasis increased the hazard of death by about 2.5 times (P < 0.0001, heart rates [HR]: 2.53, 95% confidence interval [CI]: [1.71, 3.75]), and receiving surgery as treatment, decreased the hazard of death up to 36% (P = 0.02, HR: 0.64, 95%CI: [0.46–0.89]). The other variables did not have any significant effects on the OS.

Conclusion:

The results of this study showed that lower survival (greater hazard of death) strongly and significantly associated with having distant metastasis in patients with GC and receiving surgery could significantly decrease the hazard of death in these patients instead.

Effectiveness of COVID-19 Vaccines against Delta (B.1.617.2) Variant: A Systematic Review and Meta-Analysis of Clinical Studies

The high transmissibility, mortality, and morbidity rate of the SARS-CoV-2 Delta (B.1.617.2) variant have raised concerns regarding vaccine effectiveness (VE). To address this issue, all publications relevant to the effectiveness of vaccines against the Delta variant were searched in the Web of Science, Scopus, EMBASE, and Medline (via PubMed) databases up to 15 October 2021. A total of 15 studies (36 datasets) were included in the meta-analysis. After the first dose, the VE against the Delta variant for each vaccine was 0.567 (95% CI 0.520-0.613) for Pfizer-BioNTech, 0.72 (95% CI 0.589-0.822) for Moderna, 0.44 (95% CI 0.301-0.588) for AstraZeneca, and 0.138 (95% CI 0.076-0.237) for CoronaVac. Meta-analysis of 2,375,957 vaccinated cases showed that the Pfizer-BioNTech vaccine had the highest VE against the infection after the second dose, at 0.837 (95% CI 0.672-0.928), and third dose, at 0.972 (95% CI 0.96-0.978), as well as the highest VE for the prevention of severe infection or death, at 0.985 (95% CI 0.95-0.99), amongst all COVID-19 vaccines. The short-term effectiveness of vaccines, especially mRNA-based vaccines, for the prevention of the Delta variant infection, hospitalization, severe infection, and death is supported by this study. Limitations include a lack of long-term efficacy data, and under-reporting of COVID-19 infection cases in observational studies, which has the potential to falsely skew VE rates. Overall, this study supports the decisions by public health decision makers to promote the population vaccination rate to control the Delta variant infection and the emergence of further variants.

Social inequalities in meal skipping patterns among children and adolescents: The CASPIAN-V study

BACKGROUND & AIM

The appropriate meal consumption affects the children's and adolescents' health. Few studies have shown an association between the socioeconomic inequality and the eating behavior among children and adolescents. Therefore, the aim of this study was to assess the socioeconomic inequality in meal skipping patterns among children and adolescents.

MATERIALS & METHODS

The data were accessible through the fifth round of a school-based program in Iran in 2015. In this cross-sectional nationwide study, 14,286 students aged 7-18 years were selected via the multistage cluster sampling from 30 provinces of Iran. The Global School-based Health Survey validated questionnaire was used to assess the socioeconomic variables and meal consumption patterns among children and adolescents. Socioeconomic status (SES) was computed using principle component analysis method. Multivariate logistic regression analysis was used to assess the socioeconomic inequality in meal skipping patterns.

RESULTS

The frequency of breakfast, lunch, and dinner skipping were 13.8% (95% CI: 13.3-14.5), 6.8% (95% CI: 6.4-7.2), and 7.5% (95% CI: 7.1-7.9), respectively. In multivariate model, living in a two-parent family compared to living in a single-parent family decreased the odds of breakfast skipping (OR: 0.53, 95% CI: 0.42-0.67)). Low SES level was associated with higher odds of skipping breakfast (OR: 1.79, 95% CI: 1.50-2.14) and dinner (OR: 1.80, 95% CI: 1.42-2.28). Moreover, maternal illiteracy and unemployment were associated with skipping breakfast, lunch, and dinner (all p values < 0.05).

CONCLUSION

Some demographic and socioeconomic characteristics, such as maternal illiteracy and unemployment, low SES level, and living in a single-parent family were suggested as the main predictors of meal skipping patterns in children and adolescents.

Diagnostic Accuracy of Magnetic Resonance Enterography in the Evaluation of Colonic Abnormalities in Crohn's Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

To Evaluate the diagnostic performance of magnetic resonance enterography (MRE) for detecting colonic involvement of Crohn's disease (CD).

MATERIALS AND METHODS

A systematic search of the electronic bibliographic databases was conducted. The inclusion criteria of published original articles were: (1) Utilized MRE to evaluate colon; (2) Patients with documented CD by colonoscopy; (3) Provided crude data of diagnostic performance in the large bowel; (4) Performed segmental evaluation. The colorectal segments were defined as the right colon, transverse colon, left colon, and rectum. A hierarchical bivariate method was used for analysis.

RESULTS

Eleven articles (12 populations and 987 patients) were included. The pooled sensitivity and specificity of the studies were 69% (95% CI: 0.52-0.82) and 95% (95% CI:0.92-0.97), respectively (AUC = 0.95). The pooled positive and negative likelihood ratios were 14 (95% CI:7.5-26.3) and 0.31 (95% CI:0.19-0.51), respectively. Regarding segments, the left colon had the highest sensitivity (60%) and lowest specificity (92%), while the transverse colon showed lowest sensitivity (49%) and highest specificity (95%). Comparing the age groups, MRE sensitivity and specificity was 80% and 95%, versus 62% and 94%, in pediatrics and adults respectively.

CONCLUSION

MRE has a high specificity to detect colon pathologies in CD, while the sensitivity is low. Therefore, the test has a high value to rule in CD, while negative results are not sufficient to rule it out. Meanwhile, considering the higher sensitivity rate of the test in pediatrics, it has the potential to be used as a first-line investigation.

A Reliable Prognostic Marker for Liver Dysfunction in COVID-19 Infection

BACKGROUND In December 2019, COVID-19 emerged from China and spread to become a pandemic, killing over 1,350,000 up to November 18, 2020. Some patients with COVID-19 have abnormal liver function tests. We aimed to determine the clinical significance of liver chemistries in patients with COVID-19. METHODS We performed a cross-sectional study of 1044 consecutive patients with confirmed COVID-19 in two referral hospitals in Tehran, Iran, from February to April 2020. All cases were diagnosed by clinical criteria and confirmed by characteristic changes in the spiral chest computed tomography (CT) and nucleic acid testing of the nasopharyngeal samples. We evaluated the association between abnormal liver enzymes or function tests and survival, intensive care unit (ICU) admission and fatty liver changes in CT scans. RESULTS The mean age was 61.01 ± 16.77 years, and 57.68% were male. Of 495 patients with elevated alanine transaminase (ALT) levels, 194 had chest CT scans, in which fatty liver disease was seen in 38.1%. 41 patients (21.13%) had moderate to severe, and 33 (17.01%) had borderline fatty liver disease. Bilirubin, albumin, and partial thromboplastin time (PTT), along with other markers such as HCO₃, C-reactive protein (CRP), triglyceride, and length of admission, were significantly associated with ICU admission and mortality. Prothrombin time (PT), platelet count, and low-density lipoprotein (LDL) levels were also correlated with mortality. Fasting blood sugar (FBS) and pH were important indices in ICU admitted patients. CONCLUSION Liver function tests accurately predict a worse prognosis in patients with COVID-19. However, liver enzymes were only slightly increased in those who died or needed ICU admission and were not related to the fatty liver changes.

The effects of dietary selenium supplementation on inflammatory markers among patients with metabolic diseases: a systematic review and meta-analysis of randomized controlled trials

Purpose

Selenium (Se) is a trace element having significant effects on human metabolism. Recent studies suggest that Se supplementation have a pivotal effect on the inflammatory markers. Therefore, the aim of this study was to assess the effect of Se supplementation on plasma inflammatory markers including C-reactive protein (CRP) and high-sensitivity C-reactive protein (hs-CRP) and nitric oxide (NO) as a stress oxidative index, among patients with metabolic diseases.

Methods

To assess the effects of Se on the inflammatory markers, following the PRISMA-P guidelines, we systematically searched ISI/WOS, PubMed/MEDLINE, and Scopus for studies that assessed the effect of Se supplementation on the inflammatory markers. Data extraction was performed by two independent investigators. Using the random effects or fixed-effects model depending on the results of heterogeneity tests was used to estimate the pooled standardized mean difference (SMD). Heterogeneity between studies was assessed using Cochran's Q test and I² index.

Results

The initial search revealed 3,320 papers. After screening process and considering inclusion criteria, 7 publications were eligible for inclusion in the meta-analysis. The meta-analysis results showed that Se supplementation did not significantly affect CRP and hs-CRP concentrations (mean difference (MD) = -0.15; 95% CI: -0.55- 0.23; P = 0.43). Subgroup analysis of CRP type showed that Se supplementation significantly decreased hs-CRP level (pooled SMD = -0.44; 95% CI: -0.67-0.21). Moreover, no significant change was observed in NO level by continuing to take Se supplementation, (pooled SMD: 0.003, 95%CI: -0.26, 0.26).

Conclusions

This study revealed that Se supplementation would have desirable effects on cardio-metabolic indicators through affecting the levels of inflammatory markers. Given the importance of concerns, more attention should be given to more prospective studies with longer follow-up.

Validity of continuous metabolic syndrome score for predicting metabolic syndrome; a systematic review and meta-analysis

BACKGROUND

Nowadays, use of continuous metabolic syndrome (cMetS) score has been suggested to improve recognition of metabolic syndrome (MetS). The aim of this study was to evaluate the validity of cMetS scores for predicting MetS.

METHODS

We searched the electronic databases included MEDLINE/PubMed, Embase, ISI Web of Science, and Scopus from 1 January 1980 to 30 September 2020. Observational studies on participants with different cMetS scores were included in this meta-analysis. The sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR) and diagnostic odds ratio (DOR) with 95% CI were calculated.

RESULTS

Ten studies involving a total of 25,073 participants were included. All studies had cross-sectional design. The pooled sensitivity and specificity of cMetS scores for predicting MetS were 0.90 (95% CI: 0.83 to 0.95) and 0.86 (95% CI: 0.83 to 0.89), respectively. Moreover, cMetS scores had the pooled LR+ of 6.5 (95% CI: 5.0 to 8.6), and a pooled (LR-) of 0.11 (95% CI: 0.063 to 0.21). The pooled DOR of cMetS scores to predict MetS were 57 (95% CI: 26 to 127).

CONCLUSIONS

The high sensitivity and specificity of cMetS scores indicates that it has a high accuracy to predict the risk of MetS. Furthermore, the cMetS scores has a good ability to rule out healthy people.

STUDY REGISTRATION

This study was registered as PROSPERO CRD42020157273.

Machine learning-based prognostic modeling using clinical data and quantitative radiomic features from chest CT images in COVID-19 patients

OBJECTIVE

To develop prognostic models for survival (alive or deceased status) prediction of COVID-19 patients using clinical data (demographics and history, laboratory tests, visual scoring by radiologists) and lung/lesion radiomic features extracted from chest CT images.

METHODS

Overall, 152 patients were enrolled in this study protocol. These were divided into 106 training/validation and 46 test datasets (untouched during training), respectively. Radiomic features were extracted from the segmented lungs and infectious lesions separately from chest CT images. Clinical data, including patients' history and demographics, laboratory tests and radiological scores were also collected. Univariate analysis was first performed (q-value reported after false discovery rate (FDR) correction) to determine the most predictive features among all imaging and clinical data. Prognostic modeling of survival was performed using radiomic features and clinical data, separately or in combination. Maximum relevance minimum redundancy (MRMR) and XGBoost were used for feature selection and classification. The receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC), sensitivity, specificity, and accuracy were used to assess the prognostic performance of the models on the test datasets.

RESULTS

For clinical data, cancer comorbidity (q-value < 0.01), consciousness level (q-value < 0.05) and radiological score involved zone (q-value < 0.02) were found to have high correlated features with outcome. Oxygen saturation (AUC = 0.73, q-value < 0.01) and Blood Urea Nitrogen (AUC = 0.72, q-value = 0.72) were identified as high clinical features. For lung radiomic features, SAHGLE (AUC = 0.70) and HGLZE (AUC = 0.67) from GLSZM were identified as most prognostic features. Amongst lesion radiomic features, RLNU from GLRLM (AUC = 0.73), HGLZE from GLSZM (AUC = 0.73) had the highest performance. In multivariate analysis, combining lung, lesion and clinical features was determined to provide the most accurate prognostic model (AUC = 0.95 ± 0.029 (95%CI: 0.95-0.96), accuracy = 0.88 ± 0.046 (95% CI: 0.88-0.89), sensitivity = 0.88 ± 0.066 (95% CI = 0.87-0.9) and specificity = 0.89 ± 0.07 (95% CI = 0.87-0.9)).

CONCLUSION

Combination of radiomic features and clinical data can effectively predict outcome in COVID-19 patients. The developed model has significant potential for improved management of COVID-19 patients.

Co-transplantation of bone marrow-derived mesenchymal stem cells with hematopoietic stem cells does not improve transplantation outcome in class III beta-thalassemia major: A prospective cohort study with long-term follow-up

Bone marrow transplantation is the only curative treatment for beta-thalassemia major. Data on the co-transplantation of MSCs with HSCs in beta-thalassemia major patients are scarce. We aimed to investigate the outcomes of thalassemia major patients who underwent bone marrow-derived MSC co-transplantation with HSCs compared with those who only received HSCs. This prospective randomized study included patients with class III thalassemia major undergoing HSCT divided randomly into two groups: Thirty-three patients underwent co-transplantation of bone marrow-derived MSCs with HSCs, and 26 patients only received HSCs. Five-year OS, TFS, TRM, graft rejection rate, and GVHD were estimated. The 5-year OS was 66.54% (95% CI, 47.8% to 79.9%) in patients who underwent co-transplantation of MSCs with HSCs vs 76.92% (95% CI, 55.7% to 88.9%) in patients who only received HSCs (P = .54). No significant difference was observed in the 5-year TFS between the two groups (59.1% vs 69.2%; P = .49). The 5-year cumulative incidence of TRM was not statistically significant among patients who underwent co-transplantation of MSCs with HSCs (27.27%) vs those who only received HSCs (19.23%; P = .61). There was no statistically significant difference in graft rejection, acute GvHD, and chronic GvHD between the two groups. Based on our findings, the co-transplantation of MSCs and HSCs to class III thalassemia major patients does not alter their transplantation outcomes including OS, TFS, rejection rate, transplant-related mortality, and GvHD.

Levels and Trends of BMI, Obesity, and Overweight at National and Sub-national Levels in Iran from 1990 to 2016; A Comprehensive Pooled Analysis of Half a Million Individuals

BACKGROUND

In developing countries like Iran, the burden of obesity increases through comorbid diseases. We estimated the mean body mass index (BMI) and prevalence of overweight/obesity by components of sex, age, province, and year in Iran from 1990 to 2016.

METHODS

Through a comprehensive systematic review, all relevant data sources pooled results with individual level national and sub-national population-based studies. Two stages of age-spatio-temporal modeling and Gaussian process regression were used to estimate mean BMI, followed by estimation of obesity and overweight prevalence through the crosswalk modeling.

RESULTS

In 2016, the age-standardized mean BMI was 27.9 (27.2-28.7) kg/m² in women and 25.9 (25.2-26.5) kg/m² in men. At the same time, the prevalence rates of overweight and obesity were 71.7% (67.9-75.8), and 36.8% (34.1-39.7) in females, and 57.1% (53.7-60.6), and 18.4% (16.9-20) in men. This shows a considerable increase from 1990 when the figures were respectively 24.4 (23.3-25.5) , 36.6% (32.2-41.5), and 8.2% (95% UI: 6.9-9.7) in women, and 23.5 (22.5-24.5), 30% (26.4-34), and 4.7% (4.0-5.5) in men, with 66% attributed to population growth.

CONCLUSION

Considering the increasing trends of BMI, Sustainable Development Goals (SDGs) seem far out of reach. We need to call for action, aiming for both weight loss strategies and controlling the comorbidities that mediate high BMI risk.

Levels and Trends of Hypertension at National and Subnational Scale in Iran from 1990 to 2016: A Systematic Review and Pooled Analysis

BACKGROUND

Raised blood pressure is a serious risk factor for several non-communicable diseases (NCDs) in Iran. In this study, we aimed to estimate the mean of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and subsequently, the prevalence of hypertension by sex, age, province, and year in Iran.

METHODS

We conducted a systematic review using PubMed, Web of Science, and Scopus databases through December 2017. We also used individual level data from eight national surveys, aggregated data from seven subnational population-based studies, and extracted data reported in 52 published studies. We used a two-stage model including Age-Spatio-Temporal and Gaussian process regression (GPR) to estimate mean systolic and diastolic blood pressure and used a crosswalk model to estimate the prevalence of hypertension by sex, age, province, and year.

RESULTS

The number of hypertensive adults increased in Iran from 1.8 million (882 thousand in women) in 1990 to 13.6 million (7.2 million in women) in 2016. The national age-standardized prevalence of hypertension increased from 8.7% (7.8-9.7) to 28.8% (27.7-30.0) in women and from 8.0% (7.2-8.9) to 24.2% (23.1-25.3) in men from 1990 to 2016. Mean systolic and diastolic blood pressures show a similar increasing trend.

CONCLUSION

During the past 27 years, we observed an increase in the age-standardized prevalence and mean levels of blood pressure. If the current trend in levels of blood pressure and prevalence of hypertension continue in the coming years, Iran will not achieve the sixth target of the Global Action Plan by 2020 and the Sustainable Development Goals (SDGs) by 2030.

Association of dietary acid load with anthropometric indices in children and adolescents

PURPOSE

High dietary acid load (DAL) may have an influence on anthropometric indices. Given that there was no study on the association between DAL and anthropometric indices children and adolescents, the current study was aimed to examine the association between DAL and anthropometric indices in Iranian children and adolescents.

METHODS

Students aged 6-18 years were recruited using a multi-stage, cluster sampling method from 30 provinces of Iran. Dietary intake was assessed through a validated food frequency questionnaire. Height (Ht), weight (Wt), neck circumference (NC), waist circumference (WC), wrist circumference, and hip circumference (HC) were measured. WC-to-HC ratio (WHR), WC-to-Ht ratio (WHtR), body mass index (BMI) z-score, tri-ponderal mass index (TMI), and parental BMI were computed. Potential renal acid load (PRAL) and net endogenous acid production (NEAP) were used to estimate DAL. The association between DAL and anthropometric indices was evaluated using linear regression models.

RESULTS

In total, 5326 students (46.92% girls), with mean (standard deviations (SD)) age of 12.50 (3.14) years participated in the study (response rate: 98.13%). After adjusting for confounders, there was a significant association between NEAP and NC (P < 0.05). Also, an inverse association was observed between PRAL and NEAP with parental BMI (P < 0.05).

CONCLUSION

Our findings showed a direct association between diet-induced acid load and NC and an inverse association between DAL indices and parental BMI. More well-designed clinical studies are warranted to confirm our results and the underlying mechanisms.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The Association Between REM Sleep Behavior Disorder and Autonomic Dysfunction in Parkinson's Disease

BACKGROUND

REM behavior disorder (RBD) can occur in the context of neurodegenerative alpha-synucleinopathies, such as Parkinson's disease (PD). PD patients with RBD (PD-pRBD) represent more severe symptoms and signs compared with those without RBD (PD-nRBD). On another note, autonomic dysfunction in PD patients is categorized as one of the most prominent non-motor symptoms and has been lately the field of interest in research.

OBJECTIVE

In the current study, we longitudinally studied autonomic dysfunction in PD-pRBD and PD-nRBD groups.

METHOD

This study was conducted on 420 drug-naïve PD patients selected from the Parkinson's Progression Markers Initiative database. The RBD Screening Questionnaire was used to define the presence of probable RBD. SCOPA-AUT was used to assess autonomic dysfunction. Additionally, dopamine transporter deficits on [123I] FP-CIT SPECT imaging was performed for all of the patients.

RESULTS

Out of 420 PD patients, 158 individuals (37.6%) were considered to have probable RBD (PD-pRBD) and others without RBD (PD-nRBD). Except for pupillomotor function, all the autonomic symptoms were significantly more severe in PD-pRBD group. In PD-nRBD group, caudate striatal binding ratio was negatively correlated with SCOPA-AUT scores, while no significant correlation was observed in PD-pRBD group. Finally, there was a significant difference considering the longitudinal changes of SCOPA-AUT total between PD-pRBD and PD-nRBD groups, suggesting a more severe autonomic decline in PD-pRBD patients.

CONCLUSION

Our results indicate that PD-pRBD patients have more severe autonomic dysfunction. These results support the theory that PD patients can be categorized based on the clinical presentation, possibly representing differences in the disease pathophysiology.

Association of a body shape index and hip index with cardiometabolic risk factors in children and adolescents: the CASPIAN-V study

Objective

This study designed to discover the link between a body shape index (ABSI) and hip index (HI) with cardiometabolic risk factors (CMRFs) in Iranian children and adolescents.

Subjects and methods

In a nationwide cross-sectional survey, 4200 students who were 7-18 years old were chosen via a multistage cluster sampling method in 30 provinces of Iran in 2015. Metabolic syndrome (MetS) was defined in line with the Adult Treatment Panel III criteria. ABSI and HI were defined as waist circumference (m)/ [body mass index ^2/3 * height (m)^1/2] and hip circumference (cm) *(height/ 166 cm)^0.310 *(weight / 73 kg)^-0.482 respectively. Association between ABSI and HI with CMRFs as categorical and continuous variables were evaluated using multivariable logistic and linear regression analysis respectively.

Results

Totally, information of 14,002 students and findings of blood samples of 3483 of them were involved in the current study. In the multivariable logistic regression, an association of HI with high triglyceride (TG) (OR: 0.99, 95 % CI: 0.98-0.99) and ABSI with MetS (OR: 11.41, 2.61-49.88) was statistically significant (P < 0.05). Also, both indices were significantly associated with overweight, generalized, and abdominal obesity. In the multivariable linear regression analysis, increasing HI (per one unit) was associated with body mass index z-score (z-BMI) (β: -0.01), waist circumference (WC) (β: 0.15), TG (β: -0.16), and systolic blood pressure (SBP) (β: -0.02). Moreover, in the multivariable linear models, ABSI was significantly associated with z-BMI, WC, SBP, and diastolic blood pressure (P < 0.001).

Conclusions

ABSI and HI as novel body shape indices were significantly associated with some CMRFs. Therefore, these indices can be used as some useful anthropometric risk indices for predicting MetS.

Diagnosis of Behçet's disease: clinical characteristics, diagnostic criteria, and differential diagnoses

BACKGROUND

The diagnosis of Behçet disease (BD) is challenging in many cases. The purpose of this study was to describe the clinical characteristics of patients at a referral BD clinic.

METHODS

In a retrospective study, we collected data from patients at a national referral Behçet clinic from November 2018-August 2019. A BD diagnosis was confirmed (BD group) or ruled out (Non-BD group), and the two groups were compared for differences.

RESULTS

A total of 238 patients satisfied the inclusion criteria. Forty patients (16.8%) were finally diagnosed with BD. Ocular and genital lesions were significantly more prevalent in the BD group. A positive pathergy test and HLA-B51 were also significantly more common in BD. However, oral lesions, articular involvement, and gastrointestinal manifestations were similar between groups. Also, patients with BD were significantly more likely to have multi-organ (≥2 organ systems) involvement.

CONCLUSIONS

Being the first study to evaluate the clinical characteristics of patients who are visited at a referral BD clinic and are believed to have a high probability of Behçet, the results of this study are important from an epidemiological standpoint. Also, the findings of this study could be used by referral Behçet clinics, which evaluate and diagnose patients with a high pretest probability and atypical presentations of BD on a daily basis. The alternative diagnoses established in this study could be used as the list of the most common differential diagnoses for Behçet's disease.

Selection of Suitable Alternative Donor in the Absence of Matched Sibling Donor: A Retrospective Single-Center Study to Compare between Haploidentical, 10/10 and 9/10 Unrelated Donor Transplantation

Background: Finding a suitable donor at the optimal time is one of the most challenging issues in many transplant centers. We evaluated the clinical outcomes of 248 patients with acute leukemia and without matched sibling donors (MSD) who underwent alternative transplantation, including haploidentical (n=118), 10/10 matched unrelated (MUD, n=91), 9/10 mismatched unrelated (MMUD, n=21), and 9/10 mismatched related (MMRD, n=18) between January 2010 and November 2019 in our center.

Materials and Methods: The myeloablative conditioning regimen was used in most of the patients. Both post-transplant cyclophosphamide (40mg/kg at +3, +4) and pre-transplant ATG were used in most of haploidentical transplantations. Patients with unrelated donors received ATG as a part of the conditioning regimen.

Results: The median follow-up was 31.83 months. No significant difference in probability of 3-year leukemia- free survival (LFS) and overall survival (OS) as well as 3-year relapse incidence (RI) was noted among donor sources.

A significant difference was found in the 3-year cumulative incidence (CI) of non-relapse mortality (NRM) among the donor sources: 37.89%, 24.20%, 24.30%, and 11.48%, for haplo, 9/10 MMUD, 10/10 MUD, and 9/10 MMRD (p=0.02). Using the multivariable Cox model, the advanced age of patients and Major-ABO mismatched were two risk factors independently associated with lower OS and DFS as well as higher NRM, whereas male donor and AML disease compared to ALL were associated with a better OS and DFS.

Conclusion: No significant differences were observed in the overall outcome of haplo with other alternative transplantations, suggesting that haploidentical transplantation is a suitable, accessible, and inexpensive option.

Predictive value of initial CT scan for various adverse outcomes in patients with COVID-19 pneumonia

BACKGROUND

Chest computed tomography (CT) scan is frequently used in the diagnosis of COVID-19 pneumonia.

OBJECTIVES

This study investigates the predictive value of CT severity score (CSS) for length-of-stay (LOS) in hospital, initial disease severity, ICU admission, intubation, and mortality.

METHODS

In this retrospective study, initial CT scans of consecutively admitted patients with COVID-19 pneumonia were reviewed in a tertiary hospital. The association of CSS with the severity of disease upon admission and the final adverse outcomes was assessed using Pearson's correlation test and logistic regression, respectively.

RESULTS

Total of 121 patients (60±16 years), including 54 women and 67 men, with positive RT-PCR tests were enrolled. We found a significant but weak correlation between CSS and qSOFA, as a measure of disease severity (r: 0.261, p = 0.003). No significant association was demonstrated between CSS and LOS. Patients with CSS>8 had at least three-fold higher risk of ICU admission, intubation, and mortality.

CONCLUSIONS

CSS in baseline CT scan of patients with COVID-19 pneumonia can predict adverse outcomes and is weakly correlated with initial disease severity.

Clinical characteristics and outcomes of diabetics hospitalized for COVID-19 infection: a single-centered, retrospective, observational study

Some debates exist regarding the association of diabetes mellitus (DM) with COVID-19 infection severity and mortality. In this study, we aimed to describe and compare the clinical characteristics and outcomes of hospitalized COVID-19 patients with and without DM. In this single-centered, retrospective, observational study, we enrolled adult patients with COVID-19 who were admitted to the Shariati hospital, Tehran, Iran, from February 25, 2020, to April 21, 2020. The clinical and paraclinical information as well as the clinical outcomes of patients were collected from inpatient medical records. A total of 353 cases were included (mean age, 61.67 years; 57.51 % male), of whom 111 patients were diabetics (mean age, 63.66 years; 55.86 % male). In comparison to those without DM, diabetic patients with COVID-19 were more likely to have other comorbidities, elevated systolic blood pressure (SBP), elevated blood sugar (BS), lower estimated glomerular filtration rate (eGFR) and elevated blood urea nitrogen (BUN). The association of DM with severe outcomes of COVID-19 infection (i.e. mechanical ventilation, median length of hospital stay and mortality) remained non-significant before and after adjustments for several factors including age, sex, body mass index (BMI), smoking status, and comorbidities. Based on our results DM has not been associated with worse outcomes in hospitalized patients for COVID-19 infection.

Clinical characteristics, outcomes, and risk factors for mortality in hospitalized patients with COVID-19 and cancer history: a propensity score-matched study

BACKGROUND

COVID-19 has caused great concern for patients with underlying medical conditions. We aimed to determine the prognosis of patients with current or previous cancer with either a PCR-confirmed COVID-19 infection or a probable diagnosis according to chest CT scan.

METHODS

We conducted a case control study in a referral hospital on confirmed COVID-19 adult patients with and without a history of cancer from February25th to April21st, 2020. Patients were matched according to age, gender, and underlying diseases including ischemic heart disease (IHD), diabetes mellitus (DM), and hypertension (HTN). Demographic features, clinical data, comorbidities, symptoms, vital signs, laboratory findings, and chest computed tomography (CT) images have been extracted from patients' medical records. Multivariable logistic regression was used to estimate odd ratios and 95% confidence intervals of each factor of interest with outcomes.

RESULTS

Fifty-three confirmed COVID-19 patients with history of cancer were recruited and compared with 106 non-cancerous COVID-19 patients as controls. Male to female ratio was 1.33 and 45% were older than 65. Dyspnea and fever were the most common presenting symptoms in our population with 57.86 and 52.83% respectively. Moreover, dyspnea was significantly associated with an increased rate of mortality in the cancer subgroup (p = 0.013). Twenty-six patients (49%) survived among the cancer group while 89 patients (84%) survived in control (p = 0.000). in cancer group, patients with hematologic cancer had 63% mortality while patients with solid tumors had 37%. multivariate analysis model for survival prediction showed that history of cancer, impaired consciousness level, tachypnea, tachycardia, leukocytosis and thrombocytopenia were associated with an increased risk of death.

CONCLUSION

In our study, cancer increased the mortality rate and hospital stay of COVID-19 patients and this effect remains significant after adjustment of confounders. Compared to solid tumors, hematologic malignancies have been associated with worse consequences and higher mortality rate. Clinical and para-clinical indicators were not appropriate to predict death in these patients.

A Multicenter Survey on the Trend of Chest CT Scan Utilization: Tracing the First Footsteps of COVID-19 in Iran

BACKGROUND

Chest computed tomography (CT) scan has been used widely to diagnose COVID-19 in Iran.

OBJECTIVES

To trace the footsteps of COVID-19 in Iran by exploring the trend in using chest CT scans and its economic impact on radiology departments. Methods: In this cross-sectional study, the number of imaging examinations from 33 tertiary radiology departments in 9 large cities of Iran was collected from September 23, 2019 to March 20, 2020 (Months 1 to 6) and the corresponding months in 2018-2019.

RESULTS

A 50.2% increase was noted in the chest CT scan utilization in 2019-2020 compared to 2018-2019. This increase was +15%, +15%, +27%, +2%, +1% in Months 1-5 of 2019-2020, respectively. In Month 6 of 2019-2020, a 251% increase in the acquisition of chest CT scans was observed compared to the Month 6 of 2018-2019. Following negative balance of revenue from Month 1 to 5 with respect to the inflation rate, the total income in Month 6 was further 1.5% less than the same Month in 2018-19.

CONCLUSION

The observed peak in chest CT utilization in Month 3 prior to the surge in Month 6 could be explained by the seasonal influenza. However, unawareness about an emerging viral disease, i.e. COVID-19, might have underutilized chest CT in Months 4 and 5 before the official announcement in Month 6. The unbalanced increase in the workload of radiology departments in the shortage of cardiothoracic radiologists with the simultaneous decrease in income initiated a vicious cycle that worsened the economic repercussions of the pandemic.

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study

BACKGROUND

While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

METHODS

In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

RESULTS

GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

CONCLUSIONS

GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

Epidemiology of injuries from fire, heat and hot substances: global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study

BACKGROUND

Past research has shown how fires, heat and hot substances are important causes of health loss globally. Detailed estimates of the morbidity and mortality from these injuries could help drive preventative measures and improved access to care.

METHODS

We used the Global Burden of Disease 2017 framework to produce three main results. First, we produced results on incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years from 1990 to 2017 for 195 countries and territories. Second, we analysed these results to measure mortality-to-incidence ratios by location. Third, we reported the measures above in terms of the cause of fire, heat and hot substances and the types of bodily injuries that result.

RESULTS

Globally, there were 8 991 468 (7 481 218 to 10 740 897) new fire, heat and hot substance injuries in 2017 with 120 632 (101 630 to 129 383) deaths. At the global level, the age-standardised mortality caused by fire, heat and hot substances significantly declined from 1990 to 2017, but regionally there was variability in age-standardised incidence with some regions experiencing an increase (eg, Southern Latin America) and others experiencing a significant decrease (eg, High-income North America).

CONCLUSIONS

The incidence and mortality of injuries that result from fire, heat and hot substances affect every region of the world but are most concentrated in middle and lower income areas. More resources should be invested in measuring these injuries as well as in improving infrastructure, advancing safety measures and ensuring access to care.

Burden of injury along the development spectrum: associations between the Socio-demographic Index and disability-adjusted life year estimates from the Global Burden of Disease Study 2017

BACKGROUND

The epidemiological transition of non-communicable diseases replacing infectious diseases as the main contributors to disease burden has been well documented in global health literature. Less focus, however, has been given to the relationship between sociodemographic changes and injury. The aim of this study was to examine the association between disability-adjusted life years (DALYs) from injury for 195 countries and territories at different levels along the development spectrum between 1990 and 2017 based on the Global Burden of Disease (GBD) 2017 estimates.

METHODS

Injury mortality was estimated using the GBD mortality database, corrections for garbage coding and CODEm-the cause of death ensemble modelling tool. Morbidity estimation was based on surveys and inpatient and outpatient data sets for 30 cause-of-injury with 47 nature-of-injury categories each. The Socio-demographic Index (SDI) is a composite indicator that includes lagged income per capita, average educational attainment over age 15 years and total fertility rate.

RESULTS

For many causes of injury, age-standardised DALY rates declined with increasing SDI, although road injury, interpersonal violence and self-harm did not follow this pattern. Particularly for self-harm opposing patterns were observed in regions with similar SDI levels. For road injuries, this effect was less pronounced.

CONCLUSIONS

The overall global pattern is that of declining injury burden with increasing SDI. However, not all injuries follow this pattern, which suggests multiple underlying mechanisms influencing injury DALYs. There is a need for a detailed understanding of these patterns to help to inform national and global efforts to address injury-related health outcomes across the development spectrum.