Risk factors of developing contralateral breast cancer after first primary breast cancer treatment.

BACKGROUND: Breast cancer (BC) is the most common cancer among women worldwide. Increased survival of primary BC (PBC) has increased contralateral breast cancer (CBC) and become a health problem. AIMS: This study aimed to determine the effect of disease-free interval (DFI), risk factors and PBC characteristics on the progression of CBC within primary BC survivors. METHODS AND RESULTS: This retrospective study identified 5003 women diagnosed with breast cancer between 2000 and 2020 in the cancer research center. The study included 145 CBC and 4858 PBC survivors, with CBC diagnosed at least 6 months after the detection of primary BC. ER+, PR+, and HER2+ were reported in 72.13%, 66.67%, and 30% of CBC patients. Invasive ductal carcinoma (IDC) BC was reported in 69.57% of patients, and 81.90% and 83.64% of the patients were treated with adjuvant chemotherapy and external radiotherapy. The Kaplan-Meier method indicated that the median time interval between PBC and CBC was 3.92 years, and the 5-year DFI was 97%. The Cox proportional hazard regression model indicated that although more than half of the participants had no family history of BC (69.57%), women 60 years and older were negatively associated with CBC. CONCLUSION: This study provides the first investigation of CBC and DFI risk factors among PBC survivors in Iran. Age was found to be negatively associated with CBC development particularly after the age of 60, indicating the necessity of tracking CBC survivors carefully in this age group.

Trend of mortality rate due to traffic accidents in Iran from 2006 to 2020: A cross-sectional study.

Background: Traffic accidents are a common global cause of mortality and physical disability. This study aimed to investigate traffic accident-related mortality trends across provinces in Iran. Methods: In this study, information on all deaths caused by traffic accidents in Iran from 2006 to 2020 was collected from the Iranian Legal Medicine Organization, which collects annual data from all 31 Iranian provinces. The national and provincial demographics were assessed, and the trends in mortality rates were assessed over a 15-year span using joinpoint regression based on the log-linear model, with results expressed in terms of annual percentage change (APC). The analysis for the trend was performed using the Joinpoint Regression Program 4.9.0.1. Results: During the study period, 291,774 traffic accident-related deaths occurred in Iran, of which 78.6% were men and 21.4% were women. The mean age of the deceased was 37.75 ± 20.89 years. The mortality rate has dropped from 39/100,000 in 2006 to 18.3/100,000 in 2020. In total, the national mortality rate APC for 2006-2015 was -6.3% (P < 0.05) and for 2015-2020 was - 1.70% (P > 0.05). Conclusions: Despite the overall decreasing national trend in Iran's traffic accident-related mortality over the study period, the provincial variability was noted. Therefore, it seems necessary to design and conduct epidemiological studies in different areas and provinces, for a better and more accurate understanding of the factors affecting the occurrence of traffic accident-related deaths, resulting in more focused and measurable interventions.

Development and evaluation of a customized checklist to assess the quality control of disease registry systems of Tehran, the capital of Iran in 2021.

BACKGROUND: Clinical registries facilitate medical research by providing 'real data'. In the past decade, an increasing number of disease registry systems (DRS) have been initiated in Iran. Here, we assessed the quality control (QC) of the data recorded in the DRS established by Shahid Beheshti University of Medical Sciences in Tehran, the capital city of Iran, in 2021. METHODS: The present study was conducted in two consecutive qualitative and quantitative phases and employed a mixed-method design. A checklist containing 23 questions was developed based on a consensus reached following several panel group discussions, whose face content and construct validities were confirmed. Cronbach's alpha was calculated to verify the tool's internal consistency. Overall, the QC of 49 DRS was assessed in six dimensions, including completeness, timeliness, accessibility, validity, comparability, and interpretability. The seventy percent of the mean score was considered a cut-point for desirable domains. RESULTS: The total content validity index (CVI) was obtained as 0.79, which is a reasonable level. Cronbach's alpha coefficients obtained showed acceptable internal consistency for all of the six QC domains. The data recorded in the registries included different aspects of diagnosis/treatment (81.6%) and treatment quality requirements outcomes (12.2%). According to the acceptable quality cut-point, out of 49 evaluated registries, 48(98%), 46(94%), 41(84%), and 38(77.5%), fulfilled desirable quality scores in terms of interpretability, accessibility, completeness, and comparability, however, 36(73.5%) and 32(65.3%) of registries obtained the quality requirement for timeliness and validity, respectively. CONCLUSION: The checklist developed here, containing customized questions to assess six QC domains of DRSs, provided a valid and reliable tool that could be considered as a proof-of-concept for future investigations. The clinical data available in the studied DRSs fulfilled desirable levels in terms of interpretability, accessibility, comparability, and completeness; however, timeliness and validity of these registries needed to be improved.

Investigation of Death Rate Due to Type 2 Traffic Accidents and Non-Traffic Accidents in Iran during 2013-2018.

Background: In the classification of road accidents, type 2 traffic accidents and non-traffic accidents are not considered and in Iran so far no special study has been done in the field of type 2 traffic accidents and non-traffic accidents, so we aimed to investigate the incidence of type 2 traffic accidents and non-traffic accidents in Iran. Methods: This cross-sectional was conducted on all individuals referred to Forensic Medicine Organization (FMO) from all over Iran who suffered from non-traffic accidents and type 2 traffic accidents during 2013-2018. Demographic information, accident information and other information including the location of the impact, the final cause of death and the date of the accident were examined. The information received from the FMO was first checked and then analyzed using Stata 11 statistical software. Results: During the 6-year study period, 10882 people lost their lives in type 2 traffic accidents (4779 people) and non-traffic accidents (5287 people). In terms of age, the highest incidence of type 2 traffic accidents and non-traffic accidents was observed in the age group over 65 years. The incidence of type 2 traffic accidents has not been increasing, while the trend of non-traffic accidents has been increasing. Conclusion: With respect to the high rate of deaths due to traffic accidents, including type 2 traffic accidents and non-traffic accidents, it is necessary for the national media and relevant agencies to educate the people about first aid and also inform about free relief services, timely presence is important.

Non-communicable diseases in the southwest of Iran: profile and baseline data from the Shahrekord PERSIAN Cohort Study.

BACKGROUND: Critical inter-provincial differences within Iran in the pattern of non-communicable diseases (NCDs) and difficulties inherent to identifying prevention methods to reduce mortality from NCDs have challenged the implementation of the provincial health system plan. The Shahrekord Cohort Study (SCS) was designed to address these gaps in Chaharmahal and Bakhtiari, a province of high altitude in the southwest of Iran, characterized by its large Bakhtiari population, along with Fars and Turk ethnicity groups. METHODS: This ongoing cohort, a prospective, large-scale longitudinal study, includes a unique, rich biobank and was conducted for the first time in Chaharmahal and Bakhtiari Province in Iran. SCS is a part of the PERSIAN (Prospective Epidemiological Research Studies in IrAN) cohort. The study began in 2015, recruited 10075 participants (52.8% female, 47.2% male) from both urban (n=7034) and rural (n=3041) areas, and participants will be annually followed up for at least 15 years. A cross-sectional analysis was conducted using baseline data from the SCS, using descriptive statistics and logistic regression. Data analysis was performed using Stata software. RESULTS: The prevalence of NCDs was 9.8% for type 2 diabetes, 17.1% for hypertension, 11.6% for thyroid disease, 0.2% for multiple sclerosis and 5.7, 0.9 and 1.3% for ischemic heart disease, stroke and myocardial infarction, respectively. The prevalence of multimorbidity (≥2 NCDs) was higher in women (39.1%) than men (24.9%). The means (standard deviations) of age, BMI, systolic blood pressure and fasting blood glucose were 49.5 (9) years, 27.6 (4.6) kg/m2, 115.4 (17.3) mmHg and 96.7 (27.3) mg/dL, respectively. Logistic regression models showed that older age, female gender, living in an urban area, non-native ethnicity, high wealth index, unemployment, obesity, low physical activity, hypertriglyceridemia, high fasting blood sugar, alkaline urine pH and high systolic and diastolic blood pressure were associated with increased prevalence of NCDs. CONCLUSIONS: The SCS provides a platform for epidemiological studies that will be useful to better control NCDs in the southwest of Iran and to foster research collaboration. The SCS will be an essential resource for identifying NCD risk factors in this region and designing relevant public health interventions.

O Efeito Direto do Índice de Massa Corporal nos Resultados Cardiovasculares entre Participantes sem Obesidade Central pela Estimativa por Máxima Verossimilhança Direcionada / The Direct Effect of Body Mass Index on Cardiovascular Outcomes among Participants Without Central Obesity by Targeted Maximum Likelihood Estimation

Resumo Fundamento: O índice de massa corporal (IMC) é o índice mais usado para categorizar uma pessoa como obesa ou não-obesa, e está sujeito a limitações importantes. Objetivo: Avaliar o efeito direto do IMC nos desfechos cardiovasculares em participantes sem obesidade central. Métodos: Esta análise incluiu 14.983 homens e mulheres com idades entre 45-75 anos do Estudo de Risco de Aterosclerose em Comunidades (ARIC). O IMC foi medido como obesidade geral e a circunferência da cintura (CC), a relação cintura-quadril (RCQ) e circunferência do quadril como obesidade central. A estimativa de máxima verossimilhança direcionada (TMLE, no acrônimo em inglês) foi usada para estimar os efeitos totais (TEs) e os efeitos diretos controlados (CDEs). A proporção de ET que seria eliminada se todos os participantes fossem não obesos em relação à obesidade central foi calculada usando o índice de proporção eliminada (PE). P<0,05 foi considerado estatisticamente significativo. As análises foram realizadas no pacote TMLE R. Resultados: O risco de desfechos cardiovasculares atribuídos ao IMC foi significativamente revertido com a eliminação da obesidade na RCQ (p <0,001). A proporção eliminada dos efeitos do IMC foi mais tangível para participantes não obesos em relação à CC (PE = 127%; IC95% (126,128)) e RCQ (PE = 97%; IC95% (96,98)) para doença arterial coronariana (DAC), e RCQ (PE = 92%; IC95% (91,94)) para acidente vascular cerebral, respectivamente. Com relação ao sexo, a proporção eliminada dos efeitos do IMC foi mais tangível para participantes não obesos em relação a RCQ (PE = 428%; IC95% (408.439)) para DAC em homens e CC (PE = 99%; IC95% (89,111)) para acidente vascular cerebral em mulheres, respectivamente. Conclusão: Esses resultados indicam diferentes efeitos potenciais da eliminação da obesidade central na associação entre IMC e desfechos cardiovasculares em homens e mulheres. (Arq Bras Cardiol. 2021; 116(5):879-886)

Background: Body mass index (BMI) is the most commonly used index to categorize a person as obese or non-obese, which is subject to important limitations. Objective: To evaluate the direct effect of BMI on cardiovascular outcomes among participants without central obesity. Methods: This analysis included 14,983 males and females aged 45-75 years from the Atherosclerosis Risk in Communities Study (ARIC). BMI was measured as general obesity, and waist circumference (WC), waist-to-hip ratio (WHR) and hip circumference as central obesity. Targeted maximum likelihood estimation (TMLE) was used to estimate the total effects (TEs) and the controlled direct effects (CDEs). The proportion of TE that would be eliminated if all participants were non-obese regarding central obesity was computed using the proportion eliminated (PE) index. P <0.05 was considered statistically significant. Analyses were performed in the TMLE R package. Results: The risk of cardiovascular outcomes attributed to BMI was significantly reversed by eliminating WHR obesity (p<0.001). The proportion eliminated of BMI effects was more tangible for non-obese participants regarding WC (PE=127%; 95%CI (126,128)) and WHR (PE=97%; 95%CI (96,98)) for coronary heart disease (CHD), and WHR (PE=92%; 95%CI (91,94)) for stroke, respectively. With respect to sex, the proportion eliminated of BMI effects was more tangible for non-obese participants regarding WHR (PE=428%; 95%CI (408,439)) for CHD in males, and WC (PE=99%; 95%CI (89,111)) for stroke in females, respectively. Conclusion: These results indicate different potential effects of eliminating central obesity on the association between BMI and cardiovascular outcomes for males and females. (Arq Bras Cardiol. 2021; 116(5):879-886)

The Direct Effect of Body Mass Index on Cardiovascular Outcomes among Participants Without Central Obesity by Targeted Maximum Likelihood Estimation. / O Efeito Direto do Índice de Massa Corporal nos Resultados Cardiovasculares entre Participantes sem Obesidade Central pela Estimativa por Máxima Verossimilhança Direcionada.

BACKGROUND: Body mass index (BMI) is the most commonly used index to categorize a person as obese or non-obese, which is subject to important limitations. OBJECTIVE: To evaluate the direct effect of BMI on cardiovascular outcomes among participants without central obesity. METHODS: This analysis included 14,983 males and females aged 45-75 years from the Atherosclerosis Risk in Communities Study (ARIC). BMI was measured as general obesity, and waist circumference (WC), waist-to-hip ratio (WHR) and hip circumference as central obesity. Targeted maximum likelihood estimation (TMLE) was used to estimate the total effects (TEs) and the controlled direct effects (CDEs). The proportion of TE that would be eliminated if all participants were non-obese regarding central obesity was computed using the proportion eliminated (PE) index. P <0.05 was considered statistically significant. Analyses were performed in the TMLE R package. RESULTS: The risk of cardiovascular outcomes attributed to BMI was significantly reversed by eliminating WHR obesity (p<0.001). The proportion eliminated of BMI effects was more tangible for non-obese participants regarding WC (PE=127%; 95%CI (126,128)) and WHR (PE=97%; 95%CI (96,98)) for coronary heart disease (CHD), and WHR (PE=92%; 95%CI (91,94)) for stroke, respectively. With respect to sex, the proportion eliminated of BMI effects was more tangible for non-obese participants regarding WHR (PE=428%; 95%CI (408,439)) for CHD in males, and WC (PE=99%; 95%CI (89,111)) for stroke in females, respectively. CONCLUSION: These results indicate different potential effects of eliminating central obesity on the association between BMI and cardiovascular outcomes for males and females. (Arq Bras Cardiol. 2021; 116(5):879-886).

FUNDAMENTO: O índice de massa corporal (IMC) é o índice mais usado para categorizar uma pessoa como obesa ou não-obesa, e está sujeito a limitações importantes. OBJETIVO: Avaliar o efeito direto do IMC nos desfechos cardiovasculares em participantes sem obesidade central. MÉTODOS: Esta análise incluiu 14.983 homens e mulheres com idades entre 45-75 anos do Estudo de Risco de Aterosclerose em Comunidades (ARIC). O IMC foi medido como obesidade geral e a circunferência da cintura (CC), a relação cintura-quadril (RCQ) e circunferência do quadril como obesidade central. A estimativa de máxima verossimilhança direcionada (TMLE, no acrônimo em inglês) foi usada para estimar os efeitos totais (TEs) e os efeitos diretos controlados (CDEs). A proporção de ET que seria eliminada se todos os participantes fossem não obesos em relação à obesidade central foi calculada usando o índice de proporção eliminada (PE). P<0,05 foi considerado estatisticamente significativo. As análises foram realizadas no pacote TMLE R. RESULTADOS: O risco de desfechos cardiovasculares atribuídos ao IMC foi significativamente revertido com a eliminação da obesidade na RCQ (p <0,001). A proporção eliminada dos efeitos do IMC foi mais tangível para participantes não obesos em relação à CC (PE = 127%; IC95% (126,128)) e RCQ (PE = 97%; IC95% (96,98)) para doença arterial coronariana (DAC), e RCQ (PE = 92%; IC95% (91,94)) para acidente vascular cerebral, respectivamente. Com relação ao sexo, a proporção eliminada dos efeitos do IMC foi mais tangível para participantes não obesos em relação a RCQ (PE = 428%; IC95% (408.439)) para DAC em homens e CC (PE = 99%; IC95% (89,111)) para acidente vascular cerebral em mulheres, respectivamente. CONCLUSÃO: Esses resultados indicam diferentes efeitos potenciais da eliminação da obesidade central na associação entre IMC e desfechos cardiovasculares em homens e mulheres. (Arq Bras Cardiol. 2021; 116(5):879-886).

A systematic review and meta-analysis of human biomonitoring studies on exposure to environmental pollutants in Iran.

Population exposure to environmental contaminants can be precisely observed through human biomonitoring studies. The present study aimed to systematically review all the biomonitoring studies conducted in Iran on some selected carcinogen environmental pollutants. In this systematic review study, 11 carcinogen agents were selected including arsenic, cadmium, chromium, nickel, lindane, benzene, trichloroethylene (TCE), pentachlorophenol (PCP), radon-222, radium-224, - 226, - 228, and tobacco smoke. The Web of Science, PubMed, and Scopus databases were searched for peer-reviewed articles published in English. After several screening steps, data were extracted from the studies. Meta-analyses (a random-effect model using the DerSimonian-Laired method) were performed only for the biomarkers with more than three eligible articles, including cadmium in blood and breast milk, and arsenic in breast milk. Methodological quality of the studies was assessed using the Newcastle-Ottawa Quality Assessment Scale adapted for cross-sectional studies. Of the 610 articles found in the database search, 30 studies were eligible for qualitative review, and 13 were included in the meta-analysis (cadmium in blood (n = 3), cadmium in breast milk (n = 6), and arsenic in breast milk (n = 4)). The overall pooled average concentrations (95% CI) of cadmium in blood, cadmium in breast milk, and arsenic in breast milk were 0.11 (95% CI: 0.08, 0.14), 5.38 (95% CI: 3.60, 6.96), and 1.42 (95% CI: 1.02, 1.81) µg/L, respectively. These values were compared with the biomarker concentrations in other countries and health-based guideline values. This study showed that there is a need for comprehensive action plans to reduce the exposure of general population to these environmental contaminants.

Presence of SARS-CoV-2 in the air of public places and transportation.

This study investigated the presence of SARS-CoV-2 in air of public places such as shopping centers, a post office, banks, governmental offices, and public transportation facilities including an airport, subways, and buses in Tehran, Iran. A total of 28 air samples were collected from the eight groups of public and transportation locations. The airborne particle samples were collected on PTFE or glass fiber filters using two types of samplers with flow rates of 40 and 3.5 L/min, respectively. The viral samples were leached and concentrated, and RNA was extracted from each. The presence of viral RNA was evaluated using novel coronavirus nucleic acid diagnostic real time PCR kits. In 64% of the samples, SARS-CoV-2 RNA (62% and 67% from the public places and transportation, respectively) was detected. Positive samples were detected in banks (33%), shopping centers (100%), governmental offices (50%), the airport (80%), subway stations (50%), subway trains (100%), and buses (50%). Logistic regression showed that number of people present during the sampling and the sampled air volume were positively associated with presence of SARS-CoV-2; while the percentage of people with masks, air temperature, and sampling site's volume were negatively related to SARS-CoV-2's presence. However, none of these associations were statistically significant. This study showed that most public places and transportation vehicles were contaminated with SARS-CoV-2. Thus, strategies to control the spread of COVID-19 should include reducing the number of people in indoor spaces, more intense disinfection of transport vehicles, and requiring people to wear masks.

Tramadol, Methadone and Benzodiazepines added to Alcoholic Beverages.

AIMS: To search for pharmaceutical additives in illicit alcoholic beverages referred to the laboratory of Legal Medicine Organization in Iran in 2017. METHODS: Hundred beverages were sampled. Ethanol content was determined by gas chromatography with flame ionization detection (GC-FID) and then a liquid-liquid extraction combined with reversed-phase high performance liquid chromatography equipped with a photodiode array detector (PAD) was employed for the qualitative analysis. The analysis was confirmed using gas chromatography coupled with mass spectroscopy (GC/MS). RESULTS: In 15% either one or more of the following were detected: tramadol, methadone, diazepam, oxazepam, flurazepam and alprazolam. Tramadol was found with highest frequency. CONCLUSIONS: The wide availability of addictive pharmaceutical is leading to fortification of alcoholic beverages on some countries. The addition of such depressant additives should be better known because of the potentially fatal consequences of the combination with ethanol, as well as the potential for adverse effects on behavior.

Associations between dietary risk factors and ischemic stroke: a comparison of regression methods using data from the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVES: We analyzed dietary patterns using reduced rank regression (RRR), and assessed how well the scores extracted by RRR predicted stroke in comparison to the scores produced by partial least squares and principal component regression models. METHODS: Dietary data at baseline were used to extract dietary patterns using the 3 methods, along with 4 response variables: body mass index, fibrinogen, interleukin-6, and low-density lipoprotein cholesterol. The analyses were based on 5,468 males and females aged 45-84 years who had no clinical cardiovascular disease, using data from the Multi-Ethnic Study of Atherosclerosis. RESULTS: The primary factor derived by RRR was positively associated with stroke incidence in both models. The first model was adjusted for sex and race and the second model was adjusted for the variables in model 1 as well as smoking, physical activity, family and sibling history of stroke, the use of any lipid-lowering medication, the use of any anti-hypertensive medication, hypertension, and history of myocardial infarction (model 1: hazard ratio [HR], 7.49; 95% confidence interval [CI], 1.66 to 33.69; p for trend=0.01; model 2: HR, 6.83; 95% CI, 1.51 to 30.87 for quintile 5 compared with the reference category; p for trend=0.02). CONCLUSIONS: Based primarily on RRR, we identified that a dietary pattern high in fats and oils, poultry, non-diet soda, processed meat, tomatoes, legumes, chicken, tuna and egg salad, and fried potatoes and low in dark-yellow and cruciferous vegetables may increase the incidence of ischemic stroke.

Mortality assessment attributed to long-term exposure to fine particles in ambient air of the megacity of Tehran, Iran.

Few studies regarding the health effects of long-term exposure to particulate matter with an aerodynamic diameter of 2.5 µm or less (PM2.5) have been carried out in Asia or the Middle East. The objective of our study was to assess total, lung cancer and chronic obstructive pulmonary disease (COPD) mortality attributed to long-term exposure to PM2.5 among adults aged over 30 years in Tehran from March 2013 to March 2016 using AirQ+ software. AirQ+ modeling software was used to estimate the number of deaths attributed to PM2.5 concentrations higher than 10 µg m-3. Air quality data were obtained from the Department of Environment (DOE) and Tehran Air Quality Control Company (TAQCC). Only valid stations with data completeness of 75% in all 3 years were selected for entry into the model. The 3-year average of the 24-h concentrations was 39.17 µg m-3. The results showed that the annual average concentration of PM2.5 in 2015-2016 was reduced by 13% compared to that in 2013-2014. The annual average number of all natural, COPD, and lung cancer deaths attributable to long-term exposure to PM2.5 in adults aged more than 30 years was 5073, 158, and 142 cases, respectively. The results of all three health endpoints indicate that the mortality attributable to PM2.5 decreased yearly from 2013 to 2016 and that the reduced mortality was related to a corresponding reduction in the PM2.5 concentration. Considering these first positive results, the steps that have been currently taken for reducing air pollution in Tehran should be continued to further improve the already positive effects of these measures on reducing health outcomes.

The relative efficiency of Iranian's rural traffic police: a three-stage DEA model.

BACKGROUND: Road traffic Injuries (RTIs) as a health problem imposes governments to implement different interventions. Target achievement in this issue required effective and efficient measures. Efficiency evaluation of traffic police as one of the responsible administrators is necessary for resource management. Therefore, this study conducted to measure Iran's rural traffic police efficiency. METHODS: This was an ecological study. To obtain pure efficiency score, three-stage DEA model was conducted with seven inputs and three output variables. At the first stage, crude efficiency score was measured with BCC-O model. Next, to extract the effects of socioeconomic, demographic, traffic count and road infrastructure as the environmental variables and statistical noise, the Stochastic Frontier Analysis (SFA) model was applied and the output values were modified according to similar environment and statistical noise conditions. Then, the pure efficiency score was measured using modified outputs and BCC-O model. RESULTS: In total, the efficiency score of 198 police stations from 24 provinces of 31 provinces were measured. The annual means (standard deviation) of damage, injury and fatal accidents were 247.7 (258.4), 184.9 (176.9), and 28.7 (19.5), respectively. Input averages were 5.9 (3.0) patrol teams, 0.5% (0.2) manpower proportions, 7.5 (2.9) patrol cars, 0.5 (1.3) motorcycles, 77,279.1 (46,794.7) penalties, 90.9 (2.8) cultural and educational activity score, 0.7 (2.4) speed cameras. The SFA model showed non-significant differences between police station performances and the most differences attributed to the environmental and random error. One-way main road, by road, traffic count and the number of household owning motorcycle had significant positive relations with inefficiency score. The length of freeway/highway and literacy rate variables had negative relations, significantly. Pure efficiency score was with mean of 0.95 and SD of 0.09. CONCLUSIONS: Iran's traffic police has potential opportunity to reduce RTIs. Adjusting police performance with environmental conditions is necessary. Capability of DEA method in setting quantitative targets for every station induces motivation for managers to reduce RTIs. Repetition of this study is recommended, annually.

Adjusting for reverse causation to estimate the effect of obesity on mortality after incident heart failure in the Atherosclerosis Risk in Communities (ARIC) study.

OBJECTIVES: The lower mortality rate of obese patients with heart failure (HF) has been partly attributed to reverse causation bias due to weight loss caused by disease. Using data about weight both before and after HF, this study aimed to adjust for reverse causation and examine the association of obesity both before and after HF with mortality. METHODS: Using the Atherosclerosis Risk in Communities (ARIC) study, 308 patients with data available from before and after the incidence of HF were included. Pre-morbid and post-morbid obesity were defined based on body mass index measurements at least three months before and after incident HF. The associations of pre-morbid and post-morbid obesity and weight change with survival after HF were evaluated using a Cox proportional hazard model. RESULTS: Pre-morbid obesity was associated with higher mortality (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.04 to 2.49) but post-morbid obesity was associated with increased survival (HR, 0.57; 95% CI, 0.37 to 0.88). Adjusting for weight change due to disease as a confounder of the obesity-mortality relationship resulted in the absence of any significant associations between post-morbid obesity and mortality. CONCLUSIONS: This study demonstrated that controlling for reverse causality by adjusting for the confounder of weight change may remove or reverse the protective effect of obesity on mortality among patients with incident HF.

The effect of on-site and outreach-based needle and syringe programs in people who inject drugs in Kermanshah, Iran.

BACKGROUND: Needle and syringe programs (NSPs) are widely used to reduce harms associated with drug injecting. This study assessed the effect of facility-based (on-site services at drop-in centre) and outreach models of NSP on injection risk behaviours. METHODS: Self-reported data from 455 people who injected drugs (PWID) during 2014 in Kermanshah, Iran, were examined to measure demographic characteristics and risk behaviors. Self-reported and program data were also assessed to identify their main source of injection equipment. Participants were divided into three sub-groups: facility-based NSP users, outreach NSP users and non-users (comparison group). Coarsened exact matching was used to make the three groups statistically equivalent based on age, place of residence, education and income, and groups were compared regarding the proportion of borrowing or lending of syringes/cookers, reusing syringes and recent HIV testing. RESULTS: Overall, 76% of participants reported any NSP service use during the two months prior to interview. Only 23% (95%CI: 17-27) reported outreach NSP as their main source of syringes. Using facility-based NSP significantly decreased recent syringe borrowing (OR: 0.27, 95%CI: 0.10-0.70), recent syringe reuse (OR: 0.38, 95%CI: 0.23-0.68) and increased recent HIV testing (OR: 2.60, 95%CI: 1.48-4.56). Similar effects were observed among outreach NSP users; in addition, the outreach NSP model significantly reduced the chance of lending syringes (OR: 0.31, 95%CI: 0.15-0.60), compared to facility-based NSP (OR: 1.25, 95%CI: 0.74-2.17). CONCLUSION: These findings suggest that the outreach NSP model is as effective as facility-based NSP in reducing injection risk behaviours and increasing the rate of HIV testing. Outreach NSP was even more effective than facility-based in reducing the lending of syringes to others. Scaling up outreach NSP is an effective intervention to further reduce transmission of HIV via needle sharing.

Residential segregation of socioeconomic variables and health indices in iran.

BACKGROUND: Measures of segregation are essential tools for evaluation of social equality. They describe complex structural patterns by single quantities and allow the comparison of inequalities over time or between residential places. In many countries, patterns of residential segregation are well described (e.g., South Africa, Great Britain, United States of America). In this study, for the first time in Iran, we measured residential segregation for some socioeconomic and health variables and described their pair wise correlation. METHODS: We measured evenness dimension of segregation by generalized dissimilarity segregation index and information theory index and its ordinal equivalent for some determinants of socioeconomic status and health variables using data of last national census in Iran. Segregation indices were computed for 31 socioeconomic variables and four health indices. RESULTS: All the provinces were in the category of low segregation for individual and family disability and death of at least one offspring of mother, but for infant mortality half of the provinces were moderately or highly segregated. For some of socioeconomic variables, many provinces were in the category of moderate, high, or extreme segregation. There was significant correlation between segregation of heath indices and some socioeconomic variables. CONCLUSIONS: Correlation of segregation of determinants of socioeconomic status with segregation of health indices is an indicator of existence of hot zones of health problems across some provinces. Further studies using multilevel modeling and individual data in health outcomes at individual level and segregation measures at appropriate geographic levels are required to confirm these relations.

Two-year follow-up study on neurodevelopmental outcomes after term intrapartum asphyxia using age and stages questionnaire.

Birth asphyxia is one of the multiple causes of neonatal encephalopathy. The objective of this study was to evaluate neurodevelopmental outcomes of newborn term infants with definitive asphyxia. Thirty infants met study criteria for asphyxia. The 5-year incidence of asphyxia was estimated to be 5.5 in 1000. According to the Age and Stage Questionnaire, 10.5% of 6-month-old infants, 14.3% of 12- and 18-month-old infants, and 5.3% of 24-month-old infants had neurodevelopmental delay in gross motor function in the absence of cerebral palsy. In 7.3% of 18-month-old infants, neurodevelopmental delay in problem-solving ability was observed. Higher values of Apgar score and bicarbonate levels were associated with higher Age and Stage Questionnaire total score. Delivery type, maternal age, gravidity of mother, and existence of mother disease during pregnancy were also associated with lower Age and Stage Questionnaire total score in different stages of life.