Clinical Phenotype and Disease Course of Inflammatory Bowel Disease in Iran: Results of the Iranian Registry of Crohn's and Colitis (IRCC).

BACKGROUND: Data on the epidemiology of inflammatory bowel disease (IBD) in the Middle East are scarce. We aimed to describe the clinical phenotype, disease course, and medication usage of IBD cases from Iran in the Middle East. METHODS: We conducted a cross-sectional study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) from 2017 until 2022. We collected information on demographic characteristics, past medical history, family history, disease extent and location, extra-intestinal manifestations, IBD medications, and activity using the IBD-control-8 questionnaire and the Manitoba IBD index, admissions history, history of colon cancer, and IBD-related surgeries. RESULTS: In total, 9746 patients with ulcerative colitis (UC) (n=7793), and Crohn's disease (CD) (n=1953) were reported. The UC to CD ratio was 3.99. The median age at diagnosis was 29.2 (IQR: 22.6,37.6) and 27.6 (IQR: 20.6,37.6) for patients with UC and CD, respectively. The male-to-female ratio was 1.28 in CD patients. A positive family history was observed in 17.9% of UC patients. The majority of UC patients had pancolitis (47%). Ileocolonic involvement was the most common type of involvement in CD patients (43.7%), and the prevalence of stricturing behavior was 4.6%. A prevalence of 0.3% was observed for colorectal cancer among patients with UC. Moreover,15.2% of UC patients and 38.4% of CD patients had been treated with anti-tumor necrosis factor (anti-TNF). CONCLUSION: In this national registry-based study, there are significant differences in some clinical phenotypes such as the prevalence of extra-intestinal manifestations and treatment strategies such as biological use in different geographical locations.

MR Enterography in Ulcerative Colitis: Beyond Endoscopy.

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disease (IBD) that progressively affects mucosa and submuccosa of the colon and rectum in a continual pattern. In comparison, Crohn disease (CD), the other type of IBD, is a chronic transmural inflammatory disorder that can involve any part of the gastrointestinal tract. MR enterography (MRE) has emerged as an important imaging modality for the diagnosis and detection of disease activity and complications in CD, with comparable results to those of endoscopy. But MRE has been underused for assessment of UC in recent years, and clinicians heavily rely on endoscopic findings for management of UC. Despite UC being considered an endoscopically assessable disease, MRE can provide useful information beyond that obtained with endoscopy about mural or extramural abnormalities, inaccessible parts of the colonic lumen, associated extraintestinal diseases, and superimposed pathologic conditions. Moreover, endoscopy might be contraindicated in some clinical settings due to the risk of colonic perforation. In addition to depicting the features of UC activity in different phases, MRE demonstrates findings of disease chronicity that cannot be achieved with endoscopy, particularly in a patient with colitis of unknown cause. The valuable diagnostic role of MRE to exclude undiagnosed CD in patients with UC who have refractory disease or those with postproctocolectomy complications is also emphasized. Radiologists can play a crucial role in the management of UC with MRE by addressing what is beyond endoscopy. ©RSNA, 2023 Test Your Knowledge questions are available in the supplemental material.

Iranian Consensus Guideline for Pharmacotherapy with Biologics and Small Molecules Drugs in Adults with Inflammatory Bowel Diseases.

Background: Pharmacotherapy with biologics and small molecules, as the more effective therapies for moderate to severe ulcerative colitis (UC) and Crohn's disease (CD), is complex. Choosing the best methods for their utilization in order to induce and maintain remission are critical for practicing gastroenterologists. We aimed to develop an Iranian consensus on the management of inflammatory bowel disease (IBD) patients with biologics and small molecules. Methods: A Delphi consensus was undertaken by experts who performed a literature summary and voting process. Quality of evidence was assessed using the Grading and Recommendations Assessment, Development, and Evaluation; and an additional risk of bias-protocol. Results: Following an extensive search of the literature, 219 studies were used to determine the quality of the evidence. After three rounds of voting, consensus (defined as≥80% agreement) was reached for 87 statements. Conclusion: We considered different aspects of pharmacotherapy in this consensus. This guideline, along with clinical judgment, can be used to optimize management of IBD patients.

The impact of prior performance information on subsequent assessment: is there evidence of retaliation in an anonymous multisource assessment system?

Few studies have engaged in data-driven investigations of the presence, or frequency, of what could be considered retaliatory assessor behaviour in Multi-source Feedback (MSF) systems. In this study, authors explored how assessors scored others if, before assessing others, they received their own assessment score. The authors examined assessments from an established MSF system in which all clinical team members - medical students, interns, residents, fellows, and supervisors - anonymously assessed each other. The authors identified assessments in which an assessor (i.e., any team member providing a score to another) gave an aberrant score to another individual. An aberrant score was defined as one that was more than two standard deviations from the assessment receiver's average score. Assessors who gave aberrant scores were categorized according to whether their behaviour was preceded by: (1) receiving a score or not from another individual in the MSF system (2) whether the score they received was aberrant or not. The authors used a multivariable logistic regression model to investigate the association between the type of score received and the type of score given by that same individual. In total, 367 unique assessors provided 6091 scores on the performance of 484 unique individuals. Aberrant scores were identified in 250 forms (4.1%). The chances of giving an aberrant score were 2.3 times higher for those who had received a score, compared to those who had not (odds ratio 2.30, 95% CI:1.54-3.44, P < 0.001). Individuals who had received an aberrant score were also 2.17 times more likely to give an aberrant score to others compared to those who had received a non-aberrant score (2.17, 95% CI:1.39-3.39, P < 0.005) after adjusting for all other variables. This study documents an association between receiving scores within an anonymous multi-source feedback (MSF) system and providing aberrant scores to team members. These findings suggest care must be given to designing MSF systems to protect against potential downstream consequences of providing and receiving anonymous feedback.

A Practical Index to Distinguish Backwash Ileitis From Crohn's Terminal Ileitis in MR Enterography.

BACKGROUND: Differentiating ulcerative colitis-associated "backwash" ileitis (BWI) from Crohn's terminal ileitis (CTI) is a diagnostic challenge and highly affects patient's management. This study aimed to investigate magnetic resonance enterography (MRE) features including ileocecal valve patency index (ICPI) in patients with BWI and CTI and distinguish these entities based on MRE findings. METHODS: After obtaining institutional review board approval, we reviewed 1654 MREs; 60 patients with pathologically proven BWI (n = 30) and CTI (n = 30) were enrolled. Two radiologists who were blinded to the clinical diagnosis analyzed MREs. We evaluated bowel wall thickness and enhancement pattern, ileocecal valve (ICV) diameter, and lip thickness. Ileocecal valve patency index-T and ICPI-C were calculated to normalize the ICV diameter with respect to terminal ileum (TI) and cecum, respectively. An additional group of non-BWI-UC patients (n = 30) was also included to validate indices. RESULTS: Circumferential mural thickening (90% vs 1%, P < .001) and inner-wall enhancement (P < .001) of TI were more frequent in BWI patients than CTI. Serosal irregularity (53% vs 13%, P = .002), higher mural thickness (5mm vs 3mm, P < .001), and asymmetric hyperenhancement (P < .001) of TI were more prevalent in CTI than BWI. Ileocecal valve patency and lip atrophy were significantly higher in BWI than CTI and non-BWI-UC groups (both P < .001). Ileocecal valve patency indices-C and ICPI-T indices were able to accurately distinguish BWI from CTI (area under the ROC curve [AUC], 0.864 and 0.847 for ICPI-T and ICPI-C, respectively) and non-BWI-UC (AUC, 0.777 and 0.791 for ICPI-T and ICPI-C, respectively). Ileocecal valve patency indices-T  ≥31.5% were 100% specific to distinguish BWI from CTI, but sensitivity was 63%. CONCLUSIONS: Magnetic resonance enterography features of ICV and TI can accurately differentiate BWI from CTI. Two practical indices introduced in this study showed high specificity to distinguish BWI from CTI.

Comparison of Disease Phenotype and Course among Elderly- and Early-Onset Inflammatory Bowel Diseases in the Middle East.

BACKGROUND: It is unknown if the clinical manifestations and phenotype of disease are comparable between early- and elderly-onset inflammatory bowel disease (IBD). We aimed to seek differences in disease phenotype, course, complications, and treatment between early- and elderly-onset IBD patients. METHODS: This retrospective cohort study on registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) compared demographics, disease phenotype, disease activity, IBD-related surgery and medications between early- and elderly-onset IBD. A generalized linear regression model was used to investigate the relative risk of age at diagnosis adjusted for gender and disease duration for the outcomes. RESULTS: From 10048 IBD patients, 749 with early-onset (7.5%), and 472 (4.7%) elderly-onset IBD were enrolled: 855 (63.1%) ulcerative colitis (UC) and 366 (26.9%) Crohn's disease (CD). Left-sided colitis was more frequent among elderly-onset UC patients (P<0.001). Ileum and ileocolonic locations were the most common types in elderly-onset and early-onset CD patients, respectively. In comparison with elderly-onset UC, early-onset cases more often used prednisolone (22.1% vs. 11.4%, P=0.001), immunomodulators (44.9% vs 25.2%, P<0.001) and anti-tumor necrosis factors (TNF) (20.1% vs 11.9%, P=0.002). Elderly-onset UC patients had 0.7 times lower risk of aggressive phenotype (95%CI:0.6‒0.9, P=0.005). Early-onset CD was associated with higher use of prednisolone (27.7% vs 8.1%, P<0.001), immunomodulators (58.7% vs 41.8%, P=0.005) and anti-TNF (49.6% vs 35.4%, P=0.006). CONCLUSION: Early-onset IBD was associated with a more aggressive phenotype and higher prednisolone, immunomodulators, and anti-TNF use.

The clinical significance of biliary findings in magnetic resonance enterography of patients with inflammatory bowel disease.

Purpose: Given the association of inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC), we aimed to investigate the clinical relevance of abnormal hepatobiliary findings on magnetic resonance enterography (MRE) of IBD patients considering the risk of over- or underestimation of PSC at MRE. Material and methods: Using the MRE dataset of patients referring to a tertiary hospital and the National Registry of Crohn's and Colitis, 69 MREs, including 23 IBD-PSC, 23 IBD-without PSC, and 23 healthy controls (HC), were retrospectively reviewed by 2 experienced radiologists blinded to the clinical data, to evaluate hepatobiliary abnormalities. Sensitivity, specificity, and likelihood ratios were calculated. Results: Bile duct irregularities were the most common finding in the IBD-PSC group, with a frequency of 91%. Intra- and extrahepatic bile duct (IHBD and EHBD) irregularities were observed in 87% and 78% of PSC patients, respectively. Higher frequency of IHBD and EHBD wall thickening, bile duct dilation, EHBD stricture, and periportal oedema were observed in the IBD-PSC group. Peribiliary T2-weighted hyperintensities and contrast-enhancement were significantly more common in the IBD-PSC group than in the IBD and HC groups (48% and 35%, respectively) (p < 0.001). Detection of biliary irregularities on MRE had a specificity of 94% (95% CI: 82-99%), a sensitivity of 91% (95% CI: 72-99%), and a positive likelihood ratio of 14.0 (95% CI: 4.7-42.1) for the diagnosis of PSC. Conclusions: This study emphasizes the importance of assessing and reporting hepatobiliary abnormalities visible in the MRE of patients with IBD to avoid a delayed diagnosis of PSC.

Reliability and Validation of the Persian Version of JUICE Study Questionnaire.

BACKGROUND: This study is part of a prospective international cohort study on the composition of microbiota living in the upper gastrointestinal (GI) tract and its correlations to the patients' symptoms, and their psychological and physical health status in three different populations (JUICE Study). Our study evaluates the reliability and validity of the Persian version of a three-part questionnaire which will be used in this study. METHODS: The original English version of the questionnaire was translated to Farsi and then back translated to English by an expert Iranian English teacher. The back-translation was edited by a native English speaker and then retranslated to Farsi. The questionnaire consists of three parts; the first part includes demographic data, the second part is the EQ-5D questionnaire which is an instrument developed by the EuroQol group to measure five dimensions of quality of life and health status, and the third part is the Hospital Anxiety and Depression Scale questionnaire (HADS). By convenience sampling, 22 participants were enrolled. To check reliability, they were asked to complete the questionnaire and repeat this two weeks later. For validity, one of the researchers completed the questionnaire for each of the participants after interviewing them and this was compared with the questionnaire completed by the participant. Each participant was also asked to comment on the content and structure of the questionnaire and these points were considered for improvement of the questionnaire. RESULTS: The first six questions were demographic, and completely the same in the test and retest phases. All of the other questions in the first part of the questionnaire had Kappa values above 0.6 for both reliability and validity. Four questions in this section were assessed with percentage agreement. Percentage agreements were 0.86, 0.54, 0.66 and 0.9 for reliability and 1, 0.81, 0.81 and 1 for validity for the 8th, 12th, 13th and 14th questions, respectively. In the second part, i.e. the EQ5D questionnaire, percentage agreements of the first and second items for reliability equaled 1. Percentage agreements of the three last items were 0.90, 0.63 and 0.72, respectively. Validity of the EQ5D questionnaire was 100% for the first three items and 95% for the last one. For the HADS questionnaire, percentage agreement averaged 0.63 in the reliability phase and 0.78 in the validation phase. CONCLUSION: According to our data, this three-part questionnaire has acceptable reliability and validity to be used as an instrument in Farsi-speaking populations for the JUICE study.

Outcomes of COVID-19 in Patients with Inflammatory Bowel Disease: Comparison with Household Members and the Role of IBD Medications.

BACKGROUND: Most data on the effect of inflammatory bowel disease (IBD) and its treatments on coronavirus disease 2019 (COVID-19) outcomes have not had non-IBD comparators. Hence, we aimed to describe COVID-19 outcomes in IBD compared to non-IBD patients. METHODS: We conducted a prospective cohort study of registered IBD patients with confirmed COVID-19 from six provinces in Iran from February to April 2020. Proven COVID-19 patients were followed up at four weeks and the frequency of outcomes was assessed. Multivariable logistic regression was used to assess associations between demographics, clinical characteristics and COVID-19 outcomes. RESULTS: Overall, 2159 IBD patients and 4721 household members were enrolled, with 84 (3.9%) and 49 (1.1%) participants having confirmed COVID-19, respectively. Household spread of COVID-19 was not common in this cohort (1.2%). While hospitalization was significantly more frequent in IBD patients compared with non-IBD household members (27.1% vs. 6.0%, P=0.002), there was no significant difference in the frequency of severe cases. Age and presence of IBD were positively associated with hospitalization in IBD compared with non-IBD household members (OR: 1.06, 95% CI: 1.03-1.10; OR: 5.7, 95% CI: 2.02- 16.07, respectively). Age, presence of new gastrointestinal symptoms, and 5-aminosalicylic acid (5-ASA) use were associated with higher hospitalization rate in IBD patients (OR: 1.13, 95% CI: 1.05-1.23; OR: 6.49, 95% CI: 1.87-22.54; OR: 6.22, 95% CI: 1.90-20.36, respectively). Anti-tumor necrosis factor (TNF) was not associated with more severe outcomes. CONCLUSION: Age, presence of new gastrointestinal symptoms and use of 5-ASA were associated with increased hospitalization rate among IBD patients, while anti-TNF therapy had no statistical association.

Clinical Phenotype and Disease Course of Inflammatory Bowel Disease: A Comparison Between Sporadic and Familial Cases.

BACKGROUND: The role of genetic and environmental factors in inflammatory bowel disease's (IBD) clinical course is not fully clear. We aimed to assess the clinical phenotype, disease course, and prognosis of familial IBD in comparison with sporadic cases. METHODS: We conducted a prospective national matched case-control study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) recruited from 2017 until 2020. Sporadic and familial IBD patients were matched based on age, sex, and disease duration. Data on demographics, past medical disease, family history of IBD, disease type, clinical phenotype, extraintestinal manifestations, IBD medications, IBD activity using the IBD-control-8 questionnaire and the Manitoba IBD index, emergency visits in the past 12 months, admissions in the past 3 months, history of colon cancer, IBD-related surgeries, and aggressive phenotype were gathered. Variable distributions were compared between sporadic and familial cases. RESULTS: Overall, 5231 patients with ulcerative colitis (UC, 18.3% familial) and 1438 patients with Crohn's disease (CD, 16.7% familial) were registered in the IRCC. Age at diagnosis was similar between familial and sporadic cases. After matching, 3523 UC patients and 908 CD patients were enrolled in the study. Extraintestinal manifestations, UC extent, CD location and behavior, anti-TNF use, disease activity, colon cancer, IBD-related surgeries and the aggressive phenotype were similar between these sporadic and familial cases. CONCLUSIONS: The prevalence of familial UC and CD cases in Iran was more similar to western countries, and family history did not show a predictive value for disease phenotype, course, and outcomes in our study.

Susceptibility of Patients with Inflammatory Bowel Disease to COVID-19 Compared with Their Households.

BACKGROUND: Immunosuppressive agents used in the treatment of inflammatory bowel diseases (IBDs) could potentially increase the risk of coronavirus disease 2019 (COVID-19). We aimed to compare COVID-19 frequency in patients with IBD with their households and identify the related risk factors. METHODS: Firstly, a multi-centered, observational study on 2110 patients with IBD and 2110 age-matched household members was conducted to compare COVID-19 frequency. Secondly, the data of patients with IBD and COVID-19 who had called the COVID-19 hotline were added. Multivariable logistic regression was used to evaluate the effect of age, type and severity of IBD, the number of comorbidities, and medications on the frequency of COVID-19 among the patients with IBD. RESULTS: The prevalence of COVID-19 in patients with IBD and household groups was similar (34 [1.61%] versus 35 [1.65%]; P = 0.995). The prevalence of COVID-19 increased from 2.1% to 7.1% in those with three or more comorbidities (P = 0.015) and it was significantly higher in those with severe IBD (P = 0.026). The multivariable analysis only showed a significant association with anti-TNF monotherapy (OR: 2.5, CI: 0.97-6.71, P = 0.05), and other medications were not associated with COVID-19. CONCLUSION: The prevalence of COVID-19 in patients with IBD was similar to the household members. Only patients with IBD receiving anti-TNF monotherapy had a higher risk of COVID-19 susceptibility. This finding could be attributed to the higher exposure to the virus during administration in health care facilities.

Efficacy and Safety of Tofacitinib for Treatment of Moderate to Severe Active Ulcerative Colitis: First Report from Iran.

BACKGROUND: Tofacitinib, a selective inhibitor of JAK/STAT pathway, has recently become available in our region. Here, we examined the safety and efficacy of tofacitinib in active ulcerative colitis (UC). METHODS: In a prospective, non-randomized, placebo-free, 52-week clinical trial defined in two phases of induction and maintenance, adult patients with active UC and no response or loss of response to previous conventional treatments, or anti-TNF were recruited (IRCT20181217042020N2). Patients received 10 mg/BID of tofacitinib for 8 weeks. Clinically responding patients were entered into the maintenance phase and received tofacitinib 5 mg/BID for 44 weeks. Clinical evaluation, biochemical tests and endoscopy at time points of baseline, 8, 24 and 52 weeks were performed. The primary outcome was clinical remission at 8 and 52 weeks. RESULTS: Fifty out of 53 enrolled patients completed the induction phase. Clinical response and clinical remission at 8 weeks occurred in 84% and 9.5%, respectively. Forty-two patients who had clinical response entered the maintenance phase. Clinical remission based on the total Mayo score and the partial Mayo score occurred in 38.9% and 55.3% at 24 weeks and in 61.1% and 72.2% at 52 weeks, respectively. There was significant correlation between the total and partial Mayo score with regard to clinical remission in both 24 and 52 weeks. No serious adverse events, no case of herpes zoster, but two cases of deep vein thrombosis were seen. CONCLUSIONS: Our study showed acceptable efficacy and safety for tofacitinib and suggested a correlation between the total Mayo score with partial Mayo score with regard to clinical remission.

A Reliable Prognostic Marker for Liver Dysfunction in COVID-19 Infection.

BACKGROUND In December 2019, COVID-19 emerged from China and spread to become a pandemic, killing over 1,350,000 up to November 18, 2020. Some patients with COVID-19 have abnormal liver function tests. We aimed to determine the clinical significance of liver chemistries in patients with COVID-19. METHODS We performed a cross-sectional study of 1044 consecutive patients with confirmed COVID-19 in two referral hospitals in Tehran, Iran, from February to April 2020. All cases were diagnosed by clinical criteria and confirmed by characteristic changes in the spiral chest computed tomography (CT) and nucleic acid testing of the nasopharyngeal samples. We evaluated the association between abnormal liver enzymes or function tests and survival, intensive care unit (ICU) admission and fatty liver changes in CT scans. RESULTS The mean age was 61.01 ± 16.77 years, and 57.68% were male. Of 495 patients with elevated alanine transaminase (ALT) levels, 194 had chest CT scans, in which fatty liver disease was seen in 38.1%. 41 patients (21.13%) had moderate to severe, and 33 (17.01%) had borderline fatty liver disease. Bilirubin, albumin, and partial thromboplastin time (PTT), along with other markers such as HCO3, C-reactive protein (CRP), triglyceride, and length of admission, were significantly associated with ICU admission and mortality. Prothrombin time (PT), platelet count, and low-density lipoprotein (LDL) levels were also correlated with mortality. Fasting blood sugar (FBS) and pH were important indices in ICU admitted patients. CONCLUSION Liver function tests accurately predict a worse prognosis in patients with COVID-19. However, liver enzymes were only slightly increased in those who died or needed ICU admission and were not related to the fatty liver changes.

Predictive value of initial CT scan for various adverse outcomes in patients with COVID-19 pneumonia.

BACKGROUND: Chest computed tomography (CT) scan is frequently used in the diagnosis of COVID-19 pneumonia. OBJECTIVES: This study investigates the predictive value of CT severity score (CSS) for length-of-stay (LOS) in hospital, initial disease severity, ICU admission, intubation, and mortality. METHODS: In this retrospective study, initial CT scans of consecutively admitted patients with COVID-19 pneumonia were reviewed in a tertiary hospital. The association of CSS with the severity of disease upon admission and the final adverse outcomes was assessed using Pearson's correlation test and logistic regression, respectively. RESULTS: Total of 121 patients (60±16 years), including 54 women and 67 men, with positive RT-PCR tests were enrolled. We found a significant but weak correlation between CSS and qSOFA, as a measure of disease severity (r: 0.261, p = 0.003). No significant association was demonstrated between CSS and LOS. Patients with CSS>8 had at least three-fold higher risk of ICU admission, intubation, and mortality. CONCLUSIONS: CSS in baseline CT scan of patients with COVID-19 pneumonia can predict adverse outcomes and is weakly correlated with initial disease severity.

Nodular lymphoid hyperplasia of terminal ileum: how to avoid overdiagnosis of Crohn's terminal ileitis in MR enterography?

PURPOSE: To investigate the magnetic resonance enterography (MRE) characteristics of nodular lymphoid hyperplasia (NLH) and Crohn's terminal ileitis (CTI). METHODS: Of 1552 MREs from November 2011 to July 2018, 61 individuals with biopsy-proven NLH (n = 24) and CTI (n = 37, 27 with active CTI) were selected based on the inclusion criteria. NLH cases were also followed up for median (range) of 40 (21-61) months. Two board-certified radiologists, blind to clinical data and diagnosis, reviewed MRE in consensus. Conventional, morphological, enhancement, and diffusion parameters were assessed. Mann-Whitney, χ2, and logistic regression analyses were conducted. RESULTS: No NLH patient developed inflammatory bowel disease or lymphoproliferative disorders during the follow-up. Serosal surface irregularity (65% vs. 8%), pseudo-diverticula (27% vs. 0), and mesenteric fat involvement (38% vs. 4%) were more frequent in CTI than NLH (p < 0.01), while mucosal nodularity was more prevalent in NLH (71%) than CTI (19%) (p < 0.001). The upstream luminal diameter (15.0 vs. 12.5 mm, p = 0.015) and mural thickness (6.0 vs. 4.0 mm, p < 0.001) of the terminal ileum showed higher values in CTI than NLH. CONCLUSIONS: Unlike enhancement and diffusion parameters, morphological features (mucosal nodularity, serosal surface irregularity, and mesenteric fat involvement) could distinguish NLH from CTI regardless of CTI activity.

Clinical characteristics and outcomes of diabetics hospitalized for COVID-19 infection: a single-centered, retrospective, observational study.

Some debates exist regarding the association of diabetes mellitus (DM) with COVID-19 infection severity and mortality. In this study, we aimed to describe and compare the clinical characteristics and outcomes of hospitalized COVID-19 patients with and without DM. In this single-centered, retrospective, observational study, we enrolled adult patients with COVID-19 who were admitted to the Shariati hospital, Tehran, Iran, from February 25, 2020, to April 21, 2020. The clinical and paraclinical information as well as the clinical outcomes of patients were collected from inpatient medical records. A total of 353 cases were included (mean age, 61.67 years; 57.51 % male), of whom 111 patients were diabetics (mean age, 63.66 years; 55.86 % male). In comparison to those without DM, diabetic patients with COVID-19 were more likely to have other comorbidities, elevated systolic blood pressure (SBP), elevated blood sugar (BS), lower estimated glomerular filtration rate (eGFR) and elevated blood urea nitrogen (BUN). The association of DM with severe outcomes of COVID-19 infection (i.e. mechanical ventilation, median length of hospital stay and mortality) remained non-significant before and after adjustments for several factors including age, sex, body mass index (BMI), smoking status, and comorbidities. Based on our results DM has not been associated with worse outcomes in hospitalized patients for COVID-19 infection.

Clinical characteristics, outcomes, and risk factors for mortality in hospitalized patients with COVID-19 and cancer history: a propensity score-matched study.

BACKGROUND: COVID-19 has caused great concern for patients with underlying medical conditions. We aimed to determine the prognosis of patients with current or previous cancer with either a PCR-confirmed COVID-19 infection or a probable diagnosis according to chest CT scan. METHODS: We conducted a case control study in a referral hospital on confirmed COVID-19 adult patients with and without a history of cancer from February25th to April21st, 2020. Patients were matched according to age, gender, and underlying diseases including ischemic heart disease (IHD), diabetes mellitus (DM), and hypertension (HTN). Demographic features, clinical data, comorbidities, symptoms, vital signs, laboratory findings, and chest computed tomography (CT) images have been extracted from patients' medical records. Multivariable logistic regression was used to estimate odd ratios and 95% confidence intervals of each factor of interest with outcomes. RESULTS: Fifty-three confirmed COVID-19 patients with history of cancer were recruited and compared with 106 non-cancerous COVID-19 patients as controls. Male to female ratio was 1.33 and 45% were older than 65. Dyspnea and fever were the most common presenting symptoms in our population with 57.86 and 52.83% respectively. Moreover, dyspnea was significantly associated with an increased rate of mortality in the cancer subgroup (p = 0.013). Twenty-six patients (49%) survived among the cancer group while 89 patients (84%) survived in control (p = 0.000). in cancer group, patients with hematologic cancer had 63% mortality while patients with solid tumors had 37%. multivariate analysis model for survival prediction showed that history of cancer, impaired consciousness level, tachypnea, tachycardia, leukocytosis and thrombocytopenia were associated with an increased risk of death. CONCLUSION: In our study, cancer increased the mortality rate and hospital stay of COVID-19 patients and this effect remains significant after adjustment of confounders. Compared to solid tumors, hematologic malignancies have been associated with worse consequences and higher mortality rate. Clinical and para-clinical indicators were not appropriate to predict death in these patients.

Turning unprofessional behaviors around using Holmes' reflection approach: a randomized controlled study.

Many medical schools around the world have included professionalism training in their formal curriculum. However, these efforts may not be adequate; given the exposure of students to unprofessional behaviors in the clinical settings. In the present study, we aimed to design, implement, and evaluate a longitudinal program to improve professionalism among medical students upon their transition to clinical settings. A total of 75 medical students were enrolled in the study and randomly assigned to two groups. The control group did not receive any training, while for the intervention group; a 10-hour program through 16 weeks was organized based on the Holmes' reflection approach. The effectiveness of the program was evaluated by measuring three outcomes in both groups. Data analysis was performed using paired t-test and Multiple Linear Regression. Scores of judgment of professionalism increased in the intervention group (from 7.56 to 10.17; P< 0.001), while there was no significant improvement in the control group's scores. Students' attitudes towards professionalism and their professional behaviors did not change significantly. Based on our findings, the Holmes reflection approach helps students improve their cognitive base of professionalism. Long-term follow-up and further qualitative studies will help us better understand the effects of this approach on other desirable outcomes.

Effects of soy milk consumption on gut microbiota, inflammatory markers, and disease severity in patients with ulcerative colitis: a study protocol for a randomized clinical trial.

BACKGROUND: Several strategies are recommended to alleviate clinical symptoms of ulcerative colitis (UC). Soy milk may affect UC through its anti-inflammatory properties. However, no study has examined the effects of soy milk consumption on gut microbiota and inflammatory biomarkers in patients with UC. The current study will be done to examine the effects of soy milk consumption on UC symptoms, inflammation, and gut microbiota in patients with UC. METHODS: This study is a randomized clinical trial, in which thirty patients with mild to moderate severity of UC will be randomly allocated to receive either 250 mL/day soy milk plus routine treatments (n = 15) or only routine treatments (n = 15) for 4 weeks. Assessment of anthropometric measures and biochemical indicators including serum concentrations of high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), interleukin-1ß (IL-1ß), and interferon gamma (IFN-γ) will be done at the study baseline and end of trial. In addition, the quantity of butyrate-producing bacteria including Clostridium cluster IV, Faecalibacterium prausnitzii, and Roseburia spp.; prebiotic bacteria including Lactobacillus spp. and Bifidobacteria spp.; and mucus-degrading bacteria including Akkermansia muciniphila, Bacteroides fragilis, and Ruminococcus spp., as well as calprotectin and lactoferrin levels, will be explored in fecal samples. Also, the Firmicutes to Bacteroidetes ratio which is of significant relevance in human gut microbiota composition will be assessed. DISCUSSION: Altered gut microbiota has been reported as an important contributing factor to inflammation in patients with inflammatory bowel disease (IBD). Soy milk contains several components such as phytoestrogens with potential anti-inflammatory properties. This product might affect gut microbiota through its protein and fiber content. Therefore, soy milk might beneficially affect systemic inflammation, gut microbiota, and then clinical symptoms in patients with UC. TRIAL REGISTRATION: Iranian Registry of Clinical Trials (www.irct.ir) IRCT20181205041859N1. Registered on 27 January 2019.