Knowledge, attitude, and practice among staff associated with Human Papillomavirus Vaccine of young children in Iran.

INTRODUCTION: This study aimed to evaluate knowledge, attitudes, practice associated with Human Papillomavirus (HPV) Vaccine for Young Children among lecturers and health staffs of Shahid Beheshti University of Medical Sciences (SBMU). METHOD: This was a cross-sectional study with 220 adults from five different specialties, randomly selected. Data was collected using 45-item questionnaire on knowledge (12- item), attitude (18-item) and practice (15-item) (KAP) about HPV. The demographic questionnaire included information on age, gender, level of education, occupation, and marital status. Content validity was calculated by content validity ratio (CVR) and content validity index (CVI). Reliability was evaluated using test-retest and by Cronbach's Alpha coefficient, internal consistency was calculated values >0.81 which considered as satisfactory. RESULTS: The mean age of the studied population was 37.70± 8.07 (23-67) years. Of the 220 participants, 80 (36.4%) were males and 140 (63.6%) were females. In evaluating KAP in the men and women, the mean and standard deviation of knowledge were estimated at good level and one-way ANOVA analysis showed significant differences between women and men (p=0.019). There was no significant difference in men and women related to attitude (p=0.92) and practice (p=0.38). CONCLUSION: The KAP about HPV among participants was significantly higher at good levels compared to average levels. Women's knowledge was significantly higher than men. Attitude and practice could have been higher because there was consensus to the usage of vaccine among the specialists to prevent HPV.

Correlation of OX40 ligand on B cells with serum total IgE and IL-4 levels by CD4+ T cells in allergic rhinitis.

INTRODUCTION AND OBJECTIVES: Allergic rhinitis (AR) is a classic Th2-mediated disease, with important contributions to the pathology of interleukins 4, 5, and 13. The co-stimulatory molecule of OX40 and its ligand interaction participate in the immune response by regulation of Th1/Th2 cells balance. Considering the paucity of information on the relation between OX40 ligand (OX40L) and AR, this study aimed to examine its expression on B lymphocytes. PATIENTS AND METHODS: This case-control study consisted of 20 AR patients and 20 healthy subjects. The serum level of total immunoglobulin E (IgE) was measured using the electro-chemiluminescence (ECL) technology. The percentage of B-lymphocytes expressing OX40L was assessed by flow cytometry. The amounts of IL-4 in CD4+ T cells culture supernatant was also measured by the enzyme-linked immunosorbent assay (ELISA). RESULTS: OX40L expression on B lymphocytes of patients was significantly higher than the control group (44.32±19.21% vs. 2.79±2.48% respectively, p<0.001). In AR patients, OX40L expression correlated positively with the levels of serum total IgE and IL-4 produced by CD4+ T lymphocytes (p<0.01 - p<0.05) respectively. CONCLUSIONS: Collectively, the findings of this work suggest that there is a relationship between the OX40L expression level on B lymphocytes and allergic markers such as IgE and IL-4 in patients with allergic rhinitis.

A qualitative study on a 30-year trend of tobacco use and tobacco control programmes in Islamic Republic of Iran.

We conducted in-depth interviews with key tobacco control policy-makers to explore their views and opinions of trends in tobacco use and the effectiveness of tobacco control programmes over the past 3 decades. A qualitative interview study was conducted in 2014 using a grounded theory approach. In-depth interviews were conducted with 86 key tobacco control policy-makers and data collection was based on principles of saturation. The core code "tobacco consumption and its control programme" was extracted and its related themes were listed. After review and classification by an expert panel, 9 categorized codes emerged. The final 31 codes were ordered according to their conceptual differentiations. Overall, tobacco consumption was constant over the past 3 decades; however it was increasing in females and young people and decreasing in older people; hookah consumption was increasing. A positive outcome is that tobacco use is now viewed negatively in the Islamic Republic of Iran, largely due to tobacco control programmes but the current situation is still not ideal and a comprehensive tobacco control law is needed.

Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007-2008.

While airways reactivity is among the characteristics of asthma, it is not considered a sufficient condition diagnostically and the methacholine challenge is a non-specific diagnostic aid in cases of chronic cough and reactive airways disease. The aim of this cross-sectional study was to determine the metacholine response positivity and diagnosis of asthma in patients with chronic cough presenting to a hospital in Tehran during 2007 and 2008. Of 101 patients with chronic cough (with no history of sinusitis, recent pulmonary infection, bronchitis, gasteroesophageal reflux or underlying pulmonary conditions), 51.5% showed reactive airways disease to the methacholine test, 40.6% were unreactive and 7.9% were indeterminate. A positive methacholine challenge test was positively correlated with new wheezing. Although the methacholine challenge test is not a primary test for evaluating chronic cough, if no other reason for chronic cough is found, it may be a guiding test for asthma.

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries.

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

IL-2-inducible T-cell kinase deficiency with pulmonary manifestations due to disseminated Epstein-Barr virus infection.

IL-2-inducible T-cell kinase (ITK) deficiency is a rare inherited immunodeficiency disease characterized by homozygous mutations in the ITK gene and the inability to control Epstein-Barr virus (EBV) infection leading to EBV-associated lymphoproliferative disorders of B cell origin. Many aspects of its clinical presentation and immunologic phenotype are still unclear to clinicians. We report on a 14-year-old female patient with complaints of an 8-month history of cough and fever. Imaging studies revealed diffuse pulmonary nodules and mediastinal lymphadenopathy. Transbronchial lung biopsy showed nonmalignant polyclonal B cell proliferation. High titers of EBV DNA were detected by PCR analysis in bronchoalveolar lavage fluid, bone marrow, and blood. Genomic analysis revealed a homozygous single base pair deletion in exon 5 of the ITK gene (c.468delT) in this patient. Treatment with rituximab (anti-CD20 mab) resulted in complete clinical remission with resolution of pulmonary lesions and a negative EBV titer in serum. All patients with EBV-associated lymphoproliferative disorders should be analyzed for mutations in ITK.

The role of 99mTc-MIBI scintigraphy in the management of patients with pulmonary tuberculosis.

BACKGROUND: This study aimed to determine whether 99mTc-methoxyisobutylisonitrile (MIBI) scanning could improve diagnostic accuracy of pulmonary tuberculosis (PTB) and help clinical decision making for an accurate management. MATERIAL AND METHODS: 99mTc-MIBI scintigraphy was performed in 62 cases of PTB 34 cases had active pulmonary tuberculosis (APTB) and were at the beginning of antituberculosis medication (group 1) as well as 28 cases had inactive pulmonary tuberculosis (IPTB) and were post antituberculosis medication (group 2). The qualitative and semiquantitative findings of both scanning methods were assessed. For semiquantitative evaluation, regions of interest (ROIs) were drawn over the lesion (L), non-lesion (NL) and neck soft tissue (NST). The mean count values of ROIs were obtained and L/NL and L/NST were calculated. RESULTS: Thirty-four patients with APTB (15 males and 19 females; mean age of 47.85 +/- 1.91 yrs) and 28 cases with IPTB (9 male and 19 females; mean age of 53.96 +/- 2.33 yrs) were included in this study. The sensitivity, specificity, accuracy, positive and negative predictive (PPV and NPV) values of 99mTc-MIBI were 88.2%, 75%, 82.2%, 81.1% and 84% respectively. The mean value of L/NL in the APTB for 99mTc-MIBI was 1.45 +/- 0.18 and L/NST was 1.57 +/- 0.26 which was significant statistically (p < 0.00). CONCLUSIONS: The study demonstrated that 99mTc-MIBI scanning can be complementary to other diagnostic techniques especially in patients with indeterminate APTB and those in whom recurrent disease is suspected. In addition, because of its availability, rather low costs, easy performance, and objective semiquantitative information supplied, 99mTc-MIBI scanning might be establish in routine imaging center to assess the pulmonary tuberculosis. However, further exploration is needed to validate its clinical role.

Which form of nicotine replacement therapy is more effective for quitting smoking? A study in Tehran, Islamic Republic of Iran.

Nicotine replacement therapy can double the chance of success for smokers attempting to quit. This observational study aimed to compare quit rates of different formulations of nicotine replacement among clients referred to a smoking cessation clinic in Tehran, Islamic Republic of Iran. Clients entering the study (n = 308) participated in 4 sessions of behavioural therapy, chose a type of nicotine replacement to use (patches, chewing gum, tablets or both patches and gum) and were followed up for 12 months. After 4 weeks of quitting, 88.2% (246/279) reported abstaining from smoking. Self-reported maintenance rates for quitting were 54.9% after 6 months and 36.2% after 12 months follow-up. A significant correlation was found between type of nicotine replacement and quit rate. Use of nicotine patches and chewing gum together had the highest quit rate (95.2%) after 4 weeks and at 12 months follow-up (62.5%). Consuming 2 forms of nicotine replacement in therapy could result in enhanced rates of long-term quitting.

Comparison of tobacco control policies in the Eastern Mediterranean countries based on Tobacco Control Scale scores.

This cross-sectional survey aimed to provide an overview of tobacco control strategies in the countries of the Eastern Mediterranean Region (EMR). A questionnaire to collate data on implementation of 6 major policies was developed based on the previously published Tobacco Control Scale and using MPOWER measures of the WHO Tobacco Free Initiative and the Tobacco Atlas. Only 3 of the 21 countries scored higher than 50 out of 100: Islamic Republic of Iran (61), Jordan (55) and Egypt (51) More than half of countries scored less than 26. Highest scores were achieved by Afghanistan in cigarette pricing, Oman in smoking bans in public places, Islamic Republic of Iran in budgeting, prohibition of advertisements and health warnings against smoking and Syrian Arab Republic, Tunisia and Kuwait in tobacco cessation programmes. The low mean total score in EMR countries (29.7) compared with European countries (47.2) highlights the need for better future planning and policy-making for tobacco control in the Region.

Drug resistance pattern and outcome of treatment in recurrent episodes of tuberculosis.

Patterns of drug resistance in recurrent cases of tuberculosis may be different than in those without a history of treatment. In this retrospective study, the drug resistance pattern and outcome of treatment with DOTS category I (CAT I) regimen was compared in 63 recurrent cases and 872 new cases of pulmonary tuberculosis from April 2003 to January 2008 at the National Research Institute of Tuberculosis and Lung Disease in Tehran, Islamic Republic of Iran. Resistance to isoniazid and ethambutol was significantly more common in recurrent cases, but there were no differences in rates of resistance to rifampin, pyrazinamide, streptomycin or the rate of multi-drug resistant strains. Resistance to streptomycin was the most common. No significant differences in treatment outcome and deaths were found between the 2 groups. Due to the low frequency of multi-drug resistance in the recurrent cases, a CAT I regimen may be suitable for empirical therapy before drug sensitivity results become available.

Status and costs of smoking cessation in countries of the Eastern Mediterranean Region.

The aim of this cross-sectional observational study was to address the health care situation in regard to smoking cessation efforts and expenditure, and to provide a basis for future studies and for implementing tobacco control programmes throughout the Eastern Mediterranean Region of the World Health Organization. Information collected included methods and cost of services for tobacco cessation from all 16 participating countries. In 10 countries, cessation programmes were directed by primary physicians. In 13 countries, nicotine gum and in 14 countries nicotine patches were accessible in pharmacies. Bupropion was available at pharmacies (with a written prescription) in 6 countries and varenicline in 7 countries. However, the mean cost of each service was significantly higher than the price of a pack of cigarettes. In countries with support services for tobacco cessation, directors need to provide care at the society level that is considerably less costly and widely accessible.

Comparison of Indocyanine Green Angiography and Fluorescein Angiography for Imaging of Central Serous Chorioretinopathy Patients as Candidates for Photodynamic Therapy.

PURPOSE: To compare fluorescein angiography (FA) and indocyanine green angiography (ICGA) for imaging of central serous chorioretinopathy (CSC) patients. METHODS: The observational cross-sectional clinical study was conducted on 131 eyes of 131 patients with CSC who were candidates for photodynamic therapy (PDT). An experienced ophthalmologist marked the leakage sites and choroidal hyperpermeability sites that needed PDT. For each eye, simultaneous FA and ICGA imaging with the maximum leakage area was selected for comparison regarding the site and size. RESULTS: The mean±standard deviation age of patients was 44.53±9.03 years. Of 226 leakage points, 177 (78.32%) points were in the same site, and 168 (74.34%) points were in the same size on FA. No statistical difference was found between age (P=0.45), sex (P=0.32), and chronicity (P=0.11) of the disease in comparing the ICGA images to the FA images regarding leakage at the same site. A statistically significant difference was also found regarding size of leakage and chronicity (P<0.001). CONCLUSION: The current results suggested that FA could be considered an alternative ocular imaging technology as a guide for PDT in CSC patients.

Issue 1 - "Update on adverse respiratory effects of outdoor air pollution" Part 2): Outdoor air pollution and respiratory diseases: Perspectives from Angola, Brazil, Canada, Iran, Mozambique and Portugal.

OBJECTIVE: To analyse the GARD perspective on the health effects of outdoor air pollution, and to synthesise the Portuguese epidemiological contribution to knowledge on its respiratory impact. RESULTS: Ambient air pollution has deleterious respiratory effects which are more apparent in larger, densely populated and industrialised countries, such as Canada, Iran, Brazil and Portugal, but it also affects people living in low-level exposure areas. While low- and middle-income countries (LMICs), are particularly affected, evidence based on epidemiological studies from LMICs is both limited and heterogeneous. While nationally, Portugal has a relatively low level of air pollution, many major cities face with substantial air pollution problems. Time series and cross-sectional epidemiological studies have suggested increased respiratory hospital admissions, and increased risk of respiratory diseases in people who live in urban areas and are exposed to even a relatively low level of air pollution. CONCLUSIONS: Adverse respiratory effects due to air pollution, even at low levels, have been confirmed by epidemiological studies. However, evidence from LMICs is heterogeneous and relatively limited. Furthermore, longitudinal cohort studies designed to study and quantify the link between exposure to air pollutants and respiratory diseases are needed. Worldwide, an integrated approach must involve multi-level stakeholders including governments (in Portugal, the Portuguese Ministry of Health, which hosts GARD-Portugal), academia, health professionals, scientific societies, patient associations and the community at large. Such an approach not only will garner a robust commitment, establish strong advocacy and clear objectives, and raise greater awareness, it will also support a strategy with adequate measures to be implemented to achieve better air quality and reduce the burden of chronic respiratory diseases (CRDs).

Alteration of scapula lateral rotation for subjects with the reversed anatomy shoulder replacement and its influence on glenohumeral joint contact force.

It has previously been reported that motion of the scapula varies for subjects with shoulder joint pathologies and is different from that of normal subjects. In this study, an electromagnetic tracking device was used to measure the three-dimensional scapula motion of nine patients with Bayley-Walker (B-W) reverse anatomy joint replacements. The data were then compared to scapula kinematics of 12 normal subjects with no known shoulder pathology. The scapula kinematics for each subject was determined and a regression analysis to find the mean scapula lateral rotation (SLR) for B-W and normal subjects was performed. The regression model which showed the highest change compared to normal was identified and was used in the biomechanical shoulder model to predict the glenohumeral joint contact force. A high variability of the scapula kinematics was observed, with some subjects having a maximum SLR smaller than that of the normal subjects and some similar to the normal subjects. It was found that scapula may move in such a way to keep the deltoid length at its optimum. The change in the scapula kinematics affected the predicted joint force and its point of application. Hence, knowledge of scapular kinematics is essential for realistic modelling of implanted shoulders.

Prioritised research agenda for prevention and control of chronic respiratory diseases.

The 2008-2013 World Health Organization (WHO) action plan on noncommunicable diseases (NCDs) includes chronic respiratory diseases as one of its four priorities. Major chronic respiratory diseases (CRDs) include asthma and rhinitis, chronic obstructive pulmonary disease, occupational lung diseases, sleep-disordered breathing, pulmonary hypertension, bronchiectiasis and pulmonary interstitial diseases. A billion people suffer from chronic respiratory diseases, the majority being in developing countries. CRDs have major adverse effects on the life and disability of patients. Effective intervention plans can prevent and control CRDs, thus reducing morbidity and mortality. A prioritised research agenda should encapsulate all of these considerations in the frame of the global fight against NCDs. This requires both CRD-targeted interventions and transverse NCD programmes which include CRDs, with emphasis on health promotion and disease prevention.

Bilateral diffuse pulmonary infiltration in a heart transplant recipient.

Pulmonary complications are not infrequent after heart transplantation. Kaposi sarcoma is a vascular tumor that can involve the skin as well as visceral organs. We describe a case of visceral and cutaneous Kaposi sarcoma that presented with diffuse bilateral pulmonary infiltration and breathlessness 6 month after heart transplantation. Following modulation of the immunosuppressive regimen and addition of chemotherapy, the patient had an excellent response and has had an uneventful 1-year follow-up.

Reverse anatomy shoulder replacement: comparison of two designs.

The aim of this study was to use a biomechanical model of the shoulder to examine the characteristics of two concepts of reverse anatomy implant; those that preserve the natural glenohumeral centre such as the Bayley-Walker (B-W) replacement and those medializing it such as Delta. A biomechanical model of the shoulder was used to evaluate the biomechanical characteristics of these prostheses. The moment arms of the shoulder muscles were predicted for the implanted models over a wide workspace and were compared to those of natural anatomy. The deltoid muscle moment arms through almost all of the range of motion in the Delta model were greatest. As a result the shoulder joint contact force was decreased for this implant. Furthermore, although the B-W model predicted similar moment arms to natural anatomy, the contact force decreased owing to change in the joint constraints. Finally, it was concluded that the reverse anatomy can compensate for loss of rotator cuff muscles in terms of joint stability, yet the shoulder function depends on the individual's musculature.

First-line antituberculosis drug resistance prevalence and its pattern among HIV-infected patients in the national referral tuberculosis centre, Iran.

The objective of this study was to determine the drug resistance prevalence and its pattern among tuberculosis (TB)-HIV patients in Iran. In this retrospective study, all admitted TB/HIV patients presenting to our tertiary centre during 2005-2007 were considered. After confirmation for TB-HIV, first-line DST was performed for culture-positive patients. The drug resistance patterns and the treatment outcomes were analysed. Of the total 92 TB/HIV patients, 27 were culture negative, and DST were available in 65. Intravenous drug abuse was seen in 59 (90.8%). Thirty-seven (57%) were 'sensitive' cases and 28 (43%) were 'any drug resistance' cases. Twenty-one (32.3%) were mono-drug, three (4.6%) poly-drug and four (6.1%) were multidrug-resistant TB patients. Previous anti-TB medication was significantly associated with any drug resistance (P = 0.041; 95% confidence interval =0.086-0.984); however, having any drug resistance did not affect the treatment outcome (P = 0.56). Streptomycin showed the highest resistance rate (27%) followed by isoniazid (20%), pyrazinamide (9.8%), rifampin (9.2%) and ethambutol (3%). Drug resistance to antitubercular agents in TB-HIV co-infected patients in Iran is high compared with other reports. Drug resistance is higher among those who have had prior anti-TB medication.

Drug abuse profile - patient delay, diagnosis delay and drug resistance pattern - among addict patients with tuberculosis.

Socioeconomic problems limit the access of drug users to health-care services. This descriptive cross-sectional study was carried out by making use of the medical records of new case tuberculosis (TB) patients hospitalized at Masih Daneshvari Hospital, the national referral centre in Iran, from 2003 to 2006. Demographic and personal characteristics of the patients and type of disease were collected and categorized. Of the 944 patients with confirmed TB, 143 (15.1%) were drug users, among whom 140 (97.9%) were men with just three women drug users. The mean age of the drug users group was 43.04 +/- 13.81 years. The type of drug used was opium in 100 cases (69.9%), heroin in 29 (20.3%), opium and heroin together in four (2.8%) and all three, opium, heroin and crack, in two (1.4%). For 238 high-risk patients, an HIV test was performed and HIV infection was confirmed in 33 cases. Patient delay was longer in drug users (P = 0.000) against other patients, whereas diagnosis delay was shorter (P = 0.007). Drug susceptibility tests were performed for 515 patients with positive cultures. One hundred and thirty-three (14.1%) were found to have 'any resistance' to anti-TB drugs, and 10 (1.1%) individuals had multidrug-resistant TB. Twenty-six (19.5%) of the individuals who showed resistance to first-line agents were drug users. There was no significant relation between drug resistance and drug use (P = 0.4). In conclusion, it seems that active case finding for TB and HIV in addict cases must be contained in harm reduction packages. Moreover, the manifestations of the disease should be considered seriously regardless of attributing them to drug use.

Comparison of the effectiveness of 2 treatment regimens in patients with isoniazid-resistant tuberculosis.

We compared the effectiveness of 2 treatment regimens for isoniazid-resistant tuberculosis (TB) in 42 patients attending a TB referral centre in the Islamic Republic of Iran. The patients were divided into 2 treatment groups: 26 received the 6-month standard HRZE treatment and 16 received a modified treatment of RZE for 6 months. There were no significant differences in age or sex of the groups. With the standard method of treatment, 21 (80.8%) patients were cured, 4 (15.4%) resulted in treatment failure, and 1 (3.8%) died. In the modified treatment group, 16 (100%) patients were cured, These differences were not statistically significantly different (P = 0.194).