Archives of Iranian Medicine
Volume:22 Issue: 7, Jul 2019

The incidence and survival of breast cancer (BC) vary across countries. This study aimed to determine risk factors for BC and estimate the overall survival rate in BC patients of the Golestan Cohort Study (GCS). This case-control study was performed among participants of the GCS. Cases (N = 99) consisted of women who were diagnosed with BC and controls (n = 400) were selected out of women participating in the same cohort and had not developed any cancer during the follow-up period. Controls were frequency matched to case on both place of residency and 5-year categories of age. Considering confounding variables, logistic regression analysis manifested a reverse association between parity and BC (OR [odds ratio] = 0.87, 95% CI: 0.80–0.95, P = 0.001). In addition, we found women who had family history of any cancer (OR = 1.63, 95% CI: 1.02–2.60, P = 0.04) and long term oral contraceptive (OCP) use (≥10 years) (OR = 3.17, 95% CI: 1.27–7.95, P = 0.01) were at higher risk of BC. Of the total patients, 23 (23.2%) were died due to BC after a mean follow-up of 102.4 ± 5.31 months. Using the Kaplan-Meier analysis, the 5-year survival in these patients was 74%. In the Golestan Cohort population, long term OCP use and family history of cancer were risk factors for BC, while parity was a protective factor. The 5-year survival of BC patients in the GCS is still lower relative to Europe and the United States.

The aim of this study was to determine the challenges and opportunities of the Communicable Diseases Surveillance System (CDSS) in Iran. This qualitative study was conducted using semi-structured interviews and focus group discussions (FGD) with 64 participants from October 2016 to April 2017. Purposeful sampling was used to recruit participants. The collected data were analyzed via the content analysis method. Data analysis was performed using MAXQDA10 software. The results of this qualitative study were categorized in two parts: Challenges and opportunities. The CDSS is facing challenges in the fields of stewardship, reporting, information analysis, information, interventions, and education. Good infrastructures and structure, the technical support provided by the Centre for Communicable Disease Control (CCDC), the achievements of the CDSS, and the suitable electronic systems are among the opportunities of CDSS. The results of this study showed that CDSS has several major challenges. Authorities and policymakers must not ignore communicable diseases and their management tools, including CDSS because of their focus on non-communicable diseases. Some important strategies to overcome the challenges of CDSS can be the following: motivating policy makers to put emphasis on communicable diseases as a national security issue, the ratification and modification of laws and regulations on reporting, the involvement of the CDSS in the accreditation of hospitals and the renewal of the license for healthcare professionals, and motivating organizations outside the health sector to participate in the programs through inter-institutional agreements.

To construct a dietary guideline for patients with irritable bowel syndrome (IBS), data about foods these people exclude from their diet to improve their symptoms are necessary. This study was designed to assess the prevalence of food exclusions as well as the reasons for such exclusions in a large group of IBS patients. In this cross-sectional study, data on 3846 Iranian adults, 828 of whom were patients with IBS, working in 50 different health centers were examined. A 106-item self-administered Dish-based Semi-quantitative Food Frequency Questionnaire (DSFFQ) which was designed and validated specifically for Iranian adults was used for assessing dietary intake. IBS was assessed using a modified Persian version of the Rome III questionnaire. The whole prevalence of IBS was 21.5% (n = 828) in the total population (23.9% in women and 18.6% in men). Mean age of patients with IBS was 36.26 ± 7.91 years and for subjects without IBS, it was 36.52 ± 8.12 years. IBS patients had a greater probability to avoid consumption of ketchup (90% vs 33%, P = 0.005), Dough (100% vs 1%, P = 0.003), Gaz (50% vs. 1%, P = 0.035), grapes (33% vs. 7%, P = 0.034), fresh berries (56% vs. 14%, P = 0.036) and butter (100% vs. 60%, P = 0.02) due to gastrointestinal (GI) symptoms compared with healthy individuals. Although, the exclusion of plum (1% vs. 26%, P = 0.006), pickles (39% vs. 67%, P = 0.004), lemon juice (21% vs 35%, P = 0.027), egg (5% vs. 25%, P = 0.011), fresh fig (19% vs. 44%, P = 0.038) and cake (25% vs. 100%, P = 0.028) due to GI symptoms in IBS patients were lower than non-IBS participants. The present study showed that IBS patients were more likely to avoid consumption of ketchup, Dough, Gaz, grapes, fresh berries and butter due to GI symptoms compared with healthy individuals. Further studies are required to confirm these findings.

Advanced computed tomography (CT) scanners enable concurrent assessment of coronary artery anatomy and myocardial perfusion. The purpose of this study was to assess dual-energy CT images in a group of patients suspected for ischemic heart disease and to evaluate agreement of cardiac computed tomography perfusion (CTP) images with CT angiography results in a single dual-energy computed tomography (DECT) acquisition. Thirty patients (mean age: 53.8 ± 12.9 years, 60% male) with angina pectoris or atypical chest pain, suspected for ischemic heart disease, were investigated using a 384-row detector CT scanner in dual-energy mode (DECT). Firstly, resting CTP images were acquired, and then from the same raw data, computed tomography angiography (CTA) studies were reconstructed for stenosis detection. CT-based dipyridamole-stress myocardial perfusion imaging was then performed in patients who exhibited coronary stenosis >50% or had myocardial bridge (MB). A color-coded iodine map was used for evaluation of myocardial perfusion defects using the 17-segment model. Two independent blinded readers analyzed all images for stenosis and myocardial perfusion defects. Different myocardial iodine content (mg/mL) was calculated by parametric tests. The kappa agreement was calculated between results of two methods in cardiac scans. All 30 CT angiograms were evaluated and assessment ability was 100% for combined CTA/CTP. According to the combined CT examination, 17 patients (56.7%) exhibited significant coronary stenosis and/or deep MB (DMB). A total of 510 myocardial segments and 90 vascular territories were analyzed. Coronary CTA demonstrated significant stenosis in 22 vessels (24.4% of all main coronary arteries) among 12 patients (40%), DMB in 6 vessels (6.7% of all main coronary arteries) in 17 out of 30 patients (56.7%). Twenty-eight out of 90 vascular territories (31.1%) and 41 out of 510 segments (8%) showed reversible perfusion defects on stress DECT. Kappa agreement between CTA and CTP results in whole heart was 0.79 (95% confidence interval=0.57–1). There were significant differences in mean iodine concentration between ischemic (0.59 ± 0.07 mg/mL) and normal segments (2.2 ± 0.15) with P < 0.001. Agreement of CTA and CTP in whole heart and in LAD considering DMB and significant CAD together were good to excellent; however, considering sole pathologies, most of the agreements were weak (<0.5). DECT with iodine quantification may provide a valuable method in comparison with previous methods for identifying both coronary stenosis and myocardial ischemia.

Hemophilia is a rare inherited disorder associated with abnormal repeated bleeding and debilitating joint pain due to deficiency in coagulating factors VIII and IX. This study aimed to provide an updated account on the health-related quality of life (HRQoL) in children with hemophilia in Afghanistan. This cross-sectional study included 65 randomly selected hemophiliacs out of 350 children registered with the Afghanistan Hemophilia Patient Association (AHPA). The patients were 8–16 years old and voluntarily entered the study. Data were collected through a demographic questionnaire and a Persian version of Haemo-QoL Questionnaire (short version) for children aged 8-16 years. The patients’ age averaged 12.9 ± 3.9 years with a mean QoL score of 75.9 ± 17.4. The patients were suffering from hemophilia A, mostly the severe type (80%). They were born to low income families (95 %) with high illiteracy rates (>50%) and hemophilia family history (90%). Spearman test showed a significant correlation between age and QoL scores (r = 0.8, P = 0.02). One-way ANOVA indicated no significant difference between QoL scores of patients categorized based on hemophilia severity (P = 0.2, F = 1.3), family incomes (P = 0.9, F = 0.01) and parents’ levels of education (P = 0.2–0.4, F = 0.82–1.3). The Cronbach alpha for the instrument was 0.82. Regardless of hemophilia severity, Family and Sports were the most impaired domains of QoL. Herein, we have presented the first reliable and updated data on hemophiliacs’ demographic characteristics and their quality of life in Kabul.

Pregnant women take medicinal plants for various reasons, supposing that these plants are completely safe for their fetus and their own health. This study aims to identify all types of medicinal plants and synthetic medicines used by pregnant women in Kerman and to study factors related to their use. In this cross-sectional study, 150 women who had received prenatal care at 12 health centers in Kerman in 2017 were interviewed. Chi-square, t test and logistic regression were applied to investigate factors such as age, gestational age, mother’s education, mother’s occupation, perception of safety related to the use of medicinal plants and synthetic medicine during pregnancy. In this study, the rate of taking medicinal plants was 71.3% in pregnant women. The most common used medicinal plants and synthetic medicines were mint water (30%) and vitamins (47.3%), respectively. The most important mentioned reason for taking these medicinal plants during pregnancy was digestive problems. 52% of people believed that medicinal plants don’t have any side effects. The chance of taking medicinal plants in housewives was 4.4 times more than employed women. Thinking that these medicines are safe to use increased the possibility of taking medicinal plants and synthetic medicines 4.5 and 3.1 times, respectively. Due to the potential side effects of medicinal plants, development and implementation of training programs to increase pregnant women’s knowledge and a plan for specialized training for midwives and physicians employed in health centers seems necessary.

Sepsis and septic shock are major causes of morbidity and mortality worldwide, associated with a high economic and social burden on healthcare systems and communities, yet with few definite treatment modalities. The efficacy of steroids in the management of sepsis or septic shock remains a controversy and subject of investigation due to their theoretical beneficial effects. This was a systematic literature review and meta-analysis on randomized controlled trials of hydrocortisone usage in sepsis or septic shock as of 2000, following the GRADE methodology, considering a primary outcome of 28 day all-cause mortality. Ten randomized control trials were included in the review, 9 of which reported 28 day mortality either as a primary or secondary outcome. Relative risk of dying at 28 days was 0.93 in favor of hydrocortisone (95% CI: 0.86–1.01; P = 0.056). Other secondary outcomes of the review were similarly statistically insignificant. The quality of evidence was graded as very low to low. Hydrocortisone, when used in sepsis or septic shock, in critically ill adult patients showed a statistically insignificant trend towards decreasing 28 day all-cause mortality. This warrants consideration of clinical significance for each patient individually.

Providing, maintaining, and improving the health of newborns is one of the most important goals of the health care system in the Islamic Republic of Iran. On the eve of the 40th anniversary of the Islamic Revolution of Iran, we will review factors affecting the health of Iranian neonates over the past 40 years. We investigated the evolution of neonatal health and contributing factors in all reports, documents, and articles published by the Iranian Ministry of Health and Medical Education and the former Iranian Ministry of Health as well as WHO, and UNICEF databases from 1970 to 2018. The main topics of the present study include recent developments in reduction of maternal and neonatal mortality, major measures taken to decrease risk of neonatal death, and future challenges. We have reviewed more than 3500 pages of documents and articles published by authoritative sources before and after the Islamic Revolution. A neonatal mortality rate (NMR) of 9.6 per 1000 in 2017 was recordred in Iran, demonstrating a reduction of over three-quarters compared with the pre-Revolution period. Improved prenatal care and nutrition, tetanus vaccination of pregnant mothers, performance of 96.4% of deliveries by trained individuals, circulation of clinical protocols for the integration of midwifery and maternity services, provision of neonatal resuscitation equipment in delivery rooms, promotion of breastfeeding from the first hour after birth onward, establishing and equipping NICUs, increased training of specialists and sub-specialists, prevention and treatment of infections, increasing awareness in families and family-centered neonatal care focused on neonatal brain development, the Newborn Indivisualized Developmental Care and Assessment Program (NIDCAP) and Kangaroo-Mother Care (KMC) are examples of progress made in neonate healthcare after the Islamic Revolution. Despite 8 years of war and a variety of sanctions being imposed against I.R. of Iran, very substantial improvements have been achieved in neonatal health and relevant underlying factors. However, we are still faced with challenges that require the engagement of experts and researchers in neonatal medicine.

Granulomatosis with polyangiitis (GPA) is a rare rheumatologic disease characterized by small to medium vessel vasculitis and inflammation within multiple organ systems. Majority of cases involve both upper and lower respiratory tracts but other organs including brain, kidneys, joints and skin can also be involved. Patients who have recurrent otitis media and sinusitis often initially present to internists and then to ear nose and throat (ENT) physicians and may be treated with multiple courses of antibiotics without having proper workup for GPA. We present a middle-aged white male who exemplifies this unique presentation with new onset recurrent otitis media and mastoiditis, which did not respond to repeated courses of antibiotics requiring mastoidectomy and myringotomy tube placement. On chest x-ray, he was found to have multiple lung nodules that was followed by a computed tomography (CT) scan of his chest and CT guided biopsy which revealed granulomatous inflammation and necrosis, consistent with GPA. Autoimmune laboratory work-up was also suggestive of GPA. The patient had complete resolution of symptoms with steroid therapy. This case reinforces the concept of high index of suspicion of GPA for patients with recurrent and resistant otitis media or mastoiditis not responding to optimal duration and doses of antibiotics. Appropriate work-up for GPA may allow for earlier diagnosis of this devastating vasculitic disease which can help prevent multi-organ dysfunction.

Translocations are the most common structural abnormality in the human genome. Carriers of balanced chromosome rearrangements exhibit increased risk of abortion or a chromosomally-unbalanced child. The present study was carried out in 2017 at the Iranian Blood Transfusion Research Center. This study reported a rare chromosomal disorder with 4p duplication and 10q distal deletion syndrome which is associated with various complications at birth. Defects included the following characteristics: dysmorphic facial characteristic, hand or foot anomalies, growth retardation, developmental delay, strabismus, heart defects and renal anomalies. Cytogenetic analysis and array CGH were performed and, for the first time, we reported a patient with trisomy 4p16.3p12 and monosomy 10q26.3. The patient was found to have: arr 4p16.3p12 (37,152–45,490,207) x3, 10q26.3 (134,872,562–135,434,149) x1 genomic imbalances.