The mortality rate from self-harm in Iran.

BACKGROUND: Self-harm-related death is one of the most unfortunate, tragic, and regrettable types of death owing to injuries with a variety of socio-economic and cultural causes. The study aimed to determine the trend in the mortality of self-harm by sex and age at national and provincial levels in Iran over a period of 26 years. METHODS: The Iran Death Registration System (DRS), cemetery databanks in Tehran and Esfahan, and the national population and housing censuses of Iran were used for this study. Using a growth model, the population was estimated in the age groups. Incompleteness, misalignment, and misclassification in the DRS were all considered and addressed accordingly. We used a spatio-temporal and Gaussian process regression model to estimate mortality rates in children and adults. RESULTS: Over the study period, 67,670 deaths were estimated owing to self-harm across the country. The overall age-standardized mortality rate decreased from 4.32 per 100,000 (95% unit interface (UI): 3.25-5.75) to 2.78 (2.15-3.59) per 100,000 between 1990 and 2015, a reduction of approximately 35.65%. The M/F ratio was 2.03:1 with an annual percent change of -2.38% and -1.37% for women and men, respectively. The annual self-harm mortality rate was higher among individuals aged 15-24 years, as well as it was more in men during the study period. CONCLUSION: Mortality from self-harm has declined over the study period in Iran. Higher rates in men and in population aged 15-24 years, with considerable variation by province, were the distinguishing features of self-harm. Iran needs to improve monitoring through a comprehensive multisectoral strategy; and most importantly, provide timely, effective and low-cost preventive interventions.

Trend of fatal poisoning at national and provincial levels in Iran from 1990 to 2015.

OBJECTIVES: Comprehensive and up-to-date data on fatal injury trends are critical to identify challenges and plan priority setting. This study provides a comprehensive assessment of poisoning mortality trends across Iran. STUDY DESIGN: The data were gathered from various resources, including death registration systems, cemetery databases of Tehran and Esfahan, the Demographic and Health Survey of 2000, and three rounds of national population and housing censuses. METHODS: After addressing incompleteness for child and adult death data separately and using a spatio-temporal model and Gaussian process regression, the level and trend of child and adult mortality were estimated. For estimating cause-specific mortality, the cause fraction was calculated and applied to the level and trend of death. RESULTS: From 1990 to 2015, 40,586 deaths due to poisoning were estimated across the country. The poisoning-related age-standardized death rate per 100,000 was estimated to have changed from 3.08 (95% uncertainty interval [UI]: 2.32-4.11) in 1990 to 0.96 (95% UI: 0.73-1.25) in 2015, and the male/female ratio was 1.35 during 25 years of study with an annual percentage change of -5.4% and -4.0% for women and men, respectively. The annual mortality rate was higher among children younger than 5 years and the elderly population (≥70 years) in the study period. CONCLUSIONS: This study showed that mortality from poisoning declined in Iran over the period from 1990 to 2015 and varied by province. Understanding the reasons for the differences of poisoning mortality by province will help in developing and implementing measures to reduce this burden in Iran.

Social support and its association with depression, gender and socioeconomic indicators in individuals with spinal cord injury in Iran.

STUDY DESIGN: Descriptive cross-sectional study. OBJECTIVES: To investigate the relationship between perceived social support and depression and to evaluate the role of family, friends and other caregivers in the perception of social support in Iranian individuals with spinal cord injury (SCI). SETTING: Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran. METHODS: Social support was evaluated using the Multidimensional Scale of Perceived Social Support questionnaire, which gauges perceptions of support from family, friends and 'important persons'. The presence and severity of depression were assessed with the Beck Depression Inventory (BDI-II-PERSIAN)-a 21-item multiple-choice questionnaire. RESULTS: A total of 140 individuals with SCI were enrolled in the study. The average age of the participants was 29.4±7.9 years; the mean duration of injury was 46.3±46.5 months and most patients were male (72%). Social support and all subscales of social support were numerically greater in males; however, this difference was not statistically significant. The subcategory of friends' support in men was 17.9±7.9 compared to 14.6±8.0 in women (P=0.04). The self-reported social support score (r=-0.387, P<0.001) and subscales of social support, including family (r=-0.174, P=0.045), friends (r=-0.356, P<0.001) and important persons (r=-0.373, P<0.001), were all negatively correlated with depression. CONCLUSION: Higher self-reported perception of social support appears to be associated with lower levels of depression in individuals with SCI. SCI care providers should consider the relationship between social support and depression in their continuing care.

Association of pain, social support and socioeconomic indicators in patients with spinal cord injury in Iran.

STUDY DESIGN: Descriptive cross-sectional study. OBJECTIVES: Pain is a prevalent complication of individuals with spinal cord injury (SCI). Our objective was to examine the association between social support, socioeconomic factors and psychosocial factors and pain to develop more effective management strategies. SETTING: Brain and Spinal Cord Injury Research (BASIR) Center, Tehran University of Medical Sciences, Tehran, Iran. METHODS: The Persian version of the Brief Pain Inventory was used to measure the pain, and the Multidimensional Scale of Perceived Social Support was used to measure social support through structured face-to-face interviews in SCI individuals. RESULTS: The overall prevalence of pain was 50.7%; 79.3% of individuals had bilateral pain, with lower limbs and back being the most common location. The quality of pain was described as aching (41.4%), tingling (32.9%), pressure (15.7%), coldness (5.7%) and feeling electric shock sensations (4.3%). The frequency of pain in individuals with paraplegia (60.9% vs 45.7%) and incomplete (53.5% vs 52.5%) SCI was higher than with other types of neurological injuries. Patients with a medium level of education had the least pain and those with good economic situation reported higher frequency of having pain (P=0.034). There was no significant relationship between pain and social support. There was a positive correlation between pain and impairment of mood, normal work, relations with other people and lack of sleep (P<0.001). CONCLUSION: These novel findings will inform the development of strategies to manage pain by improving access to health-care facilities and supplies.

The relationship between anxiety, depression and religious coping strategies and erectile dysfunction in Iranian patients with spinal cord injury.

This corrects the article DOI: 10.1038/sc.2016.7.

Animal models of spinal cord injury: a systematic review.

STUDY DESIGN: PRISMA-guided systematic review. OBJECTIVES: To provide a comprehensive framework of the current animal models for investigating spinal cord injury (SCI) and categorize them based on the aims, patterns and levels of injury, and outcome measurements as well as animal species. SETTING: Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. METHODS: An electronic search of the Medline database for literature describing animal models of SCI was performed on 1 January 2016 using the following keywords: 'spinal cord injuries' and 'animal models'. The search retrieved 2870 articles. Reviews and non-original articles were excluded. Data extraction was independently performed by two reviewers. RESULTS: Among the 2209 included studies, testing the effects of drug's or growth factor's interventions was the most common aim (36.6%) followed by surveying pathophysiologic changes (30.2%). The most common spinal region involved was thoracic (81%). Contusion was the most common pattern of injury (41%) followed by transection (32.5%) and compression (19.4%). The most common species involved in animal models of SCI was the rat (72.4%). Two or more types of outcome assessments were used in the majority of the studies, and the most common assessment method was biological plus behavioral (50.8%). CONCLUSIONS: Prior to choosing an animal model, the objectives of the proposed study must precisely be defined. Contusion and compression models better simulate the biomechanics and neuropathology of human injury, whereas transection models are valuable to study anatomic regeneration. Rodents are the most common and probably best-suited species for preliminary SCI studies.

The relationship between anxiety, depression and religious coping strategies and erectile dysfunction in Iranian patients with spinal cord injury.

OBJECTIVES: To assess the role of anxiety, depressive mood and religious coping in erectile function among Iranian patients with spinal cord injury (SCI). SETTING: Brain and Spinal Cord Injury Repair Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. METHODS: A sample of N=93 men with SCI participated in this cross-sectional study. Levels of anxiety and depressive mood were assessed using the Hospital Anxiety and Depression Scale. Religious coping strategies were measured using the 14-items Brief Coping Questionnaire. Erectile function was assessed using the International Index of Erectile Function. The joint effect of anxiety, depressive mood and religious coping strategies on erectile function was assessed by performing stepwise multiple linear regression analyses. RESULTS: The mean age of the SCI patients was 37.8 years with a mean post-injury time of 4.6 years. Multivariate regression analyses indicated that age (B=-0.27, 95% CI=-0.47 to -0.07), education (B for higher education=0.63, 95% CI=0.24 to 1.02), the American Spinal Injury Association impairment scale (B for complete impairment=-3.36, 95% CI=-3.82 to -2.89), anxiety (B=-3.56, 95% CI=-5.76 to -1.42), positive religious coping (B=0.30, 95% CI=0.03 to 0.57), negative religious coping (B=-0.56, 95% CI=-0.82 to -0.29) and the duration of injury (B=-0.25, 95% CI=-0.22 to -0.29) were all independent factors influencing erectile function in SCI patients. CONCLUSION: Overall, the results indicated that SCI patients who use positive religious coping strategies had better erectile function compared with individuals who applied negative religious coping strategies. Furthermore, higher levels of anxiety, greater impairment and longer duration of injury turned out to be risk factors for erectile dysfunction.

Potential variables affecting the quality of animal studies regarding pathophysiology of traumatic spinal cord injuries.

STUDY DESIGN: This is a Delphi study. OBJECTIVES: Defining variables that potentially influence the outcomes of an animal study regarding pathophysiology of traumatic spinal cord injury (TSCI). SETTING: This study was conducted in Iran. METHODS: A modified two-round Delphi study was conducted. As the first round, an initial questionnaire was developed on the basis of literature and a series of focus group discussions. In the second round, the participants were asked to score the items through a 10-point scale. Consensus was achieved through the following criteria: (1) the median of scores has to be at 7.5 or higher, and (2) at least 70% of participants need to rate 7 or higher. Also, the inter-rater reliability analysis was performed to determine consistency among raters using the Kappa coefficient and Cronbach's alpha. RESULTS: Twenty-one experts participated in our study. From the first round of the study, a 47-item checklist was developed. By considering the aforementioned criteria for consensus building on extremely important factors, we reached a 15-item checklist including species, strain, method and level of injury, control group, genetic background, severity of injury, attrition, use of appropriate test, blindness, method of allocation to treatments, regulation and ethics, age/weight, bladder expression, number of animals/group and statistics. The inter-rater reliability for the raters was found to be Kappa=0.82 (P<0.001). A Cronbach's alpha of 0.9 for all the questions indicated high internal consistency. CONCLUSION: This study introduces a checklist of variables that potentially influence the outcomes of animal studies regarding TSCI pathophysiology and describe its validity and reliability.

Factors associated with the development of pressure ulcers after spinal cord injury.

STUDY DESIGN: Cross-sectional observational study. OBJECTIVES: To examine variables associated with the development of pressure ulcers in subjects with spinal cord injury (SCI). SETTING: SCI patients under coverage of the State Welfare Organization of Iran. METHODS: Mobile rehabilitation teams gathered data from 20 of the 30 provinces in Iran. There were 8104 SCI patients registered in the database; 7489 patients were included in the analysis. The prevalence of PU in patients aged <10 years was lower than those aged >10; therefore, we used different logistic models for these groups. Likewise, separate models were created for patients who had experienced SCI during the past year versus patients injured >1 year before the evaluation. RESULTS: PU was present in 34.6% of the patients. The variables associated with PU in patients aged <10 years were female gender and the time passed since SCI. In patients aged >11 years, male gender, the time passed since SCI, lower level of education, lack of an intimate partner, quadriplegia and older age presented a significant association with PU. Patients for whom <1 year has passed since SCI, male gender, quadriplegia and older age were associated with PU. And patients for whom >1 year had passed since SCI, male gender, quadriplegia, older age, lower level of education and lack of an intimate partner were associated with PU. CONCLUSION: SCI patients are a heterogeneous group and the risk factors associated with PU may vary in specific subgroups. Different models are needed to describe PU in SCI patients depending on the patient's age and the time passed since SCI.

Epidemiology of injuries and poisonings in emergency departments in Iran.

OBJECTIVES: There are few reports on epidemiological patterns of injury and injury-related mortality in developing countries. This study aimed to report the epidemiology of injuries and poisonings in emergency departments in Iran. STUDY DESIGN: Retrospective study using available data from 20 March 2005 to 19 March 2008. METHODS: Recorded Injury Surveillance System (ISS) data including demographics, place of residence, type of injury, and outcome during emergency department stay were extracted from the databank of the national ISS and included in the final analysis. RESULTS: In total, 2,991,624 emergency department admissions due to injury were recorded at university hospitals during the study period. According to the national census in 2006, Iran had a population of 70,472,846, so the injury admission rate to university hospital emergency departments was 1.4%/year in Iran. The mean age of the patients was 26.5 [standard deviation (SD) 16.9] years, and 72.7% of the cases were male. The most common cause of injury was road traffic accidents (RTAs) (31.9%), followed by hit (25.5%) and falls (10.9%). Intoxication was associated with 5.3% of all injuries. The overall emergency department mortality rate was 0.6%. Of those who died, the mean age was 32.6 (SD 21.1) years. All fatal injuries, except burn injuries, were more common in males. Intoxication-related deaths occurred in 3.8% of cases. In patients aged <13, 13-65 and >65 years, hit (28.2%), RTAs (34%) and RTAs (27.9%) were, respectively, the most common causes of injury. In all age groups, RTAs were the most common cause of death. CONCLUSIONS: This study determined the epidemiology of injuries and poisonings in emergency departments in Iran. The mortality rate in this study was low in comparison with other research, which may be explained in the context of inappropriate prehospital or interhospital care in Iran. This finding can be employed to formulate targeted preventive strategies based on the incidence of the more common types of injury.

Burden of spinal cord injury in Tehran, Iran.

STUDY DESIGN: Investigation of burden of traumatic spinal cord injury (SCI) using disease modeling. OBJECTIVES: The present paper is intended to estimate the SCI burden for the year 2008. SETTING: Tehran, capital of Iran. METHODS: Epidemiological data needed to calculate Disability-Adjusted Life-Years (DALYs) for SCI, was estimated according to prevalence, duration and relative risk of mortality using DISMOD software. For DALY calculation, the years of life lost because of premature mortality (YLL) was added to the number of years lost because of disability (YLD). To calculate DALYs for SCI, first year DALY calculated separately and for the next years, the DALY was assessed for six different clinical presentations of traumatic SCI including quadriplegia, quadriparesis, paraplegia, paraparesis, hemiplegia and hemiparesis. RESULTS: In first year following SCI, the DALY was 3772 years, which has 0.5 DALY per 1000 people and YLL/DALY was 89.3%. Following the first year, the DALY was 435 for quadriplegia, 163 for quadriparesis, 868 for paraplegia, 164 for paraparesis, 26 for hemiplegia and 14 for hemiparesis. The total YLL for traumatic SCI was 4077 years and total YLD was 1364 years (total YLL/DALY was 74.9%) and total DALY was 5441 years, (M/F=2.0), which has 0.7 DALY per 1000 people in Tehran in 2008. CONCLUSIONS: This study showed a high burden for SCI. Identifying the risk factors of SCI, and performing cost-effective preventive interventions for reducing burden of SCI is recommended.

Controlled evaluation of injury in an international Safe Community: Kashmar, Iran.

OBJECTIVES: To determine the degree to which the Safe Community (SC) model is effective in reducing injuries. Although positive results have been reported for some communities in developed countries, there is no consistent relationship between being an international designated SC and subsequent changes in observed rate of injury, and no controlled studies have examined the effectiveness of the SC model in developing countries. The aim of this study was to evaluate and compare the injuries in the SC programme of Kashmar (population 149,358) with injuries in counties in Iran that have not applied the SC model. STUDY DESIGN: Retrospective study using available data from 20 March 2005 to 19 March 2008. METHODS: Data were obtained from the Injury Prevention and Safety Promotion Department of the Disaster and Emergency Management Centre of the Ministry of Health and Medical Education of Iran. These data are collected upon presentation of injured patients to the emergency room. Different types of injuries are evaluated, including motor vehicle injuries (including pedestrians, passengers, drivers and motorcyclists), falls, blows by an object or a person, violence, burns, scorpion and snake bites, electrocution, animal attack, toxicity, suicide and other causes. A control group was selected from all counties in Iran with a population between 100,000 and 200,000. The mean injury rate of these counties was calculated, and counties which had an injury rate within one standard deviation (SD) of the mean rate for all 3 years of the study were included in the control group (n=44 counties). RESULTS: The mean population of the 44 control counties was 142,123 in 2006. The numbers of injuries per 100,000 population in Kashmar were 4654.6 [95% confidence interval (CI) 4584.3-4762.6], 4570.9 (95% CI 4465.5-4678.0) and 4949.2 (95% CI 4839.7-5060.4) in 2005-2006, 2006-2007 and 2007-2008, respectively. At the same time, the mean numbers of injuries per 100,000 population in the 44 control counties were 822.7 (95% CI 815.6-829.8), 1130.0 (95% CI 1121.7-1138.3) and 1245.5 (95% CI 1236.8-1254.2). The injury-related fatality rate in the emergency room was 57.6, 52.9 and 44.2 per 100,000 population in Kashmar and 12.2, 13.0 and 11.9 per 100,000 population in the control counties in the three study years. Although a comparison of the fatality rate between the first and third years of the study shows a decrease of 13.4 per 100,000 population in Kashmar, this was not significant (P=0.1056). In the 44 control counties, the injury-related fatality rate decreased by 0.3 per 100,000 population between the first and third years of the study. The difference between the decrease in injury-related fatality rate in Kashmar (13.4 per 100,000 population) and the 44 control counties (0.3 per 100,000 population) was significant (P<0.0001). CONCLUSION: The controlled evaluation of injury in the international SC of Kashmar showed an increase in the number and rate of injuries in Kashmar and in the 44 control counties over 3 years, but the injury-related fatality rate decreased over the same time period. A greater decrease was seen in Kashmar than in the control counties. Long-term evaluation is necessary to confirm these results.

Analysis of trauma outcome at a university hospital in Zahedan, Iran using the TRISS method.

OBJECTIVE: To evaluate validity of TRISS (Trauma score and injury severity score) method in trauma outcome analysis and compare trauma care at a university hospital, with the standards reported in the Major Trauma Outcome Study (MTOS). DESIGN: Analytical and descriptive study. SETTING: Khatam-ol-anbia University Hospital in Zahedan, Iran, from March 22, 1997 to March 21, 1998. SUBJECTS: Seven hundred and sixty eight consecutive patients with multiple trauma were included in the study. Survival analysis was completed for all of the patients. RESULTS: The majority of patients were men (82%), and the average age was 23 years. Seven hundred and one patients (91%) sustained blunt trauma, with road traffic accidents being the most common (59%). The predicted mortality was 3.1% and the observed mortality was 8%. The M-statistics was 0.91. CONCLUSION: In developing countries the same as developed countries, the TRISS methodology is an acceptable method for evaluation of the difference between predicted and observed mortality. This study shows that our mortality is significantly more than universal standards and there are weak points in our trauma care system.