مجله دانشگاه علوم پزشکی مازندران
پیاپی 131 (آذر 1394)

Background and Family physician program was implemented in Iran since 2005. The referral system is considered to be highly important in this program. But failure in appropriate implementation of referral system is a core problem of rural family medicine program in Iran. This study investigated the viewpoints of family physicians regarding referral system in 2012. This qualitative research was conducted using a conventional content analysis. Purposive sampling was done and continued until data saturation. Semi-structure interviews were carried out with 26 respondents who had at least one year experience as family physician. Main problems were categorized as four main themes including: the role of service providers at higher levels, the role of patients, and role of executive authorities. These themes were associated with sub-themes including lack of feedback, reverse referral, patients’ lack of knowledge about the program, lack of patients’ trust in family physicians, patients who insist on receiving higher level services, and inappropriate implementation of instructions. Failure in referral system in family physician program is believed to be associated either with ministry of health as the main policy-maker or the Iran Health Insurance Organization. Therefore, the policies should be reviewed or the implementation of the program should be done with more strict supervision.

In the past two decades, epidemiological studies have shown that outdoor air pollution lead to increase in respiratory symptoms, cardiovascular diseases, chronic bronchitis and mortality. This study aimed to estimate AQI index and the risk of cardiovascular and respiratory diseases and premature mortality caused by PM10, PM2.5 and SO2 in Yazd, 2013-2014.

In this ecological-descriptive study the air quality was assessed using AQI index. The health impact assessment of PM10, PM2.5 and SO2 was obtained by AirQ software.

According to the results, PM10 was the main cause of hospital admissions (n=460) and premature death (n=283) while SO2 was observed as the least effective pollutant involving 0.29% hospitalization and 9 premature death. The days with unhealthy air quality (AQI >100) was estimated less than 10 percent per year. The highest values of AQI were observed in spring and summer. PM10 was responsible for high AQI in 11 months and O3 was only responsible in first week of April.

The AirQ showed high rates of premature death, cardiovascular and respiratory diseases associated with PM10 and PM2.5 in Yazd. Unhealthy air quality in some days could be due to fuel combustion, wind, dust, and air dryness.

Background and Gestational diabetes mellitus is one of the main complications in pregnancy. Periodontitis associated with increase in inflammatory factors is a risk factor in pregnancy. In this study we investigated the relation between periodontitis and related inflammatory mediators and gestational diabetes mellitus. A total of 100 singleton pregnant women with gestational diabetes and 100 singleton pregnant women with normal glucose level (gestational age >20 weeks) were included. The patients underwent dental examinations and those with periodontitis and gingivitis were identified. Blood samples were taken and ESR and hsCRP were measured in all patients. Data was analyzed in SPSS applying independent t-test and qui square. The prevalence of periodontitis in patients and controls were 36% and 28%, respectively (P= 0.22). All periodontitis were moderate and no severe periodontitis was observed. Gingivitis was seen in both pregnant women with diabetes (74%) and control patients (83%) (P= 0.12). Among the subjects 18% of patients and 22% of the control group had severe gingivitis while others had moderate to mild gingivitis (P= 0.45). Dental plaques were seen in 73% of pregnant women with diabetes and 91% of the control group (P= 0.01). No significant relationship was seen in inflammatory mediators between the individuals with/without periodontitis and gingivitis. In this study, no relationship was found between gestational diabetes, gingivitis, severity of gingivitis, periodontitis, and inflammatory markers. According to the lower levels of dental plaque in pregnant women with gestational diabetes other reasons rather than poor oral hygiene are believed to be involved. Due to higher false positive estimation of probing depth caused by gingival hypertrophy in pregnancy, more precise criteria are needed to investigate periodontitis in pregnant women.

Background and The aim of this study was to estimate the disease-free survival rate, in female patients with breast cancer and determining the level of influencing factors. In a retrospective cohort study, the records of 377 patients attending Mashhad Omid hospital, Iran, spanning the years 2006 to 2011 were selected using convenience sampling. The patients were followed up until April 2014. Data analyses were done in SAS (ver.9.3) applying Cox’s semi-parametric regression method. The time after surgery until first recurrence or metastasis was considered as the dependent variable. From 377 patients (mean age: 49 years) 249 (0.66%) were found to have no any metastasis, while 128 (34%) had metastasis. Using Kaplan-Meier’s nonparametric method, the probability of the disease-free survival in 2920 days (8 years) follow-up was estimated to be 52.5% (mean time: 6 years and 3 months). There were significant differences between disease-free survivals in different tumor sizes and the involved lymph nodes and type of invasive breast cancer Also, increase of recur risk or metastasis was found to be associated with increases in size of tumor, in number of involved lymph nodes and in the level of cancer anti-gene CA 15-3 before first recur. The hazard ratio of the chance of metastasis occurrence while controlling other variables increased 19% against per unit increase in the size of tumor, 10% per involved number of lymph nodes, and 0.6 % per unit increase in CA 15-3 antigen. The CA 15-3 antigen was determined as the prognostic factor for occurrence of metastasis alongside tumor size and the number of involved nodes.

Background and A low concentration of albumin is a predictor of mortality in end-stage renal disease. The aim of this study was to assess the factors influencing albumin serum amongst hemodialysis patients using random effects model. In a retrospective cohort study, 297 hemodialysis patients (137 women and 160 men, mean age: 58.3 ± 15.86 and 59.1± 17.80 years, respectively) were randomly selected from Shahid Beheshti Medical Center in Babol, Iran, during 2007- 2013. Data was collected from patient's files and blood serum albumin level was considered as a response variable. Explanatory variables included sex, age, education level, marital status, smoking history, cause of kidney disease, history of cardiovascular disease, and age at diagnosis. Random effects model was applied to investigate the factors influencing the level of blood albumin using R software. The highest levels of albumin were found in patients who were under dialysis due to diabetes (70.2%). The random effect model showed that weight (P<0.001), age of diagnosis (P=0.012), sex (P<0.001), marital status (P=0.034), and time trend (P=0.004) had significant effects on serum albumin concentration. According to this study, level of albumin serum was associated with individual characteristics such as weight, age of diagnosis, sex, marital status, and time trend. Applying random effects model could give more accurate estimates of the factors affecting the level of albumin, thereby, providing a better understanding of the state of disease.

Background and Non-alcoholic fatty liver disease (NAFLD) is the major reason for abnormal liver function and is associated with obesity. Omentin (ITLN1) gene is highly expressed in visceral adipose tissue. The plasma omentin level is inversely correlated with obesity and serum omentin is elevated in patients with fatty liver diseases. This study investigated the association between Val109Asp polymorphism in omentin gene and susceptibility to NAFLD. This case-control study was carried out in 94 patients with NAFLD (45 women aged 20-83 and 49 men aged 21-66) and 188 healthy participants (90 women aged 19-81 and 98 men aged 20-65). Genomic DNA was extracted from blood samples. The omentin gene Val109Asp polymorphism was determined using PCR-RFLP method. Logistic regression analysis was used to investigate the association between omentin gene Val109Asp polymorphism and susceptibility to NAFLD. In control and NAFLD groups the frequencies of Asp allele were 0.77 and 0.67 and Val allele frequencies were 23% and 33%, respectively. Significant association was found between Val allele and susceptibility to NAFLD (OR: 1.6, 95%CI: 1.1-2.4, P= 0.01). Also, the results showed that Asp/Val genotype is associated with increased risk of NAFLD (OR: 2.07, 95%CI: 1.2-3.5, P= 0.005). Omentin gene Val109Asp polymorphism is associated with susceptibility to NAFLD.

Background and Fatigue is a common symptom in multiple sclerosis (MS). Available fatigue measurement tools evaluate severity or impact of fatigue and none of them can be used to guide therapists on planning fatigue management interventions. Comprehensive Fatigue Assessment Battery for Multiple Sclerosis (CFAB-MS), in addition to assessment of the fatigue, evaluates factors related to fatigue, including sleep, pain, mobility, stress, anxiety, mood and fatigue management skills. The aim of this study was to translate the tool into Persian, adapt it culturally and establish validity of this measure in people with MS in Iran. After a forward-backward translation using the International Quality of Life Assessment process, the Persian-CFAB-MS was administered to 60 people with MS. The content validity and face validity of the tool was assessed by 10 therapists. Construct validity was assessed by measuring the associations between score of the Persian-CFAB-MS and Modified fatigue impact scale (MFIS), the hospital anxiety and depression scale (HADS), Pittsburg sleep quality index (PSQI), Short-Form McGill Pain Questionnaire (SF-MPQ), and WALK-12. Data was then analyzed using SPSS (version 20). From the view of 10 therapists who were experts in MS, all items of the Persian-CFAB-MS were understandable and culturally acceptable to Iranians. As hypothesized the scores were significantly correlated with MFIS, HADS, PSQI, SF-MPQ and WALK-12 (ranging from 0.470 to 0.863, P<0.001), and showed satisfactory to excellent validity. The results illustrated evidence to support validity of the Persian-CFAB-MS in studying the reasons for fatigue in patients with MS.

Background and Amniotic membrane (AM) is a proper candidate for vascular tissue engineering. The aim of this study was to evaluate the hemocompatibility of the epithelial surface of the AM. In this study, we assessed the effects of the epithelial surface of the AM on blood coagulation system by measuring activated partial thromboplastin time (aPTT), prothrombin time (PT), clotting time (CT), hemolysis and platelet aggregation compared with expanded Polytetrafluoroethylene (ePTFE). The amount of P-selectin was measured to test the platelet activation using ELISA. Adhesion and morphological changes of platelets were analyzed by scanning electron microscopy. The results of aPTT, PT and CT tests showed that the epithelial surface of the AM activated the external coagulation pathway less than ePTFE and had same effects as this synthetic material on the internal coagulation pathway. Furthermore, the epithelial surface of the AM suppressed aggregation, activation and adhesion of the platelets and in turn inhibited initiation of clot formation. In contrast, more number of platelets were adhered and activated on the surface of ePTFE. Based on suitable features of the AM and hemocompatibility results of amniotic epithelial cells which have stem cell characteristics, the AM could be a good candidate for vascular tissue engineering.

Background and Infection is one of the most important complications after coronary artery bypass surgery. The purpose of this study was to evaluate the risk factors for infection in these patients. A descriptive prospective study was performed in 986 patients hospitalized in Sari Fatemeh Zahra hospital, Iran 2014-2015. Possible risk factors for infection (before, during and after the surgery) were recorded. Patients were followed up for possible infection until 30 days after surgery. Data was analyzed in SPSS applying t-test and Chi-Square. The p value less than. 05 was considered significant. Totally, 52 patients (5.3%) developed infection including sepsis (28.8%), pneumonia (17.7%), mediastinitis (15.3%) and deep incisional surgical site infection (11.5%). Significant associations were found between developing infection following coronary artery bypass and prolonged use of Foley catheter, the balloon inside the artery during surgery, using internal mammary artery as a graft, left ventricular outputs, high blood pressure in the morning of surgery, days of hospitalization before and after the surgery, duration of intubation after surgery, duration of ICU stay, duration of bypass surgery, high BMI, and reoperation following complications (P> 0.05). In this study, the risk factors during and after the surgery were more responsible for infection after coronary artery bypass surgery compared to preoperative conditions.

Background and Petroleum hydrocarbons are one of the most common persistent organic pollutants in the environment. Phytoremediation is a new technology in which the resistant plants are used to remove or reduce organic and mineral contamination and hazardous environmental substances. The purpose of this study was to evaluate the effect of Vetiveria Zizanioides plants on total petroleum hydrocarbons (TPH) removal in soil contaminated by oil in different concentrations of oil pollution in Khuzestan industrial area. The soil samples were collected from the areas around Ahvaz oil field and were contaminated by oil in different concentrations (5%, 7%, and 10 % w/w). TPH measurement was done (and repeated twice) during four months in five retention time. Determination of TPH concentration in GC was performed using FID detector. According to the results, the best efficiency of Vetiveria Zizanioides in removal of TPH was found in treatment with 5% oil pollution (91%) during 120 days. Most changes in microbial population occurred in 7% oil pollution (106 × 9.78 CFU/g) in 120 days. Vetiveria Zizanioides showed to be highly capable of removing TPH from contaminated soil.

Background and Crohn disease (CD) is an autoimmune disorder in which a failure of tolerance to the intestinal antigens plays a pivotal role in the pathogenesis of this disease. Treg cells control immune responses to self and foreign antigens and have an important role in maintaining self-tolerance. In this study we evaluated the frequency of Tregs in the peripheral blood of patients with Crohn disease compared with healthy control group. In a case-control study, 18 patients with Crohn disease and 20 healthy volunteers were enrolled. Blood sampling was done in both patients and controls and peripheral blood mononuclear cells were isolated. Then, the frrequency of CD4+CD25+FoxP3+CD127low/– Tregs and CD4+CD25+FoxP3– activated effector T cells were evaluated by flow cytometry. Data analysis was performed in GraphPad Prism and SPSS. The results showed that the frequency of Treg cells in the peripheral blood of CD patients was significantly lower compared to that of the healthy controls. In addition, a significant decrease in Treg/activated effector T cells ratio was observed in CD patients compared to controls. The results showed that Crohn disease is associated with a decrease in the peripheral blood Tregs pool. Moreover, it seems that the balance between Tregs and effector T cells is disturbed in CD patients.

Background and Some factors are involved in progression and metastasis in colorectal cancer with same differentiation and invasion. Galectin-3 is one suspected factor which has the capacity to self–review and to differentiate to carcinoma cells. This study has evaluated the association of Galectin-3 expression with clinicopathologic features and survival in patients with colorectal cancer. This descriptive-analytic study was performed in 130 paraffin-embedded colorectal tumor specimens obtained from Sari Imam Khomeini Hospital, Iran 2006- 2012. The type and grade of the samples were identified by two independent experienced pathologists. Immunohistochemistry staining was performed by mouse monoclonal antibody kit of Galectin-3.The expression less than 50% was considered negative (score1) and more than 50% was regarded as strong or moderate (score2). Overall 130 cases were studied (70 males and 60 females, mean age 5.82 ± 11.9 years). There were18 mucinous carcinoma and 112 adenocarcinoma samples. The expression of Galectin-3 was observed in cytoplasm of all tumor cells. Weak and strong expressions were found in 69 and 61 specimens, respectively. This study demonstrated no relationship between Galectin-3 expression and the age, gender, size, place, and tumor grade (P>0.05). But the expression of Galectin-3 was associated with metastases, lymph node involvement and survival. In other words, more lymph node involvement, widespread metastases and lower survival rate were seen in patients with negative Galectin-3 expression (P<0.05). The mean survival rate in cases with weak and strong expression of Galectin-3 were 31 and 42 months, respectively. Further large-scale investigations on Galectin-3 expression could be beneficial in prognosis and improving treatment strategies.

Background and Nitrate is one of the most important water pollutants contributing to methemoglobinemia in children and stomach cancer in adults. The aim of this study was to investigate the nitrate contamination of groundwater in Shahrood and Damghan and determination of the spatial pattern of its distribution. A total of 154 wells were sampled in shahrood and Damghan and the nitrate concentration was analyzed. Kruskal-Walliss test was applied to compare the concentrations of nitrate in urban, rural and plain areas. The nitrate concentrations in agricultural and drinking wells were compared using Mann-whitney test. Empirical bayesian kriging method was used to study the spatial distribution of nitrate in the groundwater. The mean concentration of nitrate in urban, rural, and plain area wells were 29.18, 11.58, and 10. 40 mgl-1, respectively. There was a significant difference in nitrate concentration between urban areas and that of the rural and plain areas but no significant difference was found in nitrate concentration between the drinking and agricultural wells. The geostatistical analysis showed higher concentration of nitrate in southern part of the area than that of the northern part. The concentration of nitrate was higher than the permissible levels in 4.5% of the studied wells however, at present this is not considered a health risk in the region.

Background and Overactive bladder symptoms are common in patients after prostatectomy. This study aimed at evaluating the effect of diltiazem plus tolterodine on overactive bladder symptoms. In a double blind randomized clinical trial conducted in 2013-2014, 80 men aged &ge65 years old with unresolved over active bladder symptoms after prostatectomy (in Kermanshah Imam Reza Hospital) who met our inclusion criteria were studied. They were randomly divided into two groups (n=40 per group) to receive either 60 mg bid diltiazem plus 2mg bid tolterodine/twice daily or 2mg bid tolterodine plus placebo/twice daily. The treatments continued for 4 weeks. The decrease in total score of International Prostate Symptom Score (IPSS) was not significantly different between the two groups (P> 0.05). Voiding frequency significantly improved in diltazem plus tolterodine group (P< 0.05). Mouth dryness was not significantly different between the two groups. Diltiazem plus tolterodine treatment is associated with a significant improvement in reducing the symptoms of overactive bladder and could be used as a reasonable treatment option in older patients.

Background and Pulp and paper industries produce large quantities of effluent that release various pollutants daily. Among various methods for treating such effluents, anaerobic biosorption process is of interest because of lower need to mechanical energy, boigasses production, high organic loading rate (OLR), low sludge production, and resistant system. OLR is one of the most important effective hydrodynamic parameters. In this study, the effect of OLR was investigated on anaerobic biosorption reactor in treating pulp and paper effluent. A 1.96L effective volume cannon pilot was used and wastewater was injected by pumping to the bed of the reactor. Temperature and pH were maintained about 30±2°C and 6.8-7.2, respectively. The effect of OLR on efficiency of system was studied in 1-12 kgCOD/m3.d. All experiments were performed under steady state conditions using procedures outlined in Standard Methods. In OLR 7kgCOD/m3.d and upflow velocity of 0.56m/h the system was able to reduce over 80% of COD concentration after 33-39h. No significant increase was observed in efficiency of the system at more OLRs, so it was selected as optimum loading rate. System efficiency was found to have a direct relation with decrease of upflow velocity and increase of HRT. The gas generation rate was 0.32 m3/kg COD removed. According to this study, anaerobic biosorption system satisfactorily treated pulp and paper mill effluent and could perform this close to wastewater discharge standards established by national guidelines.

Background and Leptospirosis is one of the most common zoonotic diseases in the world. Some public health problems and diseases are directly associated with geographic context of places, therefore, geographic information system (GIS) could be of great benefit in management of such issues and planning to control the spread of diseases. The aim of this study was to investigate the spatial distribution pattern of leptospirosis in Mazandaran province during 2011-2013 using GIS. In this cross sectional study data was collected by GIS. The district division was found to be an inappropriate unit for analysis, therefore, we used Modifiable Areal Unit Problem for correcting the spatial units. Spatial analysis was performed after the integration of spatial data based on network coding within each cell. In our study a cluster distribution of leptospirosis was observed (P< 0.05) and Sari was seen to be the main focus and Qaemshahr and Amol were the next two foci for the disease. Leptospirosis was more common in men. Applying GIS could be useful in determining disease clustering, forecasting the spread of disease and controlling the affecting parameters in Mazandaran province.

Background and There is a high incidence of urinary tract infection (UTI) and the resistance rate of infectious organisms to antibiotics is increasing. In this study we aimed to investigate the frequency and pattern of antibiotic resistance of pathogens in urinary tract infections in hospitalized patients. This cross-sectional study was conducted using 107 urine samples with positive urine cultures form patients with urinary tract infections admitted to the department of infectious diseases in Razi Hospital (an educational hospital in Quemshar), 2011. Then the minimal inhibitory concentration (MIC) of antibiotics was determined by E-Test. Data was analyzed in SPSS (V. 18). The mean age of the samples was 61.63 ± 18.38 years (age range 10-91 years) and there were 27% male and 73% female. E. coli was found as the most common gram-negative organism (68.2%) that showed a high sensitivity to nitrofurantoin (90.4%) and imipenem (79.5%) and a high resistance against ampicillin (93.2%) and cotrimoxazole (76.7%). Among all infections, the highest antibiotic susceptibility was to nitrofurantoin (81.3%), imipenem (78.5%) and the highest resistance was observed against ampicillin (94.4%). Antimicrobial therapy should be performed according to the results of urine culture and antimicrobial susceptibility testing.

Background and Marriage is beginning of family and the cause for reproduction and genetic survival. One of the most important criteria for evaluating the physical and mental health of individuals is the age of marriage. The aim of this study was to investigate the attitude of youth towards marriage in Ghaemshahr, Iran. This cross-sectional study was carried out in 267 unmarried young individuals aged 18-38 in 2014. The samples were selected using random sampling. Data was collected by a questionnaire consisting of three sections: demographic characteristics, attitudes, and the criteria for choosing a spouse. The data was then analyzed in SPSS V.22. Some factors including economic (mean score: 3.78), social (3.65), individual (3.53) and cultural (3.25) were the main variables that could predict and explain the attitude of youth towards marriage. Among economic, social, individual and cultural factors, the employment status, taking responsibility, not finding an appropriate spouse, and religious beliefs were more important, respectively. The main criteria for choosing a spouse were loyalty and moral commitment (mean score: 4.82). No significant relationship was found between demographic variables and the attitudes of studied individuals towards marriage. According to this study, the attitude of youths towards marriage is formed by a combination of economic, social, individual and cultural factors. Thus, appropriate policies are recommended to promote marriage while prioritizing economic factors.

Background and Measuring the satisfaction of service recipients and service providers is one of the main key indices for evaluation of rural family physician program. So far, 10 years has passed since this program was implemented and different results have been published. In this study we aimed to estimate the overall level of both service recipients and service providers’ satisfaction using meta-analysis. National and international databases were reviewed and articles published in March 2005 to April 2015 were identified. We also investigated the study references and interviewed some researchers to enhance the search sensitivity. Eligible papers for final meta-analysis were selected after quality assessment and application of inclusion/exclusion criteria. There was a significant heterogeneity between the results of the studies, therefore, random effects model was applied to estimate the total level of stakeholder satisfaction using Stata SE. V.11. This meta-analysis included 18 relevant studies investigating the satisfaction level of 8009 service recipients and 921 service providers. Total levels of satisfaction among service recipients and service providers regarding the rural family physician program were estimated to be 54.03% (40.6- 67.4) and 50.4% (27.8-73.03), respectively. The current study showed a moderate level of satisfaction regarding the rural family physician program among stakeholders.

Background and Coronary heart disease is one of the most common reasons for mortality in many countries. High lipid levels such as high total cholesterol are recognized as the risk factors for cardiovascular diseases. Various studies investigated the prevalence of dyslipidemia in Iran, so, in current study we performed a systematic review and meta-analysis of all studies assessing the prevalence of dyslipidemia in Iran. The search was conducted using different databases such as Pubmed, SID, Magiran, Iranmedex, Irandoc, Medlib, and Google Scholar. The search keywords and terms included total cholesterol, prevalence, meta-analysis, and Iran. Finally 41 articles that were published during 1998-2011 were selected. Assigning weights to the studies was done based on number of samples and the prevalence was investigated using binomial distribution. Data was analyzed applying random effects model in STATA (version 10) and R software. Also, publication bias was assessed by funnel plot. Total number of samples in selected articles were 205913. Prevalence of total cholesterol &ge 200 mg/dl was 38% (CI95% = 30-46) which was 41% in male and 43% in female. The prevalence of cholesterol &ge 240 mg/dl (CI95%) was 17% (15-19) 15% in male and 18% in female. This prevalence was seen in both urban (18%) and rural (23%) areas. Precise information and knowledge on prevalence of lipid profile disorders could help clinicians and policy makers to plan for suitable interventional programs that decrease the prevalence of cardiovascular diseases.