Association of polymorphisms of renin angiotensin system and endothelial nitric oxide synthase genes with premature cardiovascular disease in an Iranian population.

INTRODUCTION: The study of polymorphisms and their relationship with diseases is very important for risk assessment. The aim of this study was to determine the relationship between early risk of coronary artery disease(CAD) with renin-angiotensin(RAS) genes and endothelial nitric oxide synthase(eNOS) in a sample of the Iranian population. METHODS & MATERIALS: In this cross-sectional study, 63 patients with premature CAD and 72 healthy samples were enrolled. Polymorphism of the promotor region of eNOS- and ACE-I/D (Angiotensin Converting Enzyme-I/D) polymorphism was evaluated. Polymerase chain reaction (PCR) test and PCR-RFLP (Restriction Fragment Length Polymorphism) was performed for ACE and eNOS-786 gene, respectively. RESULTS: The frequency of deletion(D) for the ACE gene was significantly higher in patients(96% versus 61%; P < 0.001). Conversely, the number of defective C alleles for the eNOS gene was similar in both groups (p > 0.9). CONCLUSION: ACE polymorphism seems to be an independent risk factor for premature CAD.

The association of maternal food quality score (FQS) with breast milk nutrient content and antioxidant content of infant urine: a cross-sectional study.

BACKGROUND: Breast milk (BM) is a complex fluid with a variable composition within women over time and between women in the population. The BM compositional differences are likely to be partly due to maternal dietary patterns. This study aimed to evaluate food quality score (FQS) in lactating mothers and its association with quality indicators of BM and antioxidant content of infant urine. METHODS: This cross-sectional study was undertaken in 350 lactating women aged 20 to 35 years. Data on dietary intake was collected using a validated food frequency questionnaire (FFQ) containing 65 food items. The FQS was calculated by integrating the scores obtained from healthy and unhealthy food groups. Subjects were categorized according to FQS adherence, with the greatest adherence being allocated to the third tertile and those with the lowest FQS in the first tertile. Antioxidant activity of the BM and infant urine samples was assessed using the Ferric reducing antioxidant power (FRAP), 2, 2'-diphenyl-1-picrylhydrazyl (DPPH), thiobarbituric acid reactive substances (TBARs), and Ellman's assay. The total content of BM protein, calcium, and triglyceride was measured using standard biochemical kits. RESULTS: BM from mothers from the third tertile of FQS contained significantly higher DPPH, thiol, calcium, and protein levels compared to BM from those in the lowest tertile (p˂0.05). Infant urinary DPPH and FRAP was also significantly higher in the highest tertile vs. the lowest tertile (p˂0.05). CONCLUSION: High maternal adherence to the FQS was associated with a high BM quality and antioxidant content of infant urine.

Secular trends of ischaemic heart disease, stroke, and dementia in high-income countries from 1990 to 2017: the Global Burden of Disease Study 2017.

BACKGROUND: We assessed secular trends in the burden of ischaemic heart disease (IHD), stroke, and dementia in the Organization for Economic Co-operation and Development (OECD) countries. METHODS: Using the Global Burden of Disease (GBD) Study 2017, we compared sex-specific and age-standardized rates of disability-adjusted life years (DALY); mortality, incidence, and prevalence of IHD and stroke; and dementia per 100,000 people, in the world, OECD countries, and Canada. RESULTS: From 1990 to 2017, the crude incidence number of IHD, stroke, and dementia increased 52%, 76%, and 113%, respectively. Likewise, the prevalence of IHD (75%), stroke (95%), and dementia (119%) increased worldwide. In addition during the study period, the crude global number of deaths of IHD increased 52%, stroke by 41%, and dementia by 146% (9, 6, and 3 million deaths in 2017, respectively). Despite an increase in the crude number of these diseases, the global age-standardized incidence rate of IHD, stroke, and dementia decreased by -27%, - 11%, and - 5%, respectively. Moreover, there was a decline in their age-standardized DALY rates (- 1.17%, - 1.32%, and - 0.23% per year, respectively) and death rates (- 1.29%, - 1.46%, and - 0.17% per year, respectively), with sharper downward trends in Canada and OECD countries. Almost all trends flattened during the last decade. CONCLUSIONS: From 1990 to 2017, the age-standardized burden of IHD, stroke, and dementia decreased, more prominently in OECD countries than the world. However, their rising crude numbers mainly due to population growth and ageing require urgent identification of reversible risk and protective factors.

Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT).

BACKGROUND: There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types. METHODS: We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints. RESULTS: Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year. CONCLUSION: Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.

The Association between Substance Use Disorders and Long-Term Outcome of Stroke: Results from a Population-Based Study of Stroke among 450,229 Urban Citizens.

INTRODUCTION: Little is known regarding long-term stroke outcomes in patients with substance use disorder (SUD). Based on anecdotal data, some individuals use illicit drugs, particularly opioids, in an attempt to reduce stroke mortality, disability, or recurrence. This study is aimed to assess the effect of SUD on stroke outcomes. METHODS: Patients were recruited from the Mashhad Stroke Incidence Study, a population-based study of stroke in Iran. For a period of 1 year, all patients with first-ever stroke (FES) were recruited and then followed up for the next 5 years. Disability and functional dependency were defined using modified Rankin Scale (>2) and Barthel Index (<60), respectively. We compared the cumulative rates of mortality in follow-up points using the log-rank test. We used multivariable logistic, Cox regression and competing risk models to assess adjusted hazard ratio (aHR) with 95% confidence interval (CI) of stroke disability, functional dependency, mortality, and recurrence among those with a history of SUD. RESULTS: 595 FES patients (mean age of 64.6 ± 14.8 years) were recruited in this study. Eighty-one (13.6%) were current substance users, including opium (n = 68), naswar (n = 5, 6.1%), hashish (n = 1), heroin (n = 1), and (n = 7) others. The frequency of vascular risk factors was similar between the SUD and non-SUD groups, except for a higher rate of cigarette smoking in the SUD group (p < 0.001). After adjusting for various sociodemographic variables, vascular risk factors, and the severity of stroke at admission, SUD increased the 3-month (aHR: 1.60, CI: 1.01-2.49), 1-year (aHR: 1.73, CI: 1.20-2.65), and 5-year (aHR: 1.72, CI: 1.23-2.35) poststroke mortality risk. We did not observe a significant change in the risk of stroke recurrence, disability, and functional dependency in those with a history of SUD. CONCLUSION: SUD increased the hazard ratio of stroke mortality with no effect on the disability rate. The public should be advised about the potential harm of substance abuse.

Regular physical activity postpones age of occurrence of first-ever stroke and improves long-term outcomes.

OBJECTIVE: Few data are available on the associations between the level of pre-stroke physical activity and long-term outcomes in patients with stroke. This study is designed to assess the associations between pre-stroke physical activity and age of first-ever stroke occurrence and long-term outcomes. METHODS: Six hundred twenty-four cases with first-ever stroke were recruited from the Mashhad Stroke Incidence Study a prospective population-based cohort in Iran. Data on Physical Activity Level (PAL) were collected retrospectively and were available in 395 cases. According to the PAL values, subjects were classified as inactive (PAL < 1.70) and active (PAL ≥ 1.70). Age at onset of stroke was compared between active and inactive groups. Using logistic model, we assessed association between pre-stroke physical activity and long-term (5-year) mortality, recurrence, disability, and functional dependency rates. We used multiple imputation to analyze missing data. RESULTS: Inactive patients (PAL < 1.70) were more than 6 years younger at their age of first-ever-stroke occurrence (60.7 ± 15.5) than active patients (67.0 ± 13.2; p < 0.001). Patients with PAL< 1.7 also had a greater risk of mortality at 1 year [adjusted odds ratio (aOR) = 2.31; 95%CI: 1.14-4.67, p = 0.02] and 5 years after stroke (aOR = 1.81; 95%CI: 1.05-3.14, p = 0.03) than patients who were more physically active. Recurrence rate, disability, and functional dependency were not statistically different between two groups. Missing data analysis also showed a higher odds of death at one and 5 years for inactive patients. CONCLUSIONS: In our cohort, we observed a younger age of stroke and a higher odds of 1- and 5-year mortality among those with less physical activity. This is an important health promotion strategy to encourage people to remain physically active.

Increased age, neutrophil-to-lymphocyte ratio (NLR) and white blood cells count are associated with higher COVID-19 mortality.

OBJECTIVE: Coronavirus disease 19 (COVID-19) caused by the highly pathogenic SARS-CoV-2, was first reported from Wuhan, China, in December 2019. The present study assessed possible associations between one-month mortality and demographic data, SpO2, underlying diseases and laboratory findings, in COVID-19 patients. Also, since recent studies on COVID-19, have focused on Neutrophil-to-lymphocyte ratio (NLR) as an independent risk factor of the in-hospital death and a significant prognostic biomarker of outcomes in critically ill patients, in this study, we assessed predictive potential of this factor in terms of one-month mortality. METHODS: Patients admitted to Imam Reza hospital, affiliated to Mashhad University of Medical Sciences, Mashhad, Iran, from March to June 2020, with positive RT-PCR results for SARS-CoV-2, were included in this study. Kaplan-Meier survival analysis and Cox proportional hazard model were used to respectively estimate one-month mortality since admission and determine factors associated with one-month mortality. RESULTS: In this retrospective cohort study, 219 patients were included (137 men and 82 women (mean age 58.2 ± 16 and 57 ± 17.3 years old, respectively)). Hypertension, ischemic heart disease and diabetes were respectively the most common comorbidities. Among these patients, 63 patients were admitted to the ICU and 31 deaths occurred during one-month follow-up. With respect to mean peripheral capillary oxygen saturation (SpO2), 142 patients had SpO2 ≤ 90%. Based on our analysis, older age and increased Neutrophil-to-lymphocyte ratio (NLR), and White blood cells (WBC) count were associated with increased risk of one-month mortality. Patients with SpO2 ≤ 90% had a 3.8-fold increase in risk of one-month death compared to those with SpO2 > 90%, although the difference did not reach a significant level. CONCLUSION: Multivariate analysis introduced age, WBC count, and NLR as predictors of one-month mortality in COVID-19 patients.

Evaluating the efficacy and safety of vascular IPL for treatment of acute cutaneous leishmaniasis: a randomized controlled trial.

Treatment of cutaneous leishmaniasis (CL) continues to be a health concern, and alternative therapies with fewer side effects are substantially needed. This study aimed to determine the efficacy of intense pulsed light (IPL) with wavelength spectrum affecting vascular lesions on acute cutaneous leishmaniasis. In this randomized clinical trial study, 30 patients with acute CL were enrolled. Baseline clinical and demographic data were recorded in the checklist after obtaining written informed consent. Patients were randomly allocated to receive either IPL fortnightly (intervention group) or intralesional meglumine antimoniate (MA) weekly (control group) over 10 weeks. Patients were assessed every 2 weeks to determine the size of induration and improvement rate of lesions. Follow-up visits were arranged at 3rd and 6th months. Overall, 15 patients (21 lesions) in the intervention group and 15 patients (22 lesions) in the control group were studied. The size of lesions in the control group was significantly higher at the baseline (P = 0.014) and the second week (P = 0.034), and significantly lower in the eighth week (P = 0.009), compared with the intervention group. The size of lesions in the control group changed during the study (P < 0.001), whereas changes were not significant in the intervention group. The trend of changes in size of lesions was faster in the control group (P < 0.001). More patients in the control group had higher improvement rate at the sixth (P = 0.005) and tenth (P < 0.001) weeks. At the end of study, the cure rate was 35% (7 out of 20 lesions) in intervention group and 81.8% (18 out of 22 lesions) in the control group. Complete response happened earlier in the control group (P < 0.001). None of the lesions that were cured before the tenth week relapsed after 6 months. The frequency of blistering was significantly higher in intervention group (P = 0.001). Our results indicated that IPL with wavelength spectrum affecting vascular lesions was inferior to intralesional MA in treatment of CL. However, it can be considered as a second-line option, especially in patients with limitations for use of MA. Trial registry:  https://www.irct.ir/trial/34246 IRCT20140414017271N5.

METHYLENE BLUE FOR TREATMENT OF HOSPITALIZED COVID-19 PATIENTS: A RANDOMIZED, CONTROLLED, OPEN-LABEL CLINICAL TRIAL, PHASE 2.

BACKGROUND: There is no pharmacological intervention on the treatment of hypoxemia and respiratory distress in COVID-19 patients. OBJECTIVE: The objective of the study was to study the effect of the reduced form of methylene blue (MB) on the improvement of oxygen saturation (SpO2) and respiratory rate (RR). METHODS: In an academic medical center, 80 hospitalized patients with severe COVID-19 were randomly assigned to receive either oral MB along with standard of care (SOC) (MB group, n = 40) or SOC only (SOC group, n=40). The primary outcomes were SpO2 and RR on the 3rd and 5th days. The secondary outcomes were hospital stay and mortality within 28 days. RESULTS: In the MB group, a significant improvement in SpO2 and RR was observed on the 3rd day (for both, p < 0.0001) and also the 5th day (for both, p < 0.0001). In the SOC group, there was no significant improvement in SpO2 (p = 0.24) and RR (p = 0.20) on the 3rd day, although there was a significant improvement of SpO2 (p = 0.002) and RR (p = 0.01) on the 5th day. In the MB group in comparison to the SOC group, the rate ratio of increased SpO2 was 13.5 and 2.1 times on the 3rd and 5th days, respectively. In the MB group compared with the SOC group, the rate ratio of RR improvement was 10.1 and 3.7 times on the 3rd and 5th days, respectively. The hospital stay was significantly shortened in the MB group (p = 0.004), and the mortality was 12.5% and 22.5% in the MB and SOC groups, respectively. CONCLUSIONS: The addition of MB to the treatment protocols significantly improved SpO2 and respiratory distress in COVID-19 patients, which resulted in decreased hospital stay and mortality. ClinicalTrials.gov: NCT04370288.

COVID-19 Pandemic and Burden of Non-Communicable Diseases: An Ecological Study on Data of 185 Countries.

BACKGROUND: The interaction between coronavirus disease 2019 (COVID-19) and non-communicable diseases may increase the global burden of disease. We assessed the association of COVID-19 with ageing and non-communicable diseases. METHODS: We extracted data regarding non-communicable disease, particularly cardiovascular disease, deaths, disability-adjusted life years (DALYs), and healthy life expectancy (HALE) from the Global Burden of Disease Study (GBD) 2017. We obtained data of confirmed COVID-19 cases, deaths, and tests from the Our World in Data database as of May 28, 2020. Potential confounders of pandemic outcomes analyzed include institutional lockdown delay, hemispheric geographical location, and number of tourists. We compared all countries according to GBD classification and World Bank income level. We assessed the correlation between independent variables associated with COVID-19 caseload and mortality using Spearman's rank correlation and adjusted mixed model analysis. FINDINGS: High-income had the highest, and the Southeast Asia, East Asia, and Oceania region had the least cases per million population (3050.60 vs. 63.86). Sub-saharan region has reported the lowest number of COVID-19 mortality (1.9). Median delay to lockdown initiation varied from one day following the first case in Latin America and Caribbean region, to 34 days in Southeast Asia, East Asia, and Oceania. Globally, non-communicable disease DALYs were correlated with COVID-19 cases (r = 0.32, p<0.001) and deaths (r = 0.37, p<0.001). HALE correlated with COVID-19 cases (r = 0.63, p<0.001) and deaths (r = 0.61, p<0.001). HALE was independently associated with COVID-19 case rate and the number of tourists was associated with COVID-19 mortality in the adjusted model. INTERPRETATION: Preventive measures against COVID-19 should protect the public from the dual burden of communicable and non-communicable diseases, particularly in the elderly. In addition to active COVID-19 surveillance, policymakers should utilize this evidence as a guide for prevention and coordination of health services. This model is timely, as many countries have begun to reduce social isolation.

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results.

BACKGROUND: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. METHODS: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. RESULTS: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001). CONCLUSION: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.

Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE).

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. METHODS: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. CONCLUSION: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.

Risk factors of premature coronary artery disease in Iran: A systematic review and meta-analysis.

BACKGROUND: The aim of this study was to determine the mean age at which coronary artery disease (CAD) hase decreased in recent years in Iran. This systematic review and meta-analysis compares the prevalence of different risk factors of premature CAD (PCAD) in patients vs healthy individuals. METHODS: Medline, Web of Science, Embase and Scientific Information Database were searched for studies about PCAD risk factors in Iran until 28 October 2017. Observational studies of Iranians, comparing risk factors between patients with PCAD and age- and sex-matched healthy subjects, were included. Fixed-effects and random-effects model were used for pooling data. Odds ratio (OR) with 95% CI and mean difference were used for effect size estimation among studies. RESULTS: Twelve studies were eligible for meta-analysis. Diabetes mellitus (OR: 2.4, 95% CI: 1.9-3.03; P = 0.0001, I2  = 25.5%; P = 0.2), family history of CAD (OR: 2.09, 95% CI: 1.22-3.6; P = 0.007, I2  = 86%; P = 0.0001), dyslipidaemia (OR: 2.05, 95% CI: 1.15-3.64; P = 0.01, I2  = 54%; P = 0.08), smoking (OR: 1.65, 95% CI: 1.11-2.46; P = 0.01, I2  = 77.2%; P = 0.000) and hypertension (OR: 1.35, 95% CI: 1.21 to-1.50; P < 0.001, I2  = 31%, P = 0.1) associated with PCAD. Sensitivity analysis demonstrated that patients with PCAD had significantly lower levels of high-density lipoprotein (HDL) cholesterol and significantly higher levels of triglycerides compared to healthy subjects (MD: -2.56, 95% CI: -3.54 to -1.58, P < 0.001, I2  = 42%, P = 0.01 and MD: 21.17, 95% CI: 14.73-27.62, P < 0.001, I2  = 80.12%, P < 0.001, respectively). It should be noted that although high levels of heterogeneity in LDL and HDL values among the studies were observed, when dyslipidaemia was studied as a binary variable, no significant heterogeneity among studies was observed. CONCLUSION: Diabetes mellitus, family history of CAD, dyslipidaemia, smoking, and hypertension were significantly and positively associated with CAD in young adults compared to healthy age- and sex-matched population in Iran.

The Association between Inflammatory Markers in the Acute Phase of Stroke and Long-Term Stroke Outcomes: Evidence from a Population-Based Study of Stroke.

BACKGROUND: Little is known about the association between inflammatory markers in the acute stroke phase and long-term stroke outcomes. METHODS: In a population-based study of stroke with 5 years follow-up, we measured the level of serum heat shock protein 27 immunoglobulin G antibody (anti-HSP27), C-reactive protein (CRP), and pro-oxidant antioxidant balance (PAB) in the acute stroke phase. We analyzed the association between these inflammatory biomarkers and stroke outcomes (recurrence, death and disability/functional dependency) with using multivariable Cox proportional hazard models. RESULTS: Two hundred sixty-five patients with first-ever stroke were included in this study. The severity of stroke at admission, measured by National Institute of Health Score Scale was associated with serum concentration of CRP (Spearman's rank correlation coefficient rs = 0.2; p = 0.004). CRP also was associated with 1-year combined death and recurrence rate ([adjusted hazard ratio 1.06, 95% CI 1.01-1.12; p = 0.02]). However, we did not find any association between the concentrations of CRP, anti-HSP27, PAB, and 5-year death and stroke recurrence rates. None of 3 biomarkers was associated with the long-term disability rate (defined as modified Rankin Scale >2) and functional dependency (defined as Barthel Index <60). CONCLUSION: CRP has a significant direct, yet weak, correlation to the severity of stroke. In addition, the level of CRP at admission may have a clinical implication to identify those at a higher risk of death or recurrence.

Socioeconomic Status and Long-Term Stroke Mortality, Recurrence and Disability in Iran: The Mashhad Stroke Incidence Study.

BACKGROUND: Little is known about the association between socioeconomic status and long-term stroke outcomes, particularly in low- and middle-income countries. METHODS: Patients were recruited from the Mashhad Stroke Incidence Study in Iran. We identified different socioeconomic variables including the level of education, occupation, household size, and family income. Residential location according to patient's neighbourhood was classified into less privileged area (LPA), middle privileged area and high privileged area (HPA). Using Cox regression, competing risk analysis and logistic regression models, we determined the association between socioeconomic status and 1- and 5-year stroke outcomes. Generalized linear model was used for adjusting associated variables for stroke severity. RESULTS: Six hundred twenty-four patients with first-ever stroke were recruited in this study. Unemployment prior to stroke was associated with an increased risk of 1- and 5-year post-stroke mortality (1 year: adjusted hazard ratio [aHR] 3.3; 95% CI 1.6-7.06: p = 0.001; 5 years: aHR 2.1; 95% CI 1.2-3.6: p = 0.007). The 5-year mortality rate was higher in less educated patients (<12 years) as compared to those with at least 12 years of schooling (aHR 1.84; 95% CI 1.05-3.23: p = 0.03). Patients living in LPA compared to those living in HPAs experienced a more severe stroke at admission (aB 3.84; 95% CI 0.97-6.71, p = 0.009) and disabling stroke at 1 year follow-up (OR 6.1; 95% CI 1.3-28.4; p = 0.02). CONCLUSION: A comprehensive stroke strategy should also address socioeconomic disadvantages.

Long-Term Outcomes of Ischemic Stroke of Undetermined Mechanism: A Population-Based Prospective Cohort.

BACKGROUND AND PURPOSE: Little is known about the short- and long-term outcomes of ischemic stroke of undetermined mechanism (ISUM). METHODS: Subjects were recruited from the Mashhad Stroke Incidence Study. Ischemic stroke (IS) was classified on the basis of the TOAST criteria. We further categorized patients with ISUM into ISUMneg (negative clinical/test results for large artery, small artery) and ISUMinc (incomplete investigations). Cox proportional hazard models and the competing-risk regression model were used to compare 1 and 5 years mortality (all-causes) and recurrent rate among IS subtypes. RESULTS: Overall, 1-year mortality was higher in those with ISUMinc than in ISUMneg (adjusted hazard ratio [aHR] 1.6, 95% CI 1.01-2.8; p = 0.04) and in other stroke subtypes. Cardioembolic stroke was associated with the greatest risk of stroke recurrence at one year (aHR 4.9, 95% CI 1.8-12.9; p = 0.001) and 5 years (HR 2.1, 95% CI 1.1-3.7; p = 0.01) as compared to ISUMneg. CONCLUSIONS: The classification of ISUM as a single group may lead to over- or underestimation of mortality and recurrence in this major category of IS. A better definition of ISUM is necessary to predict death and recurrence accurately.

Risk Factors and Outcome of Acute Kidney Injury after Congenital Heart Surgery: A Prospective Observational Study.

BACKGROUNDS AND AIMS: Acute kidney injury (AKI) is a frequent event after congenital heart surgery with increased mortality and morbidity. We investigated frequency, risk factors, and associated morbidity and mortality of AKI after pediatric cardiac surgery at a single institution. METHODS: Children undergoing congenital heart surgery from March 2013 to February 2016 were assessed for development of AKI based on modified pediatric Risk, Injury, Failure, Loss, and End-stage renal disease criteria. They were also investigated for predictive risk factors, associated mortality, and morbidity including duration of mechanical ventilation, Intensive Care Unit (ICU), and hospital length of stay. RESULTS: Five hundred and nineteen patients were recruited during the study period including 259 (49.9%) males and 260 (50.1%) females. AKI was seen in 150 (28.9%) patients including 101 (67.3%), 42 (28%), and 7 (4.7%) cases with risk, injury, and failure stages, respectively. Patients with AKI had longer ventilation time (P = 0.002), ICU (P = 0.05), and hospital (P = 0.56) stay. Mortality was seen in 31 (2.7%) and 44 (11.9%) patients with and without AKI, respectively (P = 0.01). After multivariable logistic regression, there was an association between AKI and preoperative abnormal levels of creatinine (adjusted odds ratio [aOR] = 0.47, 95% confidence interval [CI] 0.22-1.01; P = 0.05), presence of cyanotic heart disease (aOR = 1.97, 95% CI = 1.15-3.2; P = 0.01), duration of surgery (aOR = 1.05/10 min, 95% CI = 1.01-1.08; P = 0.007), and elevated lactate level (aOR = 1.14, 95% CI = 1.03-1.3; P = 0.01). CONCLUSION: The presence of cyanotic heart disease, duration of surgery, elevated postoperative lactate level, and likely preoperative creatinine level were independent risk factors for the development of AKI after congenital heart surgery.

The relationship between mobile phone addiction and depression, anxiety, and sleep quality in medical students.

This study investigates the prevalence of mobile phone addiction among medical students and its relationship with depression, anxiety, and sleep quality. The study was conducted at Mashhad University of Medical Sciences from 2019 to 2021, and it included medical students at four different levels of training. Participants were selected using a stratified random sampling method. All subjects completed the Mobile Phone Addiction Scale, Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory, and Beck Anxiety Inventory through online electronic self-report questionnaires. Overall, 355 medical students were included in the study, with 203 (57.2%) being female. Mild and severe mobile phone addiction was reported by 83.7 and 2.5% of the students, respectively. Furthermore, the study's findings revealed significantly higher sleep quality disorder, depression, and anxiety scores among students with severe mobile phone addiction compared to other participants ( P  < 0.001, P  = 0.007, and P  < 0.001, respectively). Although mobile phone addiction was prevalent, severe addiction was rare among medical students. Nevertheless, severe addiction was associated with an increased prevalence of mental health problems and sleep disturbances, emphasizing the importance of interventions aimed at reducing mobile phone addiction and improving mental health.