Optimisation of vitamin D status in global populations.

Vitamin D is important for musculoskeletal health. Concentrations of 25-hydroxyvitamin D, the most commonly measured metabolite, vary markedly around the world and are influenced by many factors including sun exposure, skin pigmentation, covering, season and supplement use. Whilst overt vitamin D deficiency with biochemical consequences presents an increased risk of severe sequelae such as rickets, osteomalacia or cardiomyopathy and usually warrants prompt replacement treatment, the role of vitamin D supplementation in the population presents a different set of considerations. Here the issue is to keep, on average, the population at a level whereby the risk of adverse health outcomes in the population is minimised. This position paper, which complements recently published work from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, addresses key considerations regarding vitamin D assessment and intervention from the population perspective. This position paper, on behalf of the International Osteoporosis Foundation Vitamin D Working Group, summarises the burden and possible amelioration of vitamin D deficiency in global populations. It addresses key issues including screening, supplementation and food fortification.

Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group.

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION: The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS: The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION: The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

FRAX-based intervention and assessment thresholds for osteoporosis in Iran.

We compared the utility of the current Iranian guidelines that recommend treatment in women with a T-score ≤ - 2.5 SD with a FRAX-based intervention threshold equivalent to women of average BMI with a prior fragility fracture. Whereas the FRAX-based intervention threshold identified women at high fracture probability, the T-score threshold was less sensitive, and the associated fracture risk decreased markedly with age. INTRODUCTION: The fracture risk assessment algorithm FRAX® has been recently calibrated for Iran, but guidance is needed on how to apply fracture probabilities to clinical practice. METHODS: The age-specific ten-year probabilities of a major osteoporotic fracture were calculated in women with average BMI to determine fracture probabilities at two potential intervention thresholds. The first comprised the age-specific fracture probabilities associated with a femoral neck T-score of - 2.5 SD, in line with current guidelines in Iran. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without BMD. The parsimonious use of BMD was additionally explored by the computation of upper and lower assessment thresholds for BMD testing. RESULTS: When a BMD T-score ≤ - 2.5 SD was used as an intervention threshold, FRAX probabilities in women aged 50 years was approximately two-fold higher than in women of the same age but with an average BMD and no risk factors. The relative increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of - 2.5 SD was actually protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to women with a previous fracture rose with age from 4.9% at the age of 50 years to 17%, at the age of 80 years, and identified women at increased risk at all ages. CONCLUSION: Intervention thresholds based on BMD alone do not effectively target women at high fracture risk, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a "fracture threshold" target women at high fracture risk.

Prevalence and associated factors of T-score discordance between different sites in Iranian patients with spinal cord injury.

OBJECTIVES: The present study was conducted to determine the prevalence of T-score discordance and its risk factors in a group of patients with spinal cord injury in a university teaching hospital in the Iranian capital of Tehran. METHODS: This cross-sectional study was conducted on paraplegic men undergoing bone density testing in an outpatient clinic at a hospital in the Iranian capital, Tehran, between March 2011 and 2012. A questionnaire on demographic and anthropometric characteristics, including age, height, weight, engagement in physical activity and personal smoking habits, was filled out for each subject. All the subjects underwent bone mineral density measurement and blood samples were sent for laboratory testing. RESULTS: Major T-score discordance between two sites was noted in 54 (41.22%) patients. Multivariate logistic regression revealed that every unit increase in serum calcium levels, as the only factor influencing T-score discordance, was associated with a 2.49-fold increased risk in T-score discordance in the area. As for the spine and radius, BMI was the only influencing factor as every unit increase in BMI was associated with a 14% lower risk for T-score discordance in these regions. Body mass index was the only factor, based on the multivariate model, affecting the risk of developing T-score discordance between two sites. CONCLUSION: Our study revealed the high prevalence of T-score discordance in patients with spinal cord injury. Physicians should therefore be encouraged to perform BMD at three sites when visiting patients with such injuries.

Iranian Health Research Networks and Vision of Iran by 2025: A Case of Virtual Health Network in EMRI.

BACKGROUND: The present paper aims to explore the role of Health Research Networks (HRN) in facilitating and expedite achieving the prospects for goals of health research based on the visions of Iran by 2025. METHODS: Aiming to the main function of HSR to achieve the targeted conducting of health sciences research; more cooperation and coordination between health science researchers; avoid parallel investigations; and optimum utilization and appropriate distribution of resources, in 2000 the deputy of Research and Technology of Ministry of Health and Medical Education defined and developed a comprehensive HRN. RESULT: There are currently 27 research networks operating under the supervision of the Deputy of Research and Technology at MOHME. All of the HRN policies are following based on their strategic planning's which are extracted from national visions of Iran by 2025. CONCLUSION: Promoting the current position needs a reliable and feasible new strategies. The present article introduces the lessons learned of our experience in virtual web-based health research networking in Endocrinology and Metabolism Research Institute (EMRI).

Positive exercise tolerance test (ETT) on asymptomatic Iranian cases aged over 60 years.

AIM: The purpose of this study was to determine the prognostic importance of positive exercise treadmill test (ETT) in predicting coronary artery disease (CAD) among asymptomatic population based on coronary angiographic findings. METHODS: The comparative study was conducted on a sample of over 60-year-old asymptomatic and symptomatic patients referred to our clinics for screening and clinical reasons between September 2006 and September 2007. All subjects with a positive ETT provided information about their cardiovascular risk factors through a validated questionnaire. The relationship between ETT performance and the CAD risk factors with coronary angiography were studied and compared between the two groups. RESULTS: Seven hundred thirty one symptomatic and 160 asymptomatic individuals were enrolled in the study. In the symptomatic group, gender, blood pressure and diabetes were significantly related with the angiographic findings, while blood pressure failed to show such a relation in the asymptomatic group. CONCLUSION: There is an association between positive ETT and the presence of CAD among asymptomatic elderly men but also women with diabetes or high blood pressure.

Evaluation of morning report in an emergency medicine department.

BACKGROUND: Morning report is considered as an important educational tool in different branches of medicine. The purpose of the present study was to examine the method of case selection, the leadership, the participant's satisfaction and the educational value of morning report held in our centre. METHOD: In September 2007, a formal feedback about the morning report was provided by questionnaire surveys. The data on the method of case selection, the leadership, the participant's satisfaction and the educational value of the sessions were collected from the residents, medical students and the academic staff in emergency medicine department. Each questionnaire also contained an open-ended question, asking for the responders' suggestions for improving these sessions. RESULTS: 73.2% of the responders were satisfied with the current model of the conference hall. The data showed that 46.3% of the participants believed these sessions are held for giving the medical team the required information and 65.9% for solving the patient's problems. The data showed that the participants had evaluated the presentation strategy to be good; however, the presentation pattern was reported to be traditional and based on differential diagnosis in 53.7% of the cases and modern problem oriented in only 39%. CONCLUSION: Most participants considered morning report sessions held in our hospital to be effective in the way it is; however, issues such as communication skill, emergency department management, critical thinking, ethics, professionalism and evidence-based medicine should also be added to the sessions.

Osteoarticular tuberculosis in Tehran, Iran: a 2-year study.

Osteoarticular tuberculosis (TB) accounts for 1-5% of all TB cases and 10-18% of those with extrapulmonary infection. Diagnosis is difficult, because the lungs are rarely involved and there are no specific signs or symptoms. The purpose of this study was to assess the frequency and clinical and laboratory findings in osteoarticular TB in two referral hospitals in Tehran, Iran. The hospital dataset of patients admitted with osteoarticular TB during 2003-2005 was reviewed. Patients' demographic data, clinical presentation and radiological and pathological findings were analysed. Weight loss (50%), fever (36%) and night sweats (38.5%) were the most common constitutional symptoms. Knee, ankle, hip and shoulder joints were the most frequent sites for TB arthritis. In osteomyelitis, long and short bones were equally affected. In TB spondylitis, the lumbar (22.7%) and thoracic (50%) vertebrae were the most commonly involved sites. The most frequently reported complications were sphincter disorder (39.1%), paraplegia (28.9%) and kyphosis (19.3%). TB osteomyelitis must always be borne in mind in countries where TB has high prevalence.

Remifentanil-induced abdominal pain: a randomised clinical trial.

Remifentanil is an ultra-short-acting opioid, widely used for induction and maintenance of anaesthesia in various types of operations. We recently noted that a great number of patients receiving remifentanil in their anaesthetic regimen experienced postoperative abdominal pain. As a result, we performed this study to investigate its incidence. This randomised single-blinded clinical trial was conducted on 300 patients who were undergoing elective cataract surgery under general anaesthesia. The patients were randomly divided into two groups. In the control group (n = 150), anaesthesia was induced with fentanyl and propofol and maintained with propofol by infusion and 60% N2O. In the remifentanil group, anaesthesia was induced with remifentanil and propofol and maintained with remifentanil infusion and inhalation of 60% N2O. Atracurium was used for muscle relaxation in both groups. Abdominal pain was observed in 79 patients (52.6%) in the remifentanil group, 10 of whom required a therapeutic intervention, but in only three patients in the control group, none of whom required an intervention (P value = 0.001). Postoperative nausea and vomiting were reported in seven and 10 patients (4.7%) in the remifentanil and control group, respectively. These findings indicate that abdominal pain is very common in patients receiving remifentanil by infusion for cataract surgery.

Helicopter emergency medical system in a region lacking trauma coordination (experience from Tehran).

BACKGROUND: The helicopter emergency medical service (HEMS) has been working in Iran since 2000. The present study is the first prospective research to determine the epidemiological characteristics of injured patients transported by helicopter in Tehran. METHODS: All injured patients brought to three hospitals from the injury scene by HEMS were reviewed in a 4-month period. RESULTS: The mean transport time was 54 minutes. The most common mechanism of trauma was road traffic accidents (96.2%). The mean injury severity score was 8.6 (SD 8.6) and 9.6% of patients were sent to the intensive care unit; 10.2% of patients died. CONCLUSION: This study shows that overtriage in HEMS (transportation of patients without severe injuries) and the long transportation time is mainly a result of not having a trauma system. The study has shown HEMS to be an effective and feasible option in countries with heavy traffic and no trauma system.

Clinical profile and management of brucellosis in Tehran - Iran.

BACKGROUND: Brucellosis is one of the most frequent infectious diseases in many regions of Iran. The purpose of this study was to evaluate different clinical, laboratory and therapeutic aspects of this disease. METHOD: This retrospective descriptive study was performed on patients referred to two teaching hospitals in Tehran/Iran with brucellosis diagnosis during the years 1998 - 2005. Patients' signs and symptoms, laboratory findings and clinical responses were evaluated during the study period. RESULTS: More than half of the 415 patients enrolled in this study were female. The duration of the symptoms was reported to be less than 2 months in 83.85% of the patients prior to being examined in our centre. While sweating and fever were the most common symptoms, peripheral arthritis, sacroiliitis and splenomegaly were the most frequently reported signs. Rifampin plus cotrimoxazole was the most common regimen administered in these cases (32%) and relapse was also more frequently seen in this group of patients (13.8%), whilst doxycycline and cotrimoxazole led to the least number of relapses (2.5%). CONCLUSIONS: Brucellosis is known to have various manifestations, so it should be considered as one of the differential diagnoses of any patient referred with different organs involvement accompanied with or without fever. Relapse is one of the complications reported even following an appropriate treatment.

Kaposi's sarcoma in renal transplantation: report of three cases.

Kaposi's sarcoma (KS) is one of the most common post transplant malignancies. A variety of factors appears to contribute to the development of KS including genetic factors, sex hormones, immunosuppression and oncogene viruses. We present 3 cases with concurrent KS and cytomegalovirus (CMV) infection in the first year after kidney transplantation. The suspicion on KS due to the skin lesions was confirmed by biopsy. The diagnosis of CMV infection was made by detecting pp65 antigen in blood. The KS lesions were limited to the skin in 2 patients, while skin and gastrointestinal tract were involved in 1 patient. Many factors are reported to be involved in KS development, but the simultaneous occurrence of KS and CMV infection in our three cases suggested CMV as an inducing factor for KS.

Teaching critical appraisal and statistics in anesthesia journal club.

BACKGROUND: This study was designed to assess the effectiveness of a series of journal clubs held for anesthesiology residents in promoting their awareness of research methods and statistical analysis, as well as their skills in critical thinking and appraisal. MATERIAL AND METHODS: Twenty-four journal club sessions were held between September 2006 and August 2007 for 16 residents of anesthesiology. A 31 multiple-choice question (MCQ) was taken as pretest and posttest to evaluate the participants' level of awareness in research methodology and statistical analysis. Their competence in critical thinking and appraisal was also evaluated by evaluating a randomized controlled trial paper using the CONSORT checklist before and after the course. RESULTS: Residents' awareness in the application of information improved (P = 0.012), as well as research methodology (combined study design and application of information, P = 0.017). Their ability in critical appraisal did also significantly rise at the end of the course (P < 0.001). CONCLUSION: Journal clubs can enable residents to develop the knowledge, expertise and enthusiasm needed to undertake research plans and can also enhance their ability in critical thinking and scientific reading.

Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation: a randomised clinical trial.

BACKGROUND: Anterior shoulder dislocation is one of the most common complaints of patients referred to emergency departments. Intravenous opiates and benzodiazepines are traditionally prescribed in order to relieve the pain in this group of patients; however, complications always pose a problem. OBJECTIVE: To compare the pain relief and complications following intra-articular lidocaine and intravenous meperidine/diazepam in patients with anterior shoulder dislocation. METHODS: 48 patients with non-habitual traumatic anterior dislocation of the glenohumoral joint admitted to Imam Khomeini hospital emergency department were enrolled in this randomised clinical trial. They were divided into two groups: one group of patients received intra-articular lidocaine 1%, while the other received intravenous meperidine and diazepam. Closed reduction using the countertraction-traction method was performed by a single person in all the patients. Utilising a 100 mm visual analogue scale, each patient's pain was recorded before injection, before reduction, and after reduction. RESULTS: Mean pain (mm) recorded before injection, before reduction, and after reduction in the intra-articular lidocaine group was 84.3 (95% confidence interval (CI) 79.8 to 88.8), 52.6 (95% CI 45.2 to 60.1), and 27.3 (95% CI 19.9 to 34.7), respectively. The corresponding rates in the intravenous meperidine/diazepam group were 83.2 (95% CI 79.2 to 87.2), 57.9 (95% CI 53.8 to 62.0), and 23.9 (95% CI 18.9 to 28.8), respectively. Both groups demonstrated a similar significant decline in pain after injection (p<0.005). No severe complications were reported in either of the groups. CONCLUSION: Intra-articular injection of lidocaine before closed reduction of anterior shoulder dislocation produces the same pain relief as intravenous meperidine and diazepam.

Non-operative management in blunt splenic trauma.

BACKGROUND: Splenic preservation following trauma has been decisively established as the preferred, safe and feasible therapeutic modality. OBJECTIVE: To evaluate the outcomes of non-operative management in adults with blunt splenic injuries and determine the predictive factors of failure. METHODS: Patients admitted to a tertiary trauma centre with blunt splenic trauma during a 10 year period were studied retrospectively. They were divided into three groups according to the type of management they received: emergent laparotomy; non-operative management; and those in whom failure of non-operative management led to laparotomy. Patients' age, Glasgow coma score at admission, the spleen injury score, volume of blood transfused, hospitalisation period and number of deaths were the other variables gathered from the records and analysed. RESULTS: 320 consecutive patients were enrolled in the study. A total of 188 (58.7%) went directly to the operating room, and 41.2% (132 patients) were admitted with the goal of non-operative management for close observation; however, this management failed in 23.4% (31 patients) of the cases in the latter group, and laparotomy (total or partial splenectomy) was the next step. The need for laparotomy increased significantly in cases with higher injury scores. CONCLUSION: The decision to pursue non-operative management rather than splenic preservation or splenectomy depends on the individual merits of each case. There is an increasing trend towards splenic preservation, particularly in younger, stable patients.

Poor physical activity in the elderly as assessed by a visual analogue scale is associated with dyslipidemia.

The aim of the present study was to evaluate the association between a subjective measure of physical activity assessed by a Visual Analogue Scale (VAS) and dyslipidemia in an elderly population of Iran. A total of 74 elderly subjects (39 males) aged 65 years and older who referred to the Cardiovascular Department of the Hospital were studied. Physical activity was assessed on a 100 mm VAS according to which patients were then divided in to two groups active (activity score > or = 50; n = 31) and inactive (activity score < 50; n = 43). Body Mass Index (BMI), systolic and diastolic blood pressure, triglycerides, total cholesterol, Low-Density Lipoproteins (LDL) and High-Density Lipoproteins (HDL) were measured by standard methods. TG (p = 0.021) and LDL (p = 0.006) were significantly higher and HDL was significantly lower (p = 0.028) in the inactive group. No significant associations were found for other variables. As the first report from Iran, present results are important given the race differences that exist in response of plasma lipids to exercise training. Limitations of the present study include its cross-sectional, rather than prospective, structure and the relatively small sample size. It remains to be seen whether VAS can be used as a rapid screening tool for the presence of dyslipidemia in the elderly.

Clinical manifestation, laboratory findings, and the response of treatment in kidney transplant recipients with CMV infection.

OBJECTIVES: To report clinical manifestations, laboratory findings, and treatment outcomes of in kidney transplant recipients who had cytomegalovirus (CMV) infections. METHODS: This retrospective study evaluated the records of kidney transplant recipients followed regularly from 2001 to 2006. In some patients information was also gathered through a telephone call or physical examination. The CMV infection diagnosis was also made by detecting PP.65 antigen per 50,000 peripheral blood leukocytes. RESULTS: Of the 200 kidney transplant recipients, 66 were infected with CMV including 42 men and 24 women. The mean patient age was 40 +/- 13 years (range, 14 to 67 years). Seventy-nine percent of the infected patients were diagnosed during the first 6-months after transplantation. All except 22 patients (33%) had constitutional complaints. Fever was present in 65% of patients, abdominal pain in 21%, diarrhea in 20%, and vomiting in 15%. Likewise, pulmonary complaints including cough and dyspnea were reported by 32% and 23%, respectively. However, 20% of patients were completely asymptomatic. Hematologic laboratory data showed anemia (64%), thrombocytopenia (47%), and leukopenia (21%). Seventy eight percent of patients had a serum creatinine