Cost-effectiveness of a population-based AAA screening program for men over 65 years old in Iran.

BACKGROUND: Screening program tend to recognized patients in their early stage and consequently improve health outcomes. Cost-effectiveness of the abdominal aortic aneurysm (AAA) screening program has been scarcely studied in developing countries. We sought to evaluate the cost-effectiveness of a screening program for the abdominal aortic aneurysm (AAA) in men aged over 65 years in Iran. METHODS: A Markov cohort model with 11 mutually exclusive health statuses was used to evaluate the cost-effectiveness of a population-based AAA screening program compared with a no-screening strategy. Transitions between the health statuses were simulated by using 3-month cycles. Data for disease transition probabilities and quality of life outcomes were obtained from published literature, and costs were calculated based on the price of medical services in Iran and the examination of the patients' medical records. The outcomes were life-years gained, the quality-adjusted life-year (QALY), costs, and the incremental cost-effectiveness ratio (ICER). The analysis was conducted for a lifetime horizon from the payer's perspective. Costs and effects were discounted at an annual rate of 3%. Uncertainty surrounding the model inputs was tested with deterministic and probabilistic sensitivity analyses. RESULTS: The mean incremental cost of the AAA screening strategy compared with the no-screening strategy was $140 and the mean incremental QALY gain was 0.025 QALY, resulting in an ICER of $5566 ($14,656 PPP) per QALY gained. At a willingness-to-pay of 1 gross domestic product (GDP) per capita ($5628) per QALY gained, the probability of the cost-effectiveness of AAA screening was about 50%. However, at a willingness-to-pay of twice the GDP per capita per QALY gained, there was about a 95% probability for the AAA screening program to be cost-effective in Iran. CONCLUSIONS: The results of this study showed that at a willingness-to-pay of 1 GDP per capita per QALY gained, a 1-time AAA screening program for men aged over 65 years could not be cost-effective. Nevertheless, at a willingness-to-pay of twice the GDP per capita per QALY gained, the AAA screening program could be cost-effective in Iran. Further, AAA screening in high-risk groups could be cost-effective at a willingness-to-pay of 1 GDP per capita per QALY gained.

Venoplasty and stenting in post-thrombotic syndrome and non-thrombotic iliac vein lesion.

Introduction: Venous outflow obstruction is a common condition among patients with chronic venous insufficiency. Endovascular treatment is favourable over open surgery. This study aimed to assess stent patency and clinical outcome in venous outflow obstruction of lower limbs, and also to compare it between post-thrombotic syndrome and non-thrombotic iliac vein lesions.Material and methods: The study was a historical cohort study. Patients with chronic deep venous insufficiency referred to our tertiary referral centre who underwent venoplasty were recruited. Patients were divided into two groups: non-thrombotic-iliac-vein-lesions and post-thrombotic syndrome. Stent patency rate, clinical improvement and risk factors were evaluated during a six-months course after venoplasty.Results: One-hundred-sixty-four patients were included. Six-months primary, assisted primary and secondary patency rates were 98.86%, 100% and100% in the non-thrombotic-iliac-vein-lesions group and 88%, 93% and 96% in the post thrombotic syndrome groups (p-value = .005, p-value = .02, and p-value = .09, respectively). Pain, claudication and edema were the most common symptoms in both groups and significantly improved after six months. Early thrombosis in the PTS group was more common (9 vs. 1, P value = .007).Conclusion: Percutaneous stenting in patients with venous outflow obstruction is safe and effective with a high patency rate and significant decrease in clinical score in both post-thrombotic syndrome and non-thrombotic-iliac-vein lesions groups.

Safety and efficacy of granulocyte-colony-stimulating factor administration following autologous intramuscular implantation of bone marrow mononuclear cells: a randomized controlled trial in patients with advanced lower limb ischemia.

BACKGROUND AIMS: The aim was to investigate the therapeutic effect of granulocyte-colony-stimulating factor (G-CSF) administration following implantation of autologous bone marrow mononuclear cells (BM MNC) for patients with lower limb ischemia. METHODS: The design was a randomized controlled trial. Fifteen patients with severe chronic limb ischemia were treated with autologous BM MNC [without G-CSF (MNC-G-CSF) or combined with G-CSF administration for 5 days following transplantation (MNC+G-CSF)]. RESULTS: All clinical parameters, including ankle brachial index, visual analog scale and pain-free walking distance, showed a mean improvement from baseline, which was measured at 4 and 24 weeks after transplantation in both groups. However, in three (20%) patients, the clinical course did not improve and limb salvage was not achieved. No significant difference was observed among the patients treated in the MNC-G-CSF and MNC+G-CSF groups. No severe adverse reactions were reported during the study period. No relationship was observed between both the numbers of viable MNC or CD34+ cells and the clinical outcome. CONCLUSIONS: Autologous transplantation of BM MNC into ischemic lower limbs is safe, feasible and efficient for patients with severe peripheral artery disease. However, the administration of G-CSF following cell transplantation does not improve the effect of BM MNC implantation and therefore would not have any beneficial value in clinical applications of such cases.

Traumatic vascular injuries of the lower extremity: report of the Iranian National Trauma Project.

BACKGROUND: This study aimed to determine the pattern of traumatic lower extremity vascular injuries in Iran. METHODS: Patients with vascular injury of the lower extremity were selected from the Iranian National Trauma Project. This project was conducted in eight major cities during 2000-2004 and consisted of more than 17000 patients. RESULTS: Sixty-three subjects (54 men) with a total of 92 vascular injuries of the lower extremity were identified. Mean age of the patients was 25.87 +/- 13.37 years. Blunt trauma was more frequent than penetrating (62% vs. 38%). In 36 cases (57%), road traffic crash (RTC) was the cause of injury. In 21% of the patients (n=24), vascular injury resulted from occupational trauma. Workers (n=23, 20%) were the most frequently affected group. Three patients (5%) died due to severity of the associated injuries. CONCLUSION: Our results revealed that RTC is the most frequent cause of lower extremity vascular injuries in Iran. Our findings also showed that occupational injuries have considerable prevalence. Establishment of preventive strategies to reduce the frequency of these injuries is recommended.

Comparison of Coagulation Conditions in Patients With Liver Cirrhosis Due to Primary Sclerosing Cholangitis and Nonbiliary Causes of Cirrhosis Before Orthotopic Liver Transplant.

OBJECTIVES: Orthotopic liver transplant can be accompanied by an obscure bleeding pattern in patients with severe hepatic malfunction. In the present study, coagulation conditions of patients with cirrhosis of the liver due to primary sclerosing cholangitis and nonbiliary causes of cirrhosis were compared using rotational thromboelastometry assays obtained before orthotopic liver transplant. MATERIALS AND METHODS: This case control study analyzed patients who were candidates for orthotopic liver transplant from 2010 to 2016. Eighty patients with cirrhosis of the liver (40 patients with primary sclerosing cholangitis and 40 with nonbiliary causes of cirrhosis) were randomly selected and enrolled into the study. Patients received rotational thromboelastometry assays under anesthesia just before the start of the operation, and results were compared between the 2 patient groups. RESULTS: Of 80 patients, 52 were men and 28 were women. In the assays, we found that maximum amplitudes in 10 and in 20 minutes and maximum clot firmness parameters were higher in patients with primary sclerosing cholangitis. The alpha angle and clot formation time were different in the intrinsic and extrinsic assay panels. In the intrinsic assay, we found clotting time to be shorter (P < .05). The average of all parameters in all 3 assays (intrinsic, extrinsic, and fibrinogen contribution) was lower in patients with nonbiliary causes of cirrhosis than in those with primary sclerosing cholangitis. CONCLUSIONS: In contrast with previous studies that found that patients with primary sclerosing cholangitis are hypercoagulable, our study observed that they have normal coagulable results. Furthermore, we found that, although mean coagulation indexes in patients with primary sclerosing cholangitis were within normal ranges, in patients with nonbiliary causes of cirrhosis, these indexes were generally lower.

Patterns of extremity traumas leading to amputation in Iran: results of Iranian National Trauma Project.

OBJECTIVE: To determine the patterns of traumatic extremity injuries leading to amputation in Iran. METHODS: Data of Iranian National Trauma Project was used to identify patients with upper and lower extremity traumas undergoing amputation. This project was conducted in 8 major cities during 2000-2004. RESULTS: Of 17 753 traumatic patients, 164 (0.92%) had injuries to the extremities that resulted in the limb amputation. Of these, 143 (87.2%) were men. The patient's mean age was 29.0 years +/- 15.4 years and the highest incidence was seen in the age group of 21 to 30 years (34.1%). One hundred and four cases were occupational accidents (63.4%). Blunt trauma was in 54.9% of the cases. The most common reasons for amputation were respectively stabbings (37.8%) and crush injuries (31.7%). Amputation of hand fingers was the most frequent type of amputation (125 cases, 76.2 %). One patient died from severe associated injuries. CONCLUSIONS: This study shows the patterns of traumatic limb amputation in Iran, a developing country. Results of this study may be used in preventive strategic planning.

Obturator bypass as an alternative technique for revascularization in patients with infected femoral pseudoaneurysms.

BACKGROUND: Management of the infected femoral artery pseudoaneurysm has remained controversial. Although common femoral artery ligation and local debridement is an acceptable approach, some patients need revascularization for the treatment of leg ischemia or intermittent claudication. In this study, we report obturator bypass as an alternative technique that has been done at Sina Hospital, Tehran, Iran during a 10-year period. METHODS: This was a retrospective study and the data were obtained from the patients' medical records. RESULTS: Ten obturator bypasses were done on nine patients. Two cases had previous history of ligation of the femoral artery branches. One death and two forefoot amputations occurred. CONCLUSION: Femoral artery ligation has been suggested as the treatment of choice for the management of infected femoral artery pseudoaneurysms. Among the extra-anatomic bypasses, the obturator bypass is an acceptable alternative with favorable results.

Liver Transplantation Status in Iran: A Multi-center Report on the Main Transplant Indicators and Survival Rates.

BACKGROUND: Iran's experience with liver transplantation (LT) began more than two decades ago. The purpose of this article is to present the status of LT in Iran, review specific characteristics of the programs, their outcomes, and their growth to become one of the largest LT programs in the world. METHODS: A questionnaire, asking for data on the number of transplants performed and specifics of the recipients and type of donors with focus on indications and outcomes was sent to LT programs. RESULTS: During a period of 23 years, 4,485 LTs were performed at 6 centers in the country. Of these, 4106 were from deceased donors and 379 were from living donors. There were 3553 adults and 932 pediatric recipients. Hepatitis B and biliary atresia were the most common etiologies in adult and pediatric patients, respectively. Overall survival rates at 1, 5, and 10 years were 85%, 77%, and 71% for adults and 76%, 67% and 56% for pediatric patients, respectively. CONCLUSION: Approval of the brain death law in Iran and coordinated efforts by the transplant centers to build comprehensive LT programs has resulted in the ability to procure more than 700 deceased donors per year with acceptable long-term survival.

Application of "Trauma and Injury Severity Score" and "A Severity Characterization of Trauma" score to trauma patients in a setting different from "Major Trauma Outcome Study".

To evaluate the processes of care and outcomes of injured patients, many different models have been devised and "Trauma and Injury Severity Score" and "A Severity Characterization of Trauma" score have been among the most widely used models. We conducted this study to determine the effectiveness of these systems of evaluation to our setting in Iran, which is substantially different from the North American trauma centers, where these models were developed. Using our data registry on trauma patients, we derived new coefficients for Trauma and Injury Severity Score and A Severity Characterization of Trauma scoring systems to calculate the probability of survival of patients. Finally, we determined the calibration and discrimination of the models by calculating the Hosmer-Lemeshow statistic and the area under the receiver operating characteristic curve. In our study, TRISS and A Severity Characterization of Trauma provided an adequate estimation of the survival probability and both models showed better discrimination in penetrating trauma. Discrimination in blunt injuries was a little lower, yet satisfactory. In pediatric patients the discrimination was also good and A Severity Characterization of Trauma had a better performance. Both models can be used reliably to predict outcome of trauma patients in our setting.

Randomized Trial of the Effect of Magnesium Sulfate Continuous Infusion on IL-6 and CRP Serum Levels Following Abdominal Aortic Aneurysm Surgery.

Abdominal aortic aneurysm (AAA) is widely considered as the disease of elderly white men. Inflammation is one of the most well-known mechanisms involved in the pathogenesis of AAA. Magnesium is one of the most important minerals in the body with established anti-inflammatory effects. In this study, we aimed to investigate the impact of Mg loading following AAA surgery on two inflammation markers, IL-6 and CRP, as well as patient's outcome. This study was conducted as a randomized clinical trial on 18 patients (divided into two groups) after surgical correction of Acute Aortic Aneurysm (AAA). All the patients admitted in ICU ward of Sina Hospital. In intervention group, 10 g of MgSO4 has been infused through 12 h. The control group has not received the intervention. IL-6 and CRP were measured and compared at times 0, 12, 24 and 36 h. The patients were monitored for 36 h. After intervention, the differences of heart rate and APACHE II score were not statistically significant between intervention and control groups (P = 0.097 and P = 0.472, respectively). IL-6 levels decreased consistently in both groups after inclusion in the study. However, IL-6 level was significantly less in intervention group early after the end of MgSO4 infusion comparing with control group (P = 0.01). Likewise, the CRP level decreased significantly after inclusion in the study (P = 0.005). However, these changes were not significant between intervention and control groups (P = 0.297). According to the results of this study, continuous infusion of MgSO4 after AAA surgery may provide IL-6 suppression.

Efficacy and safety of lamivudine or tenofovir plus intramuscular hepatitis B immunoglobulin in prevention of hepatitis B virus reinfection after liver transplant.

OBJECTIVES: Hepatitis B immunoglobulin prophylaxis in combination with antiviral drugs is recommended for prevention of hepatitis B virus reinfection after liver transplant. However, there is no consensus on a standard prophylactic method, and controversy exists over the duration, dose, and route of administration. We conducted a prospective study to evaluate the safety and effectiveness of intramuscular hepatitis B immunoglobulin in combination with lamivudine and/or tenofovir and discontinuation of hepatitis B immunoglobulin after 1 year for prevention of hepatitis B virus reinfection. MATERIALS AND METHODS: Patients with hepatitis Brelated liver cirrhosis who had undergone primary liver transplants were enrolled. The prophylactic protocol involved intraoperative intramuscular hepatitis B immunoglobulin at 10 000 IU, tapering to 5000 IU daily for the first 6 days, weekly for a month, every 2 weeks for the next month, and monthly for a year after liver transplant, in combination with antiviral drugs. RESULTS: From January 2002 until March 2014, two hundred sixty-eight liver transplants were performed. Forty-four patients (16.4%) who underwent liver transplants due to hepatitis B-related liver failure were enrolled. Five patients had hepatocellular carcinoma; 20 had both hepatitis D and hepatitis B virus infection. The median age was 47 years (range, 26-59 y) with a median model for end stage liver disease score of 20. Thirty-three patients were men (76%). Sixty-one percent of patients were negative for hepatitis B virus DNA at the time of transplant. The median follow-up was 13.6 months (range, 0-142 mo). Only 1 patient (2.3%) experienced hepatitis B virus reinfection (at 44.7 months posttransplant), which was successfully treated with tenofovir. Five patients died (11.4%) during the follow-up from nonhepatitis B causes. CONCLUSIONS: Intramuscular hepatitis B immunoglobulin in combination with lamivudine or tenofovir and discontinuation of hepatitis B immunoglobulin after 1 year posttransplant may provide safe and cost-effective protection against posttransplant hepatitis B reinfection.

A proof-of-principle robot with potential for the development of a hand-held tactile instrument for minimally-invasive artery cross-clamping.

One of the most common diseases of the vascular system is abdominal aortic aneurysm (AAA), for which the most definitive treatment is surgery. Minimally invasive aorta surgery is a novel method of surgery performed through small incisions and offers significant advantages including less pain, shorter hospital stay, faster patient recovery, less possibility of infection, etc. However, lack of sense of touch is the main drawback of this type of aorta surgery that would incapacitate the surgeon to exactly distinguish the aorta from its surrounding tissues which could cause various problems during the aorta cross-clamping process. One of the most important drawbacks is that it makes the aorta cross-clamping process the most time-consuming process of aortic repair surgery. The artificial tactile sensing approach is a novel method that can be used in various fields of medicine and, more specifically, in minimally invasive surgeries, where using the 'tactile sense' is not possible. In this paper, considering the present problems during aortic-repair-laparoscopy and imitating the movement of surgeons' fingers during aorta cross-clamping, a novel tactile-based artery cross-clamping robot is introduced and its function is evaluated experimentally. It is illustrated that this new tactile-based artery cross-clamping robot is well capable of dissecting an artery from its adjacent tissues in a short time with an acceptable accuracy.

Patient outcomes in a liver transplant program in Iran.

OBJECTIVES: The first liver transplant program in Tehran was started at Tehran University of Medical Sciences in 2002. The purpose of this study was to evaluate patient outcomes in this program. MATERIALS AND METHODS: From January 2002 to February 2013, there were 172 deceased-donor orthotopic liver transplants performed in 166 patients, including revision transplant in 6 patients. Outcomes were evaluated for 4 phases of the program: (1) phase 1 (2002 to 2005; 9 transplants); (2) phase 2 (2006 to 2009; 41 transplants); (3) phase 3 (2010 to 2011; 49 transplants); and (4) phase 4 (2012 to 2013; 73 transplants). RESULTS: The most frequent indications for liver transplant included cryptogenic cirrhosis, autoimmune hepatitis, and hepatitis B and C cirrhosis. During the progression from phase 1 to 4, there were significant decreases in median cold ischemia time, operative time, and transfusions (platelets, packed red blood cells, and fresh frozen plasma). The most frequent complications included infection and acute rejection. The overall median follow-up for all patients was 26 months (range, 9-144 mo). Frequency of 1-month, 3-month, 1-year, and 2-year survival increased from phase 1 to 4. Kaplan-Meier plots showed significant improvement in patient survival from phase 1 to 4 (P ≤ .001). The most common causes of death were sepsis and bleeding. CONCLUSIONS: Clinical outcomes with deceased-donor liver transplant may be improved with a cooperative multidisciplinary team, coordinated care from different specialties, increased experience, and modifications of anesthetic and surgical techniques. Comprehensive unified written protocols for preoperative, perioperative, and postoperative treatment may help improve outcomes after sufficient experience is achieved.