The Economic Burden of Malignant Brain Tumors.

Malignant brain tumors consist of primary malignant tumors and metastatic brain tumors. The global incidence and prevalence of CNS cancers are increasing, their mortality and morbidity are relatively higher than other cancers (e.g., bladder cancer), and the management of disease utilizes sophisticated and expensive diagnostic and therapeutic technology. Therefore, malignant brain tumors, both primary and metastatic, impose a significant economic burden on patients, their families, and healthcare systems all around the world. To the best of our knowledge, there is no comprehensive and global systematic review for examining the costs of brain tumors, though sporadic reports highlight the importance of the problem. Besides, each study takes place in a setting with different methods (e.g., different treatment methods) and costs to manage brain tumors; therefore, we are unable to compare the costs between countries. Nevertheless, the general patterns seem to suggest that, among all, gliomas and glioblastomas are the most financially burdensome types of malignant brain cancer. Finally, most of the available studies have examined the economic burden of all gliomas or only glioblastoma. Hence, we are left with a substantial gap in knowledge to understand the actual economic burden of metastatic brain tumors, and there is a need for further accurate and internationally comparable studies on the subject, particularly with a focus on indirect and intangible costs.

Burden of multiple sclerosis in Iran from 1990 to 2017.

BACKGROUND: Multiple Sclerosis (MS) is a burdensome, chronic and autoimmune disease of the central nervous system. We aimed to report the incidence, prevalence, mortality, and Disability Adjusted Life Years (DALYs) of MS in Iran at a national level for different age and sex groups over a period of 28 years (1990-2017). METHODS: Data were extracted from the Global Burden of Disease study (GBD) from 1990 to 2017, published by the Institute for Health Metrics and Evaluation. The incidence of DALYs and prevalence of MS were estimated to report the burden of MS based on sex and age in Iran from 1990 to 2017. RESULTS: At the national level, the Age-Standardized Incidence Rate (ASIR), Age-Standardized Prevalence Rate (ASPR), Age-Standardized DALYs Rate (ASDR) and the Age-Standardized Mortality Rate (ASMR) in Iran in 2017 were 2.4 (95% Uncertainty Interval [UI]: 2.1 to 2.7), 69.5 (62.1 to 77.8), 29.1 (23.6 to 34.7), and 0.4 (0.3 to 0.4) per 100,000 population, respectively. During the period of 1990 to 2017, all measures increased, and were higher among females. The incidence rate began upward trend at the age of 20 and attained its highest level at the age of 25. CONCLUSION: In Iran, all of the age-standardized MS rates have been increasing during the 28 years from 1990 to 2017. Our findings can help policy makers and health planners to design and communicate their plans and to have a better resource allocation, depending on the incidence and prevalence of the growing numbers of MS patients in Iran.

The level and trend of road traffic injuries attributable mortality rate in Iran, 1990-2015: a story of successful regulations and a roadmap to design future policies.

BACKGROUND: Road-Traffic-Injuries (RTIs) are predicted to rise up to the fifth leading cause of worldwide death by 2030 and Iran has the third highest RTIs mortality among higher-middle income countries. Although the high mortality of RTI in Iran is a warning, it provides the opportunity to indirectly assess the implemented RTI-related regulations' effectiveness via high-resolution relevant statistics and, hence, Iran could serve as a guide for countries with similar context. In order to do so, we utilized this study to report the time and spatial trends of RTIs-related mortality in different age and sex groups and road user classes in Iran. METHODS: Based on the national death-registration-system (DRS), cemeteries data, and the demographic characteristics, and after addressing incompleteness, we estimated mortality rates using spatiotemporal and Gaussian process regression models. We assessed Pearson seatbelt and helmet use and RTIs-attributable Age-Standardized-Morality-Rate (ASMR) associations. We also predicted RTIs-death-numbers, 2012-2020, by fitting a Generalized Additive Model to assess the status of achieving relevant sustainable development goal (SDG), namely reducing the number of RTIs-related deaths by half. RESULTS: Overall RTIs-attributable death and ASMR at the national level increased from 12.64 [95% UI, 9.52-16.86] to 29.1 [22.76-37.14] per 100,000 people in the time period of 1990-2015. The trend consisted of an increasing segment in 1990-2003 followed by a decreasing part till 2015. The highest percentage of death belonged to the three-or-more-wheels motorized vehicles. Pedestrian injuries percentage increased significantly and the highest mortality rate occurred in 85 years and older individuals. Low prevalence of seatbelt and helmet use were observed in provinces with higher than the median ASMR due to the relevant cause of each. RTIs-attributable death number is expected to reduce by 15.99% till 2020 which is lower than the established SDG goal. CONCLUSIONS: Despite the observed substantial moderation in the RTI-ASMR, Iran is till among the leading countries in terms of the highest mortality rates in the world. The enforced regulations including speed limitations (particularly for elder pedestrians) and mandatory use of seatbelt and helmet (for young adult and male drivers) had a considerable effect on ASMR, nevertheless, the RTI burden reduction needs to be sustained and enhanced.

The Epidemiologic Aspects of COVID-19 Outbreak: Spreading Beyond Expectations.

The coronavirus disease 2019 (COVID-19) outbreak started in late 2019 in Wuhan, Hubei Province of China, and quickly spread to the surrounding regions and neighboring countries. A novel coronavirus, the so-called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was found to be responsible for this outbreak potentially originating from pangolins. In China, the outbreak lasted for 1 month until it seemed to be controlled after affecting over 81,000 individuals and causing deaths in over 4200 patients. Subsequently, and after affecting over 118,000 individuals and causing over 4200 deaths, the condition was officially announced as a pandemic by the World Health Organization (WHO). In the meantime, the epidemic curve took a downtrend in China, the original epicenter of the pandemic, but started to rise in other countries with a steep slope. Among over 215 affected countries, the USA, European countries (Italy, Germany, Spain, France, the UK), Iran, and South Korea had the highest frequencies in the matters of infected patients and deaths. Importantly, different countries took different policies when encountered with an outbreak, especially in the matter of accuracy of the report and timing of the action. A part of the delays in reporting was expected, including the lag in the chain of reporting, the shortcomings of tests, missed patients, and inadequate testing facilities. However, there were also political and nontechnical reasons that caused the reporting to be inaccurate. Surveillance seems to be less of a reason for the observed in poor management, and it mostly originated from human decision-making failures and political issues. Besides, the culture of populations and their trust in their governments played an important role on how they reacted to the COVID-19 pandemic and acquired policies. Finally, the characteristics of the world today indicate the danger of probable upcoming outbreaks, and policymakers should utilize the existing opportunities, particularly the advancements in technology and media, to prevent or adequately manage them.

Structural white matter alterations as compensatory mechanisms in Parkinson's disease: A systematic review of diffusion tensor imaging studies.

Compensation is described as normal or near to normal performance in Parkinson's disease (PD), despite the ongoing neural loss. Functional compensation typically proceeds in an inverse U-shaped manner: compensation initiates in the prodromal phase, followed by an increasing episode until plateauing and diminishes in the advanced stages of the disease. The first evidence of the structural compensation was reported by functional magnetic resonance imaging studies. Recent studies, which have used diffusion tensor imaging (DTI) as the basis for their investigation, have shown improved white matter diffusional properties both in motor- and non-motor-related structures in association with improved clinical scores in patients with PD. The majority of DTI studies have demonstrated microstructural compensation in the prodromal/early stages of PD at the regional scale. However, there have been reports of compensation in later stages of the disease and the whole-brain/network scale that are probably due to the heterogeneous nature of PD. Although serving as a promising beginning to characterize compensation, lots remain to be clarified in understanding the underlying mechanisms of compensation and its structural pattern in PD. The existing knowledge gap necessitates studies that their main research questions are focused on structural compensation. This requirement becomes more apparent because structural compensation evidence has mostly emerged from the post hoc analysis of data and incidental findings of studies. Thus, future studies are required to investigate compensatory microstructural changes in PD to clarify the exact underlying mechanisms. These studies would also provide a basis to develop clinical improvements in the early diagnosis and management of PD.

Estimated cut-off values for pemphigus severity classification according to pemphigus disease area index (PDAI), autoimmune bullous skin disorder intensity score (ABSIS), and anti-desmoglein 1 autoantibodies.

BACKGROUND: Pemphigus is a potentially fatal disease if left untreated. Valid scoring systems and defined cut-off values for classification of patients would help with better management through specified pharmaceutical and non-pharmaceutical treatments. METHODS: In this study, pemphigus patients who were receiving immunosuppressive treatments and had recent disease relapse were recruited for examination of pemphigus disease area index(PDAI), autoimmune bullous skin disorder intensity score (ABSIS), physician global assessment (PGA), autoimmune bullous disease quality of life (ABQoL), anti-desmoglein 1 (anti-Dsg1), and anti-Dsg3 autoantibody titers from December-2017 to February-2018. Cut-off values were estimated using model-based clustering classification and the 25th and 75th percentiles approach, performed separately for the exclusive cutaneous, exclusive mucosal, and mucocutaneous groups. RESULTS: In the 109 included patients, the 25th and 75th percentiles cut-offs were 6.2 and 27 for PDAI score, and 4 and 29.5 for ABSIS score. The model-based analysis resulted in two groups (cut-point:15) for PDAI score, and three groups (cut-points:6.4 and 31.5) for ABSIS score. The groups were significantly different for the PDAI, ABSIS, PGA, and ABQoL values. Based on anti-Dsg1 autoantibody values, the model-based analysis cut-point was 128 and the 25th and 75th percentiles cut-offs were 98 and 182. Anti-Dsg3 autoantibody values did not differentiate between pemphigus severity classes. CONCLUSIONS: Estimated cut-off values based on the anti-Dsg1 level, PDAI, and ABSIS scoring systems could be used to classify patients into different severity grades for better management and prognosis.

Physical activity profile of the Iranian population: STEPS survey, 2016.

BACKGROUND: Insufficient physical activity (IPA) is one of the leading causes of premature mortality through the increased burden of non-communicable diseases. From 1990 to 2017, the percentage of low physical activity attributable disability-adjusted life years (DALY) increased globally by 1.5 times and 2-fold in Iran, causing more than 1.2 million deaths worldwide and 18,000 deaths in Iran in 2017. Reports suggest that Iran, a developing middle-income country, suffers from a high level of IPA. Socioeconomic and cultural alterations along with the country's developments expose the population to IPA risk. We aimed to describe IPA prevalence in Iran's adult population, categorized by demographics, geographical region, and activity domains to assess the present pattern of physical inactivity and its domains in the country. METHODS: In 2016, in order to represent Iran's adult population, adult participants (n: 30541) from 30 provinces were selected using systematic proportional to size cluster sampling. Physical activity (PA) was assessed via the Global Physical Activity Questionnaire, calculating the Metabolic Equivalent of Task (MET) value in minutes per week for work, recreation, and transport domains. Insufficient physical activity (IPA) was defined according to WHO's recommendation (less than 600 METs per week). Adjusted odds ratios of IPA associates for sociodemographic, lifestyle related variables, and metabolic risk factors were reported. RESULTS: A high prevalence of IPA was seen in the total population (54.7%, 95%CI: 54.0-55.3) with a considerable difference between the two genders (males: 45.3% (95%CI: 44.3-46.3); females: 61.9% (95%CI: 61.0-62.7)). Work-related activity was the domain with the greatest percentage of total PA, whereas, both genders lacked recreational activities. In our findings, being female, a housekeeper, younger and living in urban areas were significantly associated with higher levels of IPA. Moreover, insufficient fruit and vegetable consumption, lack of alcohol consumption, having a personal vehicle, and finally, having a medical history of diabetes were significantly associated with the presence of IPA in our population. Among the study population, 33.6% (95%CI: 33.0-34.2) had at least 4 h of sedentary behavior in a typical day. CONCLUSIONS: Widespread IPA among the Iranian adult population is of major concern. In our findings, we observed a considerable gap in the prevalence and pattern of IPA between the two genders. Additionally, IPA was associated with living in urban areas, unhealthy lifestyle habits and a history of other metabolic risk factors. Thus, a prompt initiative for population-specific actions should be taken.

Validation of the self-reported diagnosis of diabetes mellitus, hypercholesterolemia, and hypertension in Iran; STEPS 2016.

Purpose: As a part of STEPwise approach to risk factor Surveillance (STEPS) study, our aim was to evaluate the validity of the self-reported diagnosis of diabetes (DM), hypertension (HTN), and hypercholesterolemia (Hyper-Chol) in the Iranian population. Methods: Using systematic proportional to size cluster sampling, 27,232 participants were included in our study. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to assess the validity of self-reported diagnoses. Furthermore, logistic regression was employed to examine the relationship between the validity of self-reported diagnoses and sociodemographic and lifestyle factors. All analyses were performed using STATA version 14. Results: The PPV for self-report of DM, HTN, and Hyper-Chol were estimated to be 69%, 74% and 80%, and NPV measured up to 95%, 84%, and 50%, respectively. Positive/negative self-reports were more accurate among older (younger) individuals. Age had a negative correlation with the validity of self-reported Hyper-Chol but a positive correlation with the validity of self-reported DM and hypertension HTN. Additionally, an increase in BMI was associated with an increase/decrease in PPV and a decrease/increase in NPV across all diseases. Conclusion: Self-report studies hold value in situations where direct in-person interaction is not feasible, either due to prohibitive costs or restrictions imposed by infectious diseases (COVID-19). Self-report surveys are valuable tools in studying the epidemiology of diseases; however, the type of the disease, the study purpose, either finding sick people or healthy people, the age subgroups, and socioeconomic status should be taken into consideration.

The Duke University Religion Index (DUREL): validation and reliability of the Farsi version.

This study examined the validation and reliability of the Farsi version of the Duke University Religion Index (FDUREL), a brief measure designed to evaluate the primary dimensions of religiosity. The study was conducted in two phases. In the first phase, after translation of the original version of DUREL by using standard forward-backward translation, the FDUREL was administered to 427 medical students at different training levels. Reliability of the FDUREL was assessed by internal consistency and test-retest reliability. Principal components factor analysis was employed to assess the construct validity of the measure. In the second phase, 557 medical students were asked to fill out the FDUREL and Hoge Intrinsic Religiosity Scale to examine concurrent validity. The FDUREL was unidimensional and had good internal consistency and test-retest reliability. Results suggest that the FDUREL is a reliable and valid measure of religiosity in Farsi-speaking populations.

The incremental cost of implementing the world health organization Package of essential non-communicable (PEN) diseases interventions in Iran.

World-Health-Organization's PEN package proposes a minimum set of cost-effective interventions for early diagnosis and management of Non-Communicable-Disease (NCD). IraPEN (the PEN package implemented in Iran), adopted from PEN and Iran National Action Plans for NCDs, addresses challenges regarding NCD prevention and control. IraPEN was piloted in four districts of Iran. In this research, we estimate incremental per-capita cost of IraPEN program implementation in two of the pilot districts. We utilized a bottom-up, ingredient-based costing approach. Institutional expenditure data was collected via information forms. Information pertaining to personnel costs was gathered by performing task time measurements using Direct Observation Method. An individual-level survey was conducted in under-study districts to determine program coverage and its users' demographic information via systematic random cluster sampling. Sampling of districts was based on systematic random cluster sampling. In each district, 250 families in 25 clusters proportional to urban or rural populations were randomly selected by postal codes. All family members eligible for the program were interviewed. Interviews were organized and conducted in each district by NCD experts in provincial Universities of Medical Sciences. Costs were re-categorized into fixed and variable costs based on their dependency on the program's coverage. Fixed and variable costs were, respectively, divided by total eligible populations and covered populations in each district to calculate cost per-capita for each protocol. Total per-capita cost per-service was then calculated for each protocol and whole program by adding these figures. All costs are reported in US$ 2015-2016. The incremental costs of IraPEN implementation per user, with and without introduction cost, were US$24.90 and US$25.32, respectively. Total incremental cost per-capita for each protocol ranged between US$1.05 to US$7.45. The human resources and supplies had the highest contribution in total program cost (74.97% and 15.76%, respectively). The present study shows that IraPEN program implementation to be a high-cost package within Iranian context, that necessitates cautions in other similar contexts for implementation. It is, however, difficult to make decisions on implementation of NCD prevention and control programs purely based on their cost. Informed decision making requires assessment of a programs' effectiveness and justifications and alterations to the current package could reduce the costs, leading to increased efficiency of the program.

Quality and cost of healthcare services in patients with diabetes in Iran: Results of a nationwide short-term longitudinal survey.

Aims: To investigate the journey of patients with diabetes in the healthcare system using nationally-representative patient-reported data. Methods: Participants were recruited using a machine-learning-based sampling method based on healthcare structures and medical outcome data and were followed up for three months. We assessed the resource utilization, direct/indirect costs, and quality of healthcare services. Results: One hundred fifty-eight patients with diabetes participated. The most utilized services were medication purchases (276 times monthly) and outpatient visits (231 times monthly). During the previous year, 90% of respondents had a laboratory fasting blood glucose assessment; however, less than 70% reported a quarterly follow-up physician visit. Only 43% had been asked about any hypoglycemia episodes by their physician. Less than 45% of respondents had been trained for hypoglycemia self-management. The annual average health-related direct cost of a patient with diabetes was 769 USD. The average out-of-pocket share of direct costs was 601 USD (78.15%). Medication purchases, inpatient services, and outpatient services summed up 79.77% of direct costs with a mean of 613 USD. Conclusion: Healthcare services focused solely on glycemic control and the continuity of services for diabetes control was insufficient. Medication purchases, and inpatient and outpatient services imposed the most out-of-pocket costs.

Patient experience with chronic obstructive pulmonary disease: a nationally representative demonstration study on quality and cost of healthcare services.

Introduction: Due to insufficient data on patient experience with healthcare system among patients with chronic obstructive pulmonary disease (COPD), particularly in developing countries, this study attempted to investigate the journey of patients with COPD in the healthcare system using nationally representative data in Iran. Methods: This nationally representative demonstration study was conducted from 2016 to 2018 using a novel machine-learning based sampling method based on different districts' healthcare structures and outcome data. Pulmonologists confirmed eligible participants and nurses recruited and followed them up for 3 months/in 4 visits. Utilization of various healthcare services, direct and indirect costs (including non-health, absenteeism, loss of productivity, and time waste), and quality of healthcare services (using quality indicators) were assessed. Results: This study constituted of a final sample of 235 patients with COPD, among whom 154 (65.5%) were male. Pharmacy and outpatient services were mostly utilized healthcare services, however, participants utilized outpatient services less than four times a year. The annual average direct cost of a patient with COPD was 1,605.5 USDs. Some 855, 359, 2,680, and 933 USDs were imposed annually on patients with COPD due to non-medical costs, absenteeism, loss of productivity, and time waste, respectively. Based on the quality indicators assessed during the study, the focus of healthcare providers has been the management of the acute phases of COPD as the blood oxygen levels of more than 80% of participants were documented by pulse oximetry devices. However, chronic phase management was mainly missed as less than a third of participants were referred to smoking and tobacco quit centers and got vaccinated. In addition, less than 10% of participants were considered for rehabilitation services, and only 2% completed four-session rehabilitation services. Conclusion: COPD services have focused on inpatient care, where patients experience exacerbation of the condition. Upon discharge, patients do not receive appropriate follow-up services targeting on preventive care for optimal controlling of pulmonary function and preventing exacerbation.

Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes.

BACKGROUND: Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran. METHODS: We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication. RESULTS: Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits. CONCLUSION: The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.

Prevalence of Diabetes and Prediabetes, and Achievements in Diabetes Control in Iran; The Results of the STEPS of 2016.

BACKGROUND: Using the WHO STEPwise approach to NCD risk factor surveillance (STEPS), first round of Iran's STEPS completed in 2005. It has been repeated six times afterward. Here we report the results of 2016 round on the population characteristics and prevalence of diabetes and prediabetes, along with an assessment of the country-level performance on diabetes care in Iran. METHODS: Using a proportional-to-size cluster random sampling method, the STEPS 2016 included 18947 subjects aged≥25 years who matched the criteria (non-missing information on diabetes self-report, and biomarkers). For the analyses, survey design methods with weighted samples were employed. Different definitions of diabetes (biomarker-based, self-report, anti-diabetes medication use, or a combination) and prediabetes (different cutpoints of the biomarker) were calculated and presented. RESULTS: An estimated 5171035 persons aged≥25 years or 10.6% (95% CI: 10.0%-11.1%) had diabetes according to the serologic diagnosis of diabetes (FPG≥126 mg/dL) or the use of at least one anti-diabetes medication (1896 out of 18947). Employing the serologic diagnosis of diabetes among those who responded no to the self-reported question, 2.7% (2.5%-3.0%) of the population were not aware of their diabetes compared to 11.5% (10.9%-12.0%) who were diabetics according to the just self-reported question. Defining prediabetes as 100≤FPG<126 mg/dL or 5.7≤HbA1c<6.5%, an estimated 15244299 persons had prediabetes (5885 out of 18947). Overall, 52.1% (49.4%-54.7%) of patients with self-reported diabetes were under strict glycemic control (HbA1c<7%). Poor diabetes control (HbA1c>9%) was found in 18.4% (16.3%-20.6%) of the patients with self-reported diabetes. CONCLUSION: Since 2005, the prevalence of diabetes in Iran has been on a gradual increase in both genders with an increasing gap between females and males.

Level and trend of total plasma cholesterol in national and subnational of Iran: a systematic review and age-spatio-temporal analysis from 1990 to 2016.

Purpose: We aimed to estimate the level and trend of plasma cholesterol and raised total cholesterol (TC > 200 mg/dl) prevalence at national and subnational level of Iran. Methods: Nine national surveys and 27 studies, encompassing 3,505 unique points on over 500,000 adults, aged > 25 years with a report of laboratory measurement of TC were found. Age-spatio-temporal model and Gaussian Process Regression were used to estimate mean TC for each sex, 5-year age groups, and 31 provinces from 1990 to 2016. Results: At national level, age-standardized prevalence of TC > 200 mg/dL has decreased from 57·2%(53·3-61·1) to 22·4%(20·5-24·3) in women and 53·2%(49·1-57·3) to 18·0%(16·4-19·6) in men. TC distribution presented a condensation between 170-200 mg/dL. At subnational level, decreasing and converging patterns of raised TC prevalence were detected. Conclusion: The decrease in raised TC is likely the result of statin widespread use, food industry improvements, and the expanded primary health care. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-022-01052-w.

Prevalence and incidence of multiple sclerosis in Ardabil, Northwest of Iran.

BACKGROUND: Multiple sclerosis (MS) epidemiology is studies in many populations; however, studying populations with unique characteristics could provide opportunities to deepen the understanding of the underlying reason of the disease. In this regard, we aimed to study the epidemiology of MS in Ardabil, a province in northwest Iran, where the majority are of Iranian Azerbaijanis. METHOD: A retrospective population-based study was conducted from 2008 to 2018 in Ardabil, based on the data of Iran's Ministry Of Health. Collected information includes sex, age, age at disease onset, education and type of MS. We used t-test to compare means and chi-square test to analyze the association among variables. RESULTS: The total number of patients was 760 with 533 (70.13%) females and 227 (29.87%) males. The crude prevalence was 59.37 per 100,000 in 2018 (95% CI: 55.31, 63.73). The crude incidence rate was 7.65 per 100,000 in 2018 (95% CI: 6.28, 9.32). The most frequent educational level was high school diploma (38.36%). The relapsing-remitting (RR) form was the most frequent type of MS (48.16%). The F/M ratio was 2.92:1 and the mean onset age was 33.14 (95% CI: 31.56, 34.72) in 2018, significantly higher in males (P value= 0.01). CONCLUSION: Ardabil is a medium risk zone of MS. The different ethnicity of its population, climate and environmental features, may explain the factors modulating the risk of MS in similar areas and present windows of opportunity to understand the causes of MS.

White matter microstructural abnormalities in primary insomnia: A systematic review of diffusion tensor imaging studies.

Primary insomnia (PI), the most common sleep disorder, is primarily characterized by difficulties in initiating and maintaining sleep and deficits in daytime functioning. Study of white matter (WM) connections of the brain might provide valuable information regarding the underlying neural mechanism of PI. Diffusion tensor imaging (DTI) provides non-invasive access to the microstructural and network properties of brain WM, and thus, a great opportunity to quantitatively and sensitively study the human brain. The current literature of PI does not provide a consistent explanation of the etiology and pathology of the disorder; thus, we searched PubMed, EMBASE, and SCOPUS for DTI studies that compared WM integrity or network organization between PI patients and healthy controls to integrate all existing literature as an insight for further studies, and, hopefully, effective prevention and management of the disorder. English peer-reviewed full-text publications that investigated the diffusion indices of PI patients or those with insomnia symptoms compared with a group of healthy controls were included. We included 11 studies and extracted the data for qualitative synthesis. Except for one study, all studies were rated as high-quality, based on quality assessment. In aggregation, a total of 541 patients with PI and 679 healthy controls were included in this study. Our review of DTI studies suggests that WM disruptions in PI are better characterized in the context of neural networks. Frontostriatal, frontothalamic, and corticocortiscal networks, as well as the limbic system, seem to be the main neural networks with microstructural and network alterations in patients with PI. To illustrate, different parts of corona radiate and internal capsule within the corticosubcortical networks and superior longitudinal fasciculus within the corticocortical networks showed altered microstructural properties in PI patients. In view of the fact that the findings from individual studies are heterogeneous, it is difficult to derive consistent findings from the results, and the divergence of the findings must not be disregarded. Thus, this study is a starting point for future studies, and its implications for etiology and pathogenesis of insomnia should be regarded cautiously.

Levels and Trends of BMI, Obesity, and Overweight at National and Sub-national Levels in Iran from 1990 to 2016; A Comprehensive Pooled Analysis of Half a Million Individuals.

BACKGROUND: In developing countries like Iran, the burden of obesity increases through comorbid diseases. We estimated the mean body mass index (BMI) and prevalence of overweight/obesity by components of sex, age, province, and year in Iran from 1990 to 2016. METHODS: Through a comprehensive systematic review, all relevant data sources pooled results with individual level national and sub-national population-based studies. Two stages of age-spatio-temporal modeling and Gaussian process regression were used to estimate mean BMI, followed by estimation of obesity and overweight prevalence through the crosswalk modeling. RESULTS: In 2016, the age-standardized mean BMI was 27.9 (27.2-28.7) kg/m² in women and 25.9 (25.2-26.5) kg/m² in men. At the same time, the prevalence rates of overweight and obesity were 71.7% (67.9-75.8), and 36.8% (34.1-39.7) in females, and 57.1% (53.7-60.6), and 18.4% (16.9-20) in men. This shows a considerable increase from 1990 when the figures were respectively 24.4 (23.3-25.5) , 36.6% (32.2-41.5), and 8.2% (95% UI: 6.9-9.7) in women, and 23.5 (22.5-24.5), 30% (26.4-34), and 4.7% (4.0-5.5) in men, with 66% attributed to population growth. CONCLUSION: Considering the increasing trends of BMI, Sustainable Development Goals (SDGs) seem far out of reach. We need to call for action, aiming for both weight loss strategies and controlling the comorbidities that mediate high BMI risk.

A national and sub-national metaregression of the trend of insufficient physical activity among Iranian adults between 2001 and 2016.

Insufficient physical activity (IPA) caused approximately 5% of mortalities in 2017 in Iran, almost double its global average. Despite the relatively considerable burden, a knowledge gap exists regarding the trend of IPA in recent years. We described the trend of IPA prevalence utilizing the data from six rounds of STEPwise approach to risk factor Surveillance (STEPS) in Iran. We estimated the physical activity status of Iranian adults from 2006 to 2016 after adjusting for years of schooling, urbanization percentage, and wealth index. We used the spatiotemporal model to interpolate and extrapolate the IPA prevalence for the years in-between the series and from 2001 to 2006, respectively. We used the data of 177,910 participants from six STEPS surveys and found that the national prevalence of IPA had steadily increased over the course of 16 years and had almost doubled in this time period (23.1% in 2001 to 55.4% in 2016). The increase was persistent across all age and gender strata and in every province. Moreover, IPA was more prevalent among women than their male peers regardless of their age category or province of residence. The prevalence of IPA in Khuzestan (highest prevalence) was almost double compared to that in Lorestan (lowest prevalence) in 2016. The IPA prevalence increased considerably and almost doubled in 16 years among Iranian adults, particularly women. Policies need to target IPA as a high priority contributing to the burden of Non-communicable diseases.

Improved Population Health in Iran from 1979 to 2019; Decreasing Mortality Rates and Increasing Life Expectancy.

BACKGROUND: In this study, we seek to evaluate the population health improvements during the previous four decades in Iran. We have estimated the levels and trends of child and adult mortality in addition to life expectancy from 1979 to 2019 at national and sub-national levels using all the available data. METHODS: In this study, we used data from National and Sub-National Burden of Diseases study and employed Bayesian Averaging Model (BAM) to predict mortality rates and life expectancy from 1979 to 2019. By including all available data sources of death information of Iran, including national level data from the Institute for Health Metrics and Evaluation (IHME), national censuses, Demographic and Health Survey (DHS), and Death Registration System (DRS) and using Spatio-Temporal and Gaussian Process Regression (ST-GPR) models, we estimated mortality rates and life expectancy from 1990 to 2015. We also used a BAM to project our desired indices until 2019. RESULTS: Both child and adult mortality rates decreased dramatically over the period. At the national level in Iran, in 2019, child mortality rate (deaths per 1000 livebirths), was 16.0 (95%UI: 13.0-19.6), adult mortality rates [probability of death (%)] for females and males were 6.1 (5.4-6.8) and 11.5 (10.3-12.8), respectively. Also, life expectancy values for females and males were 81.6 (80.7-82.2) and 76.1 (75.3-76.6), respectively. The results were consistent for both sexes. Despite the total narrowing gaps among provinces, a difference can still be observed particularly for the border provinces regarding child mortality rates. However, the difference in the other measures are inconsiderable. From 1979 to 2019, the overall change percent in child mortality rate, adult mortality rate for females and males and life expectancy for females and males were -86.3% (-89.0%--83.1%), -52.5% (-60.9%--42.9%), -48.7% (-56.9%- -39.6%), 25.3% (20.8%-31.5%), and 31.3% (25.5%-41.3%), respectively. CONCLUSION: This study provides an overview of the previous 40 years of mortality rates (child and adult) and life expectancy. The provided framework of national and sub-national evaluation can be used by researchers to continue the path of providing information for prioritization and evaluation of programs and also performing cost-effectiveness analysis for proposing efficient strategies to policy makers.