Outbreak of colistin and carbapenem-resistant Klebsiella pneumoniae ST16 co-producing NDM-1 and OXA-48 isolates in an Iranian hospital.

BACKGROUND: Colistin and carbapenem-resistant Klebsiella pneumoniae (Col-CRKP) represent a significant and constantly growing threat to global public health. We report here an outbreak of Col-CRKP infections during the fifth wave of COVID-19 pandemic. METHODS: The outbreak occurred in an intensive care unit with 22 beds at a teaching university hospital, Isfahan, Iran. We collected eight Col-CRKP strains from seven patients and characterized these strains for their antimicrobial susceptibility, determination of hypermucoviscous phenotype, capsular serotyping, molecular detection of virulence and resistance genes. Clonal relatedness of the isolates was performed using MLST. RESULTS: The COVID-19 patients were aged 24-75 years with at least 50% pulmonary involvement and were admitted to the intensive care unit. They all had superinfection caused by Col-CRKP, and poor responses to antibiotic treatment and died. With the exception of one isolate that belonged to the ST11, all seven representative Col-CRKP strains belonged to the ST16. Of these eight isolates, one ST16 isolate carried the iucA and ybtS genes was identified as serotype K20 hypervirulent Col-CRKP. The blaSHV and blaNDM-1 genes were the most prevalent resistance genes, followed by blaOXA-48 and blaCTX-M-15 and blaTEM genes. Mobilized colistin-resistance genes were not detected in the isolates. CONCLUSIONS: The continual emergence of ST16 Col-CRKP strains is a major threat to public health worldwide due to multidrug-resistant and highly transmissible characteristics. It seems that the potential dissemination of these clones highlights the importance of appropriate monitoring and strict infection control measures to prevent the spread of resistant bacteria in hospitals.

Proportion of toxin and non-toxin virulence factors of Staphylococcus aureus isolates from diabetic foot infection: a systematic review and meta-analysis.

BACKGROUND: Staphylococcus aureus isolates are the leading cause of diabetic foot infections (DFIs). Identification of specific virulence factors of S. aureus involved in the pathogenesis of DFIs may help control the infection more effectively. Since the most prevalent virulence factor genes are probably related to the DFI pathogenesis, the aim of this study is to evaluate the proportion of virulence factor genes of S. aureus isolates from DFIs. MATERIALS AND METHODS: We conducted a systematic search of PubMed, Embase, Web of Science, and Scopus to identify all articles reporting the proportion of different types of virulence factors of S. aureus isolates from DFI samples. RESULTS: Seventeen studies were eligible, in which 1062 S. aureus isolates were obtained from 1948 patients and 2131 DFI samples. Among the toxin virulence factors, hld 100.0% (95% CI: 97.0, 100.0%), hlg 88.0% (95% CI: 58.0, 100.0%), hla 80.0% (95% CI: 31.0, 100.0%), hlgv 79.0% (95% CI: 35.0, 100.0%) and luk-ED 72.0% (95% CI: 42.0, 95.0%) had the highest proportion respectively. Among the genes associated with biofilm formation, both icaA and icaD had the highest proportion 100.0% (95% CI: 95.6, 100.0%). CONCLUSION: The results of the present study showed that among the toxin virulence factors, hemolysins (hld, hlg, hla, hlgv) and luk-ED and among the non-toxin virulence factors, icaA and icaD have the greatest proportion in S. aureus isolates from DFIs. These prevalent genes may have the potential to evaluate as virulence factors involved in DFI pathogenesis. Finding these probable virulence factor genes can help control diabetic foot infection more effectively via anti-virulence therapy or preparation of multi-epitope vaccines.

Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: a national multicenter study.

BACKGROUND AND PURPOSE: The lack of timely foot care among individuals with diabetics often lead to ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening practices among patients with type 2 diabetes in various cities across Iran. METHODS: The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, and diabetic foot self-care (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow's 60-Second Screen. RESULTS: The study included 1094 diabetic patients with, with a majority being female (64.8%) and married (92.5%). The average age of the participants was 57.6 ± 10.21 (mean ± SD), and the mean duration of diabetes was 11.56 ± 7.41 years. Based on Inlow's 60-Second Screen criteria, 58% of the patients should undergo yearly foot ulcer screening, 47% exhibited peripheral neuropathy, and 37% were found to have inappropriate footwear. CONCLUSION: The high prevalence of peripheral neuropathy observed in approximately half of the participants across different regions of Iran underscores the importance of continuous patient education regarding foot care and appropriate footwear. Furthermore, regular foot ulcer screenings, following the recommended intervals outlined in Inlow's screening protocol, should be implemented to effectively manage diabetic foot complications.

Effects of sumac supplementation on metabolic markers in adults with metabolic syndrome: a triple-blinded randomized placebo-controlled cross-over clinical trial.

BACKGROUND: Despite the prior evidence of the impacts of sumac on glycemic indices, lipid profile and visceral fat, there is a lack of evidence regarding the efficacy of sumac in cases with metabolic syndrome (MetS). Therefore, we aimed to assess the effect of sumac supplementation on MetS markers among adults with this syndrome. METHODS: In this triple-blinded randomized placebo-controlled cross-over clinical trial 47 adults with MetS were randomly assigned to receive 500 mg sumac or placebo (lactose) capsule, twice a day. Each phase took 6 weeks and there was a 2-week washout between phases. All clinical evaluations and laboratory tests were conducted before and after each phase. RESULTS: At the baseline of the study, mean (± SD) age, weight, and waist circumference of participants were respectively 58.7 (± 5.8) yr, 79.9 (± 14.3) kg, and 107.6 (± 10.8) cm. Intention to treat analysis (ITT) analyses revealed that sumac supplementation decreased systolic blood pressure by 5 mmHg (128.8 ± 21.4 at the baseline vs. 123.2 ± 17.6 after 6 weeks intervention, P = 0.001). The comparison of changes in two trial arms showed that sumac supplementation significantly reduced systolic blood pressure (sumac group -5.59 ± 10.6 vs. control group 0.76 ± 10.5, P = 0.004), but did not change anthropometric indices or diastolic blood pressure. Similar results were also found in the per-protocol analyses. CONCLUSIONS: This cross-over trial revealed that sumac supplementation could reduce systolic blood pressure in men and women with MetS. Daily intake of 1000 mg sumac, as an adjuvant therapy, may be beneficial in management of MetS in adults.

Secondary bacterial infection caused by ST16 NDM-1 and OXA-48-producing colistin and carbapenem-resistant Klebsiella pneumoniae treated with tigecycline in a pregnant woman with COVID-19.

During the COVID-19 pandemic, the rapid emergence of carbapenem and colistin-resistant Klebsiella pneumoniae has resulted in an alarming situation worldwide. We aimed to describe secondary infections and antimicrobial use, in a pregnant woman admitted to hospital with COVID-19. A 28-year-old pregnant woman was admitted to the hospital due to COVID-19. According to the clinical conditions, the patient was transferred to the ICU on the second day. She was empirically treated with ampicillin and clindamycin. Mechanical ventilation through an endotracheal tube was started on the 10th day. During her hospitalization in the ICU, she was infected with ESBL-producing K. pneumonia, Enterobacter spp and carbapenemase-producing colistin-resistant Klebsiella pneumoniae isolates. Finally, the patient was treated with tigecycline monotherapy that was associated with ventilator-associated pneumonia clearance. Bacterial co-infection is relatively infrequent in hospitalized patients with COVID-19. Treatment of infections caused by carbapenemase-producing colistin-resistant K. pneumoniae isolates is challenging, with limited antimicrobials available in Iran. In order to prevent the spread of extensively drug-resistant bacteria, infection control programs must be implemented more seriously.

Effect of propolis on mood, quality of life, and metabolic profiles in subjects with metabolic syndrome: a randomized clinical trial.

Metabolic syndrome (MeS) is a common multifaceted disorder. Plants contain antioxidant bioactive compounds, which are beneficial to improve the health condition of patients with MeS. Propolis is a hive natural product that is composed of various constituent. We aimed to assess the effects of Iranian propolis as a natural and safe agent on indicators of MeS, quality of life and mood status in individuals with MeS. In total, 66 interested eligible patients recruited to the present study. Participants were randomly assigned to consume a tablet at dose of 250 mg of propolis extract, twice daily for 12 weeks or placebo. Propolis supplementation could lead to a significant reduction in waist circumference (WC), increase in physical functioning, general health and the overall score of SF-36 compared with placebo group (P-value < 0.05). However, no significant differences were observed regarding other anthropometric indices and biochemical parameters between two groups (P-value > 0.05). The current study indicated that propolis can be effective in decreasing WC and improving physical health and quality of life, while had no significant effects on other components of MeS among subjects with this syndrome. Clinical trials registration Iran Registry of Clinical Trials.ir IRCT20121216011763N49, registration date 23/12/2020.

Is there any link between Hyperphosphatemia, Hypoalbuminemia, and Hypocalcemia with Hospital Outcomes in COVID-19 Patients?

Background: Disturbed biochemical factors have been observed in viral infections including SARS, Ebola virus, and now COVID-19. This study aimed to evaluate the association between Calcium axis' derangements and hospital duration, ICU admission, mechanical ventilation, and death in patients with COVID-19. Methods: 428 hospitalized patients with COVID-19 were included in this study. On the first day of admission, the patients were extensively evaluated for biochemical and hormonal factors and followed up until discharge/death. The association between hyperphosphatemia, hypoalbuminemia, and hypocalcemia and major outcomes, including hospital duration, ICU admission, mechanical ventilation, and death, was investigated by logistic regression analysis. Results: Hyperphosphatemia and hypoalbuminemia were present in 27 (6.3%) and 59 (13.8%) cases, respectively in the study population. The results of the present study reveal the relation of these factors with worse outcomes in COVID-19 patients; such as hospital duration, ICU admission, mechanical ventilation, and death. On the other hand, high frequency of hypocalcemia (59.1%, 253 subject) has no significant influence on the mentioned outcomes (All P values were greater than 0.05). Conclusions: Poor outcomes were associated with hyperphosphatemia and hypoalbuminemia. It seems that we should evaluate the patients for derangements of phosphate, albumin, and calcium and try to treat them for all COVID-19 patients.

The effect of sumac supplementation on insulin resistance, inflammation, oxidative stress, and antioxidant capacity in adults with metabolic syndrome: A randomized crossover clinical trial.

The impact of sumac supplementation was not previously examined in patients with metabolic syndrome (MetS). So, we investigated the influence of sumac supplementation on insulin resistance, inflammation, oxidative stress, and antioxidant markers in adults with MetS. The current study was a single-center, triple-blind, randomized, placebo-controlled crossover clinical trial that was conducted on 47 patients with MetS. Participants were randomly divided into two groups of intervention and control in the first phase. They received capsules containing 500 mg sumac or placebo (lactose) twice a day, after lunch and dinner, for 6 weeks. After a 2-week washout period, the subjects crossed over to the alternate arm. In both arms, fasting venous blood samples were obtained at baseline and at the sixth week of the intervention to determine glycemic status, high-sensitivity C-reactive protein (hs-CRP), malondialdehyde (MDA), total antioxidant capacity (TAC), and antioxidant enzymes activity. The mean (±SD) age, weight, and body mass index of participants were respectively 58.7 ± 5.83 years, 79.9 ± 14.35 kg, and 31.6 ± 4.6 kg/m2 ; 80.9% of subjects were females (n = 38). Based on per-protocol analyses, the serum fasting insulin concentration was unexpectedly decreased in the placebo group (change in sumac vs. control: 0.95 ± 3.9 vs. -1.17 ± 3.9 mU/L; p = 0.04). Sumac supplementation, compared to control, has marginally enhanced catalase activity (change in sumac vs. control: 2.91 ± 9.5 vs. -1.07 ± 9.1 nmol/min/ml; p = 0.06). This supplementation has also increased serum TAC and the activity of superoxide dismutase, but these changes were not significant. This intervention did not affect other insulin resistance, inflammatory, or oxidative stress markers. We found that 1 g/day sumac consumption for 6 weeks, as adjuvant therapy, could improve the antioxidant defense system in adults with MetS but did not affect insulin resistance, inflammation, or oxidative stress.

Coexistence of Type B Insulin Resistance and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in Type 2 Diabetes Mellitus: Various Manifestations With the Same Pathophysiologic Base?

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a rarely reported disease. The association between diabetes mellitus (DM) and CIDP has been a matter of controversy. Here we presented a 59-year old male patient with uncontrolled type 2 DM presented with simultaneous type B insulin resistance (TBIRS) and CIDP. Both blood glucose and neurological manifestations responded well to corticosteroid therapies. Although the pathogenesis of CIDP remains to be elucidated, the role of antibodies in the pathogenesis of TBIRS and CIDP might be a promising platform for further studies to provide additional insights into the origin of these 2 rare complications.

Design, development, and evaluation of a self-care program for women with osteoporosis: The protocol of a mixed-method study.

BACKGROUND: Osteoporosis, the fourth most common disease in the world, affects the elderly and postmenopausal women and imposes a great financial and social burden on individuals and society. Furthermore, it has a significant impact on the quality of patients' life. This study tries to take an effective step toward improving the quality of patients' life by developing and evaluating the self-care program of women with osteoporosis. MATERIALS AND METHODS: In this research, a hybrid sequential design of quantitative and qualitative type consisting of three phases is used. This mixed-method study aimed to develop and evaluate a self-care program for women with osteoporosis. CONCLUSION: Familiarity with the needs of these patients and the use of self-care programs and considering social, cultural, and psychological factors could be effective steps to improve the health of women with osteoporosis. These steps can improve the quality of life and reduce the costs of treatment for this group of women.

Assessment of the psychometric properties of the Persian version of the diabetes self-management questionnaire (DSMQ) in patients with type 2 diabetes.

Background: Performing self-care behaviors by diabetic patients is essential to achieve optimal glycemic control, reduction of complications, and improvement in the quality of life. The Diabetes Self-care Questionnaire (DSMQ) is designed to assess self-care behaviors that can predict glycemic control. The present study aimed to evaluate the psychometric properties of the Persian version of the DSMQ in patients with type 2 diabetes. Methods: The present methodological cross-sectional study investigated 460 patients with T2DM referred to the Isfahan Endocrine and Metabolism Research Center, Isfahan, Iran through the convenience sampling procedure. The translation process of the DSMQ was carried out based on the guidelines suggested by Beaton et al. We assessed the reliability (internal consistency), content validity, convergent validity and construct validity. Construct validity was evaluated using exploratory factor analysis (calibration sample = 230) and confirmatory factor analysis (validation sample = 230). Furthermore, a linear regression analysis was used to determine the prediction power of self-care behaviors in explaining the variance of the HbA1c level. Results: In the EFA with Varimax rotation, we extracted four factors that could explain 67.46% of the total variance of the DSMQ scale. The CFA exhibited a satisfactory fit level for the four-factor structure extracted from EFA with the following measures. CFI: 0.980, IFI: 0.980, NFI: 0.956, TLI: 0.974, RMSEA: 0.042). Internal consistency was good (Cronbach's alpha coefficient for the whole scale: 0.84; the subscales: 0.75-0.91). The convergent validity showed significant negative correlations (GM: -0.53; DC: -0.22; PA: -0.16; HU: -0.17; SS: -0.45; p < 0.01) between DSMQ subscales and HbA1c. However, only two factors of glucose management and diet control in the statistical model obtained from regression analysis (stepwise) were able to explain 30% of the HbA1c level (P < 0.001). Conclusion: The Persian version of the DSMQ is a valid and reliable instrument to assess self-care behaviors associated with glycemic control in Iranian patients with T2DM. Therefore, this instrument can be used in both future research and clinical practices.

Development and evaluation of a new questionnaire to assess social cognitive factors of self-management in patients with type 2 diabetes: a psychometric study.

Background: Self-care behaviors are essential to control blood sugar and to prevent mortality and complications of diabetes. The evidence suggests that social cognitive factors play a crucial role in adopting self-care behaviors. This study aimed to develop and examine the psychometric properties of the Diabetes Self-Management Questionnaire based on the social cognitive theory (DSMQ-SCT). Methods: The present methodological cross-sectional study investigated 460 patients with T2DM referred to the Isfahan Endocrine and Metabolism Research Centre, Isfahan, Iran using the convenience sampling method. We assessed the reliability (internal consistency), content validity, convergent validity and construct validity. Construct validity was evaluated using exploratory factor analysis (calibration sample = 230) and confirmatory factor analysis (validation sample = 230). Results: In the EFA with the varimax rotation, we extracted four factors that could explain 65.9% of the total variance of the DSMQ-SCT scale. The CFA exhibited a satisfactory fit level for the four-factor structure extracted from the EFA with the following measures. CFI: .971, IFI: .971, NFI: .942, TLI: .966, RMSEA: .046).Internal consistency was good (Cronbach's alpha coefficient for the whole scale: 0.88; the subscales: 0.85 to 0.92). The convergent validity showed significant negative correlations between DSMQ-SCT subscales and HbA1c. Conclusion: DSMQ-SCT is a valid and reliable instrument to assess social cognitive factors associated with self-management behaviors in patients with T2DM. Therefore, this instrument can be used in both future research and clinical practices.

Bacterial Profile and Antimicrobial Resistance Patterns of Infected Diabetic Foot Ulcers in Iran: A Systematic Review and Meta-Analysis of Cross-Sectional Studies.

Since infectious foot ulcers represent one of the major causes of lower-limb amputation, it calls for an appropriate action for early detection and sufficient treatment of diabetic foot infection (DFI). The present study aimed at investigating the bacterial epidemiology and antimicrobial resistance (AMR) patterns of DFIs in Iran. We have conducted a systematic search in PubMed, Embase, Web of Science, Scopus, Google Scholar, and Scientific Information Database to identify all articles reporting the proportion of different kinds of bacteria isolated from Iranian DFI samples. Quality was assessed using Joanna Briggs Institute tool. A pooled estimate of proportion with a corresponding 95% confidence interval (95% CI) was calculated using the random effect method. Fifteen studies were eligible, of which 1970 bacterial isolates were obtained from 1316 patients. The most predominant isolates recovered from DFIs was Staphylococcus aureus with a pooled proportion of 24.29% (95% CI: 20.25%, 28.57%) from which 55% (95% CI: 38%, 72%) were methicillin-resistant S. aureus (MRSA). Among Gram-negative strains, Escherichia coli had the highest proportion (17.19%; 95% CI: 13.96%, 20.68%) followed by Pseudomonas aeruginosa, 7.54% (95% CI: 4.56%, 11.14%). The highest pooled estimates of resistance against cotrimoxazole and ciprofloxacin were found in S. aureus 66% (95% CI: 48%, 82%) and E coli isolates 68% (95% CI: 51%, 84%), respectively. Our study revealed that AMR is at a high level in Iran and clinicians should be aware of bacterial resistance patterns to prescribe appropriate antibiotic regimens.

Improved wound healing of diabetic foot ulcers using human placenta-derived mesenchymal stem cells in gelatin electrospun nanofibrous scaffolds plus a platelet-rich plasma gel: A randomized clinical trial.

AIM: The effectiveness of nanofibers containing human placenta-derived mesenchymal stem cells (hPDMSCs) plus platelet-rich plasma (PRP) for healing of diabetic foot ulcers (DFUs) was investigated. METHODS: hPDMSCs were isolated from human donor placentas, and cultured in electrospun gelatin nanofibrous scaffolds (GNS). Twenty-eight patients with DFUs were randomized into three groups in a 12-week trial: (A) Treated with hPDMSCs; (B) Treated with hPDMSCs after coating the ulcer with PRP gel; (C) Control group received standard wound care. Wound area and pain freewalkingdistance were measured every 2 weeks. RESULTS: Flow cytometry showed the expression of mesenchymal markers. SEM images and DAPI staining indicated significantly higher levels of hPDMSC proliferation on GNS after 3 and 7 days of culture. The MTS assay showed a significant increase in proliferation on GNS, compared to controls. Wound size reduction was 66% in group A, 71% in group B, and 36% in control group C. A significant difference in wound closure and pain-free walking distance was observed between groups A and B, compared to control group C (p < 0.05), but no difference between groups A and B. Biopsy of the implanted tissue showed the development of new capillary formation in groups A and B. CONCLUSION: Implantation of hPDMSCs in GNS accelerated wound healing and improved clinical parameters in DFU patients.

Oral Pulse Betamethasone, Methotrexate, and Combination Therapy to Treat Severe Alopecia Areata: A Randomized, Double-blind, Placebo-controlled, Clinical Trial.

The purpose of this study is to compare oral betamethasone pulse therapy, methotrexate therapy and a combination of the two for patients with Alopecia Areata (AA) as an autoimmune disorder. In this study, 36 patients with severe AA were selected and classified into three groups of 12: 1- Oral betamethasone therapy (3 mg, once a week) with placebo; 2- Oral methotrexate (15 mg, once a week) with placebo; and 3- A combination of methotrexate (15 mg, once a week) and betamethasone (3 mg, once a week). The Severity Alopecia Tool (SALT) was used to measure improvements in the lesions through photographs, and the patients also rated their condition on the Visual Analogue Scale (VAS). Assessments were performed, and the results were compared at baseline and then at intervals of three months for nine months. The demographics and SALT score were similar in the three groups (P > 0.05). All the groups showed improvements in SALT, VAS and photographic scores three months after beginning the treatment (P < 0.001). Betamethasone therapy (P = 0.006) and combination therapy (P < 0.001) provided greater SALT improvement than methotrexate, and combination therapy led to a greater improvement in VAS and photographic findings compared to the two other groups (P < 0.05). Oral steroid, methotrexate and combination pulse therapy were effective treatments for AA, while oral steroid pulse therapy and combination therapy were superior to methotrexate.

The effect of vitamin D therapy in the improvement of cardiac performance and exercise capacity in patients with heart failure: A double-blind, randomized, placebo-controlled trial.

BACKGROUND: Low vitamin D status may contribute to the pathogenesis of heart failure (HF), but therapeutic roles of vitamin D on cardiac performance are not well known. We evaluated vitamin D effects on left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) functional class in patients with HF for the first time. METHODS: This study was a double-blind, randomized, placebo-controlled trial. 110 patients with HF admitted to Shahid Chamran and Khorshid Hospitals, Isfahan, Iran, randomly received 500 mg calcium daily plus either 50000 IU vitamin D3 per week (case group) or placebo (control group) for 6 months. Biochemical variables, LVEF, and NYHA functional class were assessed at baseline and after 6 months. RESULTS: 81 patients completed the study. Vitamin D supplementation increased mean serum 25-hydroxyvitamin D [25(OH)D] concentration in the case group by 33.9 ng/ml (P < 0.001). After 6 months of treatment, both groups showed improvement in LVEF, but the extent of improvement was significant only in the case group (5.48% versus 0.44%, P < 0.001). The NYHA functional class improved in the case group but remained constant in the control group (P < 0.001). CONCLUSION: Vitamin D3 improved LVEF and NYHA functional class in patients with HF and might serve as a new agent for the future treatment of this disease.

Efficacy of Maggot Debridement Therapy on Refractory Atypical Diabetic Foot Ulcers: An Open-Label Study.

Atypical or refractory diabetic foot ulcers (DFUs) are still a major health problem. Maggot debridement therapy (MDT) by larva of Lucilia sericata is an ancient and a modern option for wound healing. It works by debridement, stimulation of wound healing, and disinfection. In this study, we aimed to evaluate the efficacy of MDT for healing atypical and refractory DFUs. Patients with atypical DFUs were selected and further evaluated for some predefined differential diagnoses like atypical fungal, parasitic, or bacterial infections, malignancy, trauma, and so on. Multiple MDT sessions were carried out. Ulcer size was measured before every MDT session. Complete wound healing, time to heal, and adverse effects were recorded as well. Forty-two DFU patients (26 men, 16 women) with 42 nonhealing atypical ulcers participated in this study. Complete wound healing was achieved in 35 patients (83.3%) by MDT. Complete debridement and then healing of the wounds happened in less than 1.79 ± 0.8 months. Four ulcers persisted, and 3 (7.1%) were eventually amputated. MDT may be considered as an effective treatment for atypical DFUs, which are unresponsive to conventional therapies.