مجله تحقیقات نظام سلامت حکیم
سال هشتم شماره 4 (پیاپی 31، زمستان 1384)

Non-alcoholic Fatty Liver Disease (NAFLD) constitutes a spectrum of liver disorders including the simple steatosis at one end and steatohepatitis at the other. In contrast to the previous believes, Non-alcoholoc Steatohepatitis (NASH) can lead to advanced fibrosis and cirrhosis. Implementation of a valid and reliable scoring system is necessary for better determination of prognosis and monitoring the effectiveness of different treatment modalities in this disease. We faced some practical difficulties using the system proposed by Brunt and coworkers from Saint Louis University in 1999 and proposed some revisions in the original scoring system. This study was performed to evaluate the validity, reliability and practicability of the revised scoring system by correlating the scores with the serum levels of the aminotransferases in the patients with NASH. Microscopic slide sets of 60 patients with NASH were reviewed by two independent pathologists expert in histological diagnosis of liver diseases. The four histological criteria of steatosis, ballooning degeneration, lobular and portal inflammation were scored zero to 3 according to the existence and severity of each criterion. Spearman's rho test was used for determination of correlation of the level of serum transaminases with the necro-inflammatory scores. Degree of inter-observer variation of the proposed scoring system was evaluated by the Cohen Kappa Coefficient. Except for portal inflammation, significant statistical correlation existsted between the scores for the histological criteria and level of serum aminotransferases (p<0.01). The interobserver agreement for the histological diagnosis was good (p<0.01). The proposed revised scoring system is easy to use, reliable and reproducible and shall be considered in clinical practice for grading of the necro-inflammatory process in non-alcoholic fatty liver disease.

In recent years, various reports indicate that gastric cancer is highly prevalent in our country it is the second most common cancer in men, and fourth in the general population. This study was designed and carried out to determine the five-year survival rate of gastric cancer patients who had undergone surgical treatment at one of the most important cancer treatment centers, the Iran Cancer Institute, and to assess its associated factors. During a study period, patients may often experience events that are likely to affect the final outcome as well. It has been suggested that such variables be assigned in the model as time-dependent covariates, but using models with joint distribution of time before death and time before an intermediate event (in this study, relapse), will certainly provide more accurate results. In this study we analyzed the data using a non-homogenous semi-Markovian stochastic process, regarding life span and intensity rate as the doubly stochastic processes. One hundred and 29 gastric cancer patients with adenocarcinomatous pathology and lymph node metastasis who had been admitted to and operated on at the Iran Cancer Institute between March 1995 and March 1999 were enrolled in this study. The patients’ life expectancy after surgery and its relationship with variables of age at the time of surgery, gender, and factors related to the disease such as the cancer site, number of affected lymph nodes, type of gastrectomy, presence of liver metastases or distance metastasis, number of complementary or secondary treatments received, relapse, and time to relapce were assessed. In the analyses, methods of Kaplan-Meier, Cox proportional hazards model, non-homogenous Markovian process, and Breslow estimator were used. The software used for the analyses were S Plus 2000 and R, and an alpha level of 0.05 was considered significant. The five-year survival rate and the median life expectancy in the studied patients were 18.6% and 18.90 months, respectively. The Cox proportional hazards model was used to assess the effect of different variables simultaneously, and it showed that age, and relapse influenced the chances of survival. It was also shown (based on non-homogenous Markovian stochastic processes) that sex, type of gastrectomy and cancer site correlated with time of relapse, while age affected survival after relapse, and age correlated with survival of patients without relapse. Gastric cancer patients in Iran have a low five-year survival rate. One of the most important reasons seems to be delayed consultation and diagnosis. Most patients are seen first with the disease in the late stages. At this point, most have lymph node, liver, or even distant metastases which makes treatment even more complex. Thus, it is necessary to employ mass media for extensive public education about the early warning signs of the disease and performing periodic examinations.

While the prevalence of thalassemia carriers is 4-8% in Iran, it reaches to 10% in Sistan-Balouchestan and Fars Provinces. Regarding the high prevalence of the disease and different cultural, social, and economic situation in the mentioned provinces, we have attempted to calculate the marginal cost-effectiveness ratio through a decision analysis approach based upon the best evidences. Screening was included as part of existing mandatory premarital blood tests. The couples at risk (thalassemia minor) were offered information and genetic counseling for dissuation. This study is a summative external program evaluation. The required data were collected from Health Deputy of the Governor House, Civil Registry Organization, Governor House, and other related centers during a 4-year period from 1998 to 2002. Collected data and costs were placed in the decision tree and analyzed through average folding back method. The marriage dissuasion rate was 3.5% in carrier couples of Sistan-Balouchestan in 2000 and reached to 0.5% in 2002. It is while marriage dissuasion rate was 61.1% in 2000 and 48% in 2002 in Fars province. The incidence rate of major thalassemia was 150 per 100,000 live births in Sistan-Balouchestan in 1999 and increased to 180 per 100,000 live births in 2002. The rate was 54.5 per 100,000 live births in Fars in 1999 and decreased to 24.8% in 2002. Marginal cost-effectiveness ratio of the program reveals that prevention from birth of a thalassemia major child costs 36470.5$ in Sistan-Balouchestan and 1568.2$ in Fars. Although the thalassemia prevention program has been successful over the country, evaluation studies show major differences in the assessed provinces. Despite all activities for prevention of thalassemia and small increase in coverage index of the program in Sistan-Balouchestan in recent years, cost of prevention from birth of a major thalassemic child in the province is 30 times more than Fars. One of the main reasons of the difference is ineffective consultation in Sistan-Balouchestan. In this province, religious marriage is often performed before official registration. Consultation is a prerequisite before official registration. Many couples are visited in the consultation centers even after having a child.

Malaria is still one of the important parasitic diseases aroud the country and the major health problem in south – east of Iran. Based on the role of therapeutic effect and importance of failure rate of antimalaria drugs in national drug policy a joint study with collaboration of WHO on montoring of therapeutic efficacy of chloroqine has been done according to the latest WHO guideline in south & southeast provinces َin 2002-03. According to the findings, from 144 uncomplicated cases who were eligible for 28 days follow up, only 21. 5 % showed adequate clinical & parasitological response to chloroquine (ACPR), 17. 4% showed early treatment failure (ETF), 34. 7% late clinical failure and 26. 4% late parasitologcal failure (LPF). Based on the results, drug changing the first line antimalaria drug regimen is recommended for treatment of uncomplicated falciparum malaria.

Community orientation is an important indictor in assessment of the functions of a health system and implementing this in pharmaceutical care, needs the roles and functions of pharmacists to be defined apparently. Augmented the professional relationships of the pharmacists and executing the community oriented principles, would lead in improved health care delivery. In a cross-sectional descriptive-analytical study, 480 physicians and pharmacists practicing inside the territory of Isfahan were selected. A self administered attitude assessment questionnaire was designed and its validity and reliability were calculated and improved in the pre-pilot and pilot stages. An amount of 0.8 was calculated for the Cronbach’s α, as a measure of reliability. Data entry and analysis was done through SPSS software (version 10). Student t-test, Chi-square and ANOVA were employed for data analysis. Factor analysis and Eigen value measurement were used for more complex data analysis and interpretation. The final questionnaire was validated and corrected as 35-item one, with defined validity and reliability. After deleting 13 items from the preliminary questionnaire, the Cronbach’s α improved to 0.8. The 2 professions had significantly different views regarding educational curricula in medicine and pharmacy for the related issue as well as, the community oriented pharmacy. Also, the 2 groups agreed on the revision of the role of pharmacists to improve the profession in practice. Most physicians and pharmacists agree that pharmacist should be able to handle their professional role in practice also, they should deliver the pharmaceutical care in a community oriented setting. More targeted education and curricular revision can help reaching the goal.

Intrusive thoughts are a core feature of obsessive-compulsive disorder. Recent research suggests that patients and normal individuals have different strategies in dealing with intrusive thoughts. The aim of this study was to examine the relationship between obsessive-compulsive severity and intrusive thoughts control strategies. In order to assess the obsessive-compulsive symptoms and thought control strategies the Padua Inventory and Thought Control Questionnaire were used, respectively. The sample consisted of 110 students (57 boys and 63 girls) who completed the questionnaires. Data were analyzed using Pearson coefficient correlation and multiple regression methods. Results indicated that intrusive thought control strategies including re-appraisal, worry and punishment could positively predict the severity of obsessive-compulsive symptoms. In addition, the distraction strategy could predict the decrease of impaired control over mental activities- a subscale of the Padua. Therefore, we suggest that in the process of psychotherapy, people with obsessional symptoms should be encouraged to put away re-appraisal, worry and punishment strategies and make use of distraction strategy more efficiently.

Intrusive thoughts are a core feature of obsessive-compulsive disorder. Recent research suggests that patients and normal individuals have different strategies in dealing with intrusive thoughts. The aim of this study was to examine the relationship between obsessive-compulsive severity and intrusive thoughts control strategies. In order to assess the obsessive-compulsive symptoms and thought control strategies the Padua Inventory and Thought Control Questionnaire were used, respectively. The sample consisted of 110 students (57 boys and 63 girls) who completed the questionnaires. Data were analyzed using Pearson coefficient correlation and multiple regression methods. Results indicated that intrusive thought control strategies including re-appraisal, worry and punishment could positively predict the severity of obsessive-compulsive symptoms. In addition, the distraction strategy could predict the decrease of impaired control over mental activities- a subscale of the Padua. Therefore, we suggest that in the process of psychotherapy, people with obsessional symptoms should be encouraged to put away re-appraisal, worry and punishment strategies and make use of distraction strategy more efficiently.

The value of decompression surgery after complete spinal cord injury is controversial. This study examines whether decompression is useful in paraplegic (not paraparetic) rats and, if so, what the optimim time is after injury. The spinal cords of 126 female rats were compressed at thoracic level 9 with a mini Yasargil clips. Rats were assigned to 5 case groups, and one sham-operated group. Clips were removed after 3 seconds (3s), 1 hour (1h), 6h, 3 weeks (3w), or no decompression. Locomotor behavior scoring categories ranked based on the BBB Locomotor Rating Scale. Under histopathologic evaluation, the maximum surface (%) of damaged area was measured and the severity of inflammation, congestion and hemorrhage, necrosis, fibrosis and gliosis were evaluated in double-blind manner. There was not significant difference in survival among all groups of compressed spinal cord. There was neither statistically meaningful difference nor progressive changes in BBB except for 3s group at 4, 11, 18, 25, 32, 39, 46-days (p<0.05). In complete spinal cord injured rats, a good correlation between absence of tail reflex and consistency of zero BBB was found. Mean ranking percent of damaged surface area revealed significant difference between damaged groups (P=0.039). Very early spinal cord decompression is useful in traumatic paraplegia in rats. Absence of tail reflex shows poor prognosis.