Archives of Iranian Medicine
Volume:15 Issue: 10, Oct 2012

Quantifying the quality of care in high-cost and fatal conditions such as acute myocardial infarction (AMI) is a crucial step toward improving clinical outcomes in these patients. The main objective of this pilot study is to show whether abstraction of medical charts would be a useful method to systematically assess quality of care in patients hospitalized for AMI in a general hospital that has no interventional cardiac technology. A general physician and a cardiologist working with Shahid Gholipour Hospital in Bukan, Northwest Iran, retrospectively abstracted medical records of all patients with verified diagnoses of myocardial infarction who were hospitalized between April 1, 2010 and March 31, 2011. The targeted outcome variables were risk-adjusted mortality and risk-adjusted length of hospital stay. Process quality indicators were selected from those developed by the National Quality Forum (NQF) of the United States. We reported completeness of selected variables used to build and calculate quality indicators in this study. For most variables, missing values were negligible. However, missing data on fields related to contraindications for prescribed medications were common. Medical chart abstractions provide useful first steps in assessing differences in the quality of hospital care for patients with AMI. Extension of our pilot study is highly recommended and may help trigger policy decisions to promote hospital quality in Iran.

Multiple sclerosis (MS) typically affects young adults; however, the first symptoms can occur after age 50 and is classified as late-onset MS (LOMS). In this retrospective study, we extracted the records of 3522 MS patients (2716 females and 806 males) registered in the Isfahan MS Society (IMSS) from 2003 to 2010. Next, we searched for LOMS cases. We aimed to compare these cases with 1698 non-LOMS subjects also extracted from the IMSS database. We found 48 LOMS patients (28 females and 20 males), which gave a crude frequency of 1.36%. The frequency by sex of LOMS in males (2.4%) was significantly greater than in females (1.0%, P = 0.002). The mean age at onset was 55.1 ± 4.3 years. The female to male ratio of 1.4:1 in these patients was significantly lower than in non-LOMS subjects (3.37:1, P = 0.003). The leading pattern of MS was relapsing-remitting (RR) in 62.5%, followed by primary progressive (PP) in 27.1%, and secondary progressive (SP) in 10.4%. Predominant presenting symptoms and signs were motor disturbances (35.4%), followed by brainstem (25%), optic neuritis (22.9%), and sensory related deficits (18.7%). The mean progression index (PI) in LOMS patients (0.88 ± 0.48) was significantly higher than in non-LOMS cases, 0.37 ± 0.17 (P < 0.0001). In comparing LOMS patients with the non-LOMS cohort, there was a higher frequency of the PP pattern and a higher PI in the LOMS group. In comparing other high-risk populations with the Isfahan cohort, LOMS formed a lower percentage of the total Isfahan MS population.

The aim of this study was to investigate the ability of diet quality indices in predicting obesity and abdominal obesity in a population in nutrition transition. This study explored the association of the Mediterranean Diet Scale (MDS), Healthy Eating Index-2005 (HEI-2005), and Diet Quality Index-International (DQI-I) with body mass index (BMI) and waist circumference (WC) in a cross-sectional study after 6.7 years of follow-up in the Tehran Lipid and Glucose Study (TLGS) population. Out of 192 subjects who had BMI < 25kg/m2 and of 283 subjects who were free of abdominal obesity at baseline, 39.6% developed overweight and obesity and 43.1% developed abdominal obesity, respectively during 6.7 years of follow-up in the study population. In cross-sectional analysis, after adjusting for age, sex, energy intake, physical activity and smoking status, multivariate analysis of covariance did not show any significant results regarding the relation of the diet quality indices, BMI and WC. According to follow-up analysis, none of the indices had significant associations with BMI and WC after adjustments for confounders and baseline values of BMI and WC. Adherence to MDS, HEI-2005, and DQI-I could not predict BMI and WC in Iranian participants after 6.7 years of follow-up.

This study examines the characteristics and agreement between different definitions of metabolic syndrome (MetS) and insulin resistance (IR). A total of 347 non-diabetic individuals who were ≥ 20 years of age were selected from the Tehran Lipid and Glucose Study (TLGS). Subjects were categorized as having MetS by the Adult Treatment Panel III (ATP III) and the Joint Interim Statement (JIS). IR was estimated by using the homeostasis model assessment (HOMA-IR). According to ATP III and JIS criteria 38.9% and 38.2% of subjects had MetS respectively. The sensitivity of ATP III was 52.3% and specificity was 65%; for JIS the sensitivity was 52.3%, with a specificity of 66.5%. Kappa between ATP III or JIS and HOMA-IR was 0.14 and 0.16, respectively. Based on receiver operating characteristic (ROC) analysis, the use of waist circumference (WC) and fasting plasma glucose (FPG) for the diagnosis of IR in women showed a diagnostic accuracy equal to or instead of counting MetS components using modified ATP III or JIS. WC optimal cut points for prediction of IR were 93.5 cm for men and 92.5 cm for women. ATP III and JIS definitions have low sensitivities and specificities for detecting IR. There is poor agreement between these criteria and IR

Adiponectin plays important roles in the endocrine and cardiovascular systems, in fat and carbohydrate metabolism, and inflammation. In this study the relationship between adiponectin levels with the presence and severity of coronary artery disease (CAD) is evaluated. This was a cross-sectional study that enrolled 213 persons who referred for coronary angiography. One cardiologist reported the results of each coronary angiography by using two scoring systems [number of vessel disease (usual method) and Gensini scoring system]. Then, the relationship between adiponectin levels with the presence and severity of CAD as well as predictive factors for CAD were evaluated. There was a significant negative association between mean serum adiponectin levels and presence of CAD (P = 0.04) after adjustment for all conventional risk factors for CAD. Also there was a significant negative correlation between serum adiponectin levels and severity of CAD based on the usual method for reporting coronary angiograms (P = 0.01). After adjustment for all conventional risk factors for CAD the serum adiponectin level tended to be inversely associated with the Gensini score (P = 0.09). Logistic regression analysis showed that a higher serum adiponectin level was negatively and independently associated with CAD (odds ratio: 0.94; 95% confidence interval: 0.88–1.00; P < 0.05). The variables predictive of serum adiponectin levels were determined as follows: HDL-cholesterol (P = 0.001); age (P = 0.002); insulin resistance (P = 0.005) and triglycerides (P = 0.036). This cross-sectional study showed a significant negative association between serum adiponectin levels to the presence and severity of CAD.

Several investigations have indicated that cholestasis decreases opioid receptor expression in the brain following increased opioidergic neurotransmission. The opioidergic system plays an important role in regulation of reward circuits that may be produced via dopamine-dependent mechanisms. It has been suggested that the dopaminergic system of the nucleus accumbens is necessary in conditioned place preference (CPP). The aim of this study is, therefore, to test if cholestasis can alter the reward system and the involvement of opioidergic and dopaminergic systems in this phenomenon. We used CPP and hole-board paradigms to measure the reward effect and exploratory behaviors, respectively, in mice. Cholestasis was induced by ligation of the main bile duct, using two ligatures and transecting the duct between them (BDL mice). The data showed that morphine (1 and 2 mg/kg), sulpiride (80 mg/kg) and SKF38393 (20 mg/kg) produced CPP, while naloxone (1 mg/kg) and SCH23390 (1mg/kg) produced conditioned place aversion (CPA), whereas quinpirole had no effect in sham-operated mice. However, morphine (2 mg/kg, i.p.), sulpiride (40 mg/kg) and? SKF38393 (10 mg/kg) induced CPP in BDL mice compared to sham-operated mice. Naloxone- or SCH23390-induced CPA was reduced in BDL mice compared with the respective sham-operated mice. Quinpirole tended to induce aversion in BDL mice which was, however, not significant. In addition, quinpirole 1 mg/kg) and SCH23390 (1 mg/kg) increased head-dip exploratory behavior, whereas naloxone (2 mg/kg) caused a decrease in head-dip exploratory behavior in sham-operated mice. Morphine (2 mg/kg), SCH23390 (1 mg/kg) and quinpirole (0.25 and 0.5 mg/kg) induced anxiogenic-like behavior in BDL mice. It can be concluded that cholestasis differentially alters the reward effects of opioidergic and dopaminergic agents.

Infectious complications are a major etiology of morbidity and mortality in febrile neutropenic patients. Low serum mannose-binding lectin (MBL)-associated serine protease-2 (MASP-2) concentration may represent a risk factor for infection in leukemia patients receiving chemotherapy. This study evaluates the relationship between serum levels of MASP-2 with neutropenic febrile attacks in children with leukemia. This prospective cohort study conducted between 2009–2010, we measured baseline serum MASP-2 levels by enzyme-linked immunosorbent assay (ELISA) prior to chemotherapy in leukemia patients less than 14 years of age. The relationship of febrile neutropenia (FN) episodes and duration of hospitalization with MASP-2 concentration was analyzed. We evaluated 75 children [38 girls (51%), 37 boys (49%); mean age, 61.6 ± 43.7 months]. There were 8 (10.7%) children with MASP-2 deficiency (< 200 ng/mL). Mean MASP-2 was 673.2 ± 288.7 ng/mL (range: 116–1112). Eight patients had no FN episodes. Of the 129 FN episodes recorded, 19 (average 2.4 times) were from the MASP-2deficient group and 110 (average 1.6 times) were in the normal group. There was a significant difference between the mean MASP-2 concentration and FN episodes (P = 0.043).There was an inverse relationship between FN episodes (r = -0.332, P = 0.004) and the duration of hospitalization (r = -0.334, P = 0.005) with MASP-2 concentration. MASP-2 deficient patients were hospitalized longer than the normal group, which was strongly significant (P < 0.001). Our study confirmed the results of several previous studies. MASP-2 deficiency in leukemic children treated with chemotherapy was associated with an increased risk of FN episodes, prolonged cumulative duration of hospitalization, and intravenous antimicrobial therapy.

The current study aims to identify demographic, clinical characteristics, echocardiographic and/or mitral valve morphological parameters that may predict the successful result of percutaneous transvenous mitral commissurotomy (PTMC). The medical records of 196 patients (48 males, mean age: 42.7 ± 11.5 years) who underwent PTMC were reviewed. Prior to PTMC, a combination of transthoracic and transesophageal echocardiography were used to investigate substantial mitral valve morphological subcomponents (thickening, mobility, calcification, and subvalvular thickness) and suitability for PTMC. The second transthoracic echocardiographic assessment was performed within six weeks after PTMC. Patients were divided into two categories of successful or unsuccessful according to PTMC results. Successful PTMC was defined as: final mitral valve area (MVA) ≥1.5 cm2 without a post-procedure mitral regurgitation (MR) grade >2. The significant predictor of the result was identified by comparing demographic data, initial echocardiographic assessments and mitral valve morphological scores within both groups. The mean MVA increased from 1.0 ± 0.2 cm2 to 1.7 ± 0.4 cm2, and mitral valve mean gradient (MVMG) decreased from 11.5 ± 5.2 to 5.2 ± 3.3 mmHg (P < 0.001 for both). Successful results were obtained in 139 (70.9%) patients compared to unsuccessful results in 57 (29.1%). Unsuccessful results were due to suboptimal secondary MVA < 1.5 cm2 in 50 (25.5%) patients and post-procedure MR grade >2 in 7 (3.6%). Multiple logistic regression analysis indicated that young age, lower size of the left atrium (LA), and smaller degree of mitral valve thickness were the predictors of successful result. Pre-procedure echocardiographic assessment appears to be helpful in predicting PTMC results. Successful PTMC is influenced by the patient's age, LA size, and mitral valve thickness

Diabetic retinopathy is a chronic complication of diabetes that can result in blindness. Generally, there are two stages of diabetic retinopathy, non-proliferative and proliferative. The longer a person has diabetes and the poorer metabolic control, the higher the chance of developing diabetic retinopathy. The majority of people with type 2 diabetes will ultimately develop diabetic retinopathy. Multifactorial therapy targeted to lifestyle modification and optional glycemic control reduces the risk. However, diabetic retinopathy develops or progresses with time. Primary (preventive) strategies include glycemic, lipid, and blood pressure control. Glycemic control effectively reduces the incidence of diabetic retinopathy. In additional, its effect on progression of diabetic retinopathy has been demonstrated in randomized clinical trials. Furthermore, tight control of blood pressure significantly reduces the progression of retinopathy and visual loss. However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye Study Group has shown that intensive blood pressure control has no beneficial effect on reducing the rate of diabetic retinopathy in subjects with type 2 diabetes. Elevated serum lipids and dyslipidemias are associated with a higher risk of diabetic retinopathy. The beneficial effects of lipid-lowering agents on the progression of retinopathy have been reported. Intensive combination therapy for dyslipidemia has been shown to effectively reduce the rate of progression of diabetic retinopathy in type 2 diabetes. Secondary strategies are focused on various pathophysiologic approaches such as blockade of the renin angiotensin system (RAS), anti-vascular endothelial growth factor agents, somatostatin analogues, protein kinase inhibitors, and anti-inflammatory agents. The purpose of the current overview is to look into the medical management of diabetic retinopathy, and to explore the primary (preventive) measures as well as secondary strategies proposed to be effective in its medical management.

This article provides an introduction to the meaning of causality in epidemiology and methods that epidemiologists use to distinguish causal associations from non-causal ones. Alternatives to causal association are discussed in detail. Hill’s guidelines, set forth approximately 50 years ago, and more recent developments are reviewed. The role of religious and philosophic views in our understanding of causality is briefly discussed.

Pseudoaneurysms arise from a disruption in the arterial wall and blood dissecting into the tissues around the damaged artery creating a perfused sac that communicates with the arterial lumen. Trauma to the wall of the artery may lead to the development of a pseudoaneurysm. Post-traumatic pseudoaneurysm development is very rare in the peripheral artery and often is a consequence of venipuncture.We have reported the case of the four-month-old boy who developed a pseudoaneurysm following an accidental arterial puncture. In the antecubital area we noticed a pulsative mass and palpable thrill. The patient underwent a Doppler ultrasound examination and CT with contrast. Surgery was indicated. Following excision of the pseudoaneurysm, an end-to-end anastomosis was performed. Follow-up for four years revealed palpable peripheral pulsation at the wrist level. In the postoperative period, all ultrasound findings were normal.End-to-end anastomosis is preferable if it can be performed without tension or damage to the major collateral vessels.

A case of a 31-year-old woman with sudden respiratory distress is presented. Preliminary evaluations and imaging studies did not reveal the underlying cause. Workup during hospital stay showed advanced metastatic cancer of unknown primary origin. This is an unusual presentation of cancer of an unknown primary involving the thyroid with sudden suffocation. It suggests that malignancies involving the thyroid gland should be considered in patients with abrupt onset of respiratory distress. Also, this case shows the application of fine needle aspiration in diffuse thyroid enlargements mimicking thyroiditis without nodules. Diagnostic approach to cancer of unknown primary origin (CUP) is reviewed in further detail.