Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study.

BACKGROUND: Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia. METHODS: We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs. RESULTS: Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080). CONCLUSIONS: We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Oxidative stress and nitrate/nitrite (NOx) status following citrulline supplementation in type 2 diabetes: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: The pathogenesis of diabetes is accompanied by oxidative stress. Citrulline can be considered as a potent antioxidant. The present study aimed to examine the effects of citrulline supplementation on the status of oxidative stress and serum levels of nitrite/nitrate (NOx) in patients suffering from type 2 diabetes (T2DM). METHODS: The present study comprises a double-blind placebo-controlled randomised clinical trial. The study subjects include 54 patients with T2DM chosen from specialised clinics of Tabriz University of Medical Sciences. The patients were allocated to one of the placebo or intervention groups. The patients in the placebo and the intervention group received one sachet of microcrystalline cellulose or l-citrulline (3 g), respectively, every day for 2 months. Malondialdehyde (MDA), glutathione peroxidase (GPx), total antioxidant capacity (TAC), superoxide dismutase (SOD), serum levels of fasting blood sugar (FBS), citrulline and NOx were assessed before and after the intervention. RESULTS: Forty-five patients completed the trial. Significant decreases were found in serum levels of FBS and MDA. Serum levels of TAC, citrulline and NOx in the intervention group increased compared to those of the placebo group, after adjusting the data for the baseline values and confounders. Differences between and within the two groups were statistically nonsignificant for GPx and SOD at the end of the study. Body mass index and energy intake were not changed significantly after the intervention. CONCLUSIONS: The results of the present study show the positive effects of citrulline supplementation with respect to attenuating FBS levels and oxidative stress, as well as boosting NOx status, in patients with T2DM.

A double-blind, placebo-controlled trial related to the effects of melatonin on oxidative stress and inflammatory parameters of obese women.

Obesity, the global epidemic health problem, results in chronic disorders. Melatonin supplementation may prevent the adverse health consequences of obesity. The aim of this study was to assess the effects of melatonin supplementation on inflammatory and oxidative stress parameters in obese women. In randomized, double-blind, placebo-controlled trial, 44 obese women were randomly assigned to melatonin (n=22) and placebo (n=22) groups. Subjects were supplemented with a daily dose of 6 mg melatonin or placebo with low calorie diet for 40 days. Serum TNF-α, IL-6, hsCRP, TAC, and MDA levels were assessed before and after intervention. In the melatonin group, mean serum TNF-α, IL-6, hsCRP, and MDA levels decreased significantly (p<0.05) from 3.52±0.72 pg/ml, 27.12±6.32 pg/ml, 2.54±0.49 mg/l, and 3.81±0.29 nmol/l to 1.73±0.07, 16.34±6.32, 1.67±0.27, and 2.79±0.29, respectively. Whilst in the placebo group the decrease in values were not statistically significant. Mean TAC level increased slightly (from 1.11±0.30 to 1.14±0.45 mmol/l) in the melatonin group whereas it decreased slightly (from 1.13±0.15 to 1.08±0.21 nmol/l) in the placebo group. Significant differences were observed only for TNF-α (p=0.02) and IL-6 (p=0.03) between the 2 study groups. Considering the improvements in inflammatory and oxidative stress factors in obese women, it seems that melatonin supplementation may provide beneficial effects in obesity treatment by ameliorating some of its complications. However, further studies are needed to make concise conclusions.

Circulating levels of interleukin-35 in patients with multiple sclerosis: evaluation of the influences of FOXP3 gene polymorphism and treatment program.

The regulatory T (Treg) cells play a major role in the control of the autoimmunity and inflammation, and IL-35 has been described as an immunosuppressive cytokine that is mainly produced by CD4(+)FOXP3(+) Treg cells. The aim of this study was to evaluate the serum levels of IL-35 and a single nucleotide polymorphism (SNP), rs3761548, in FOXP3 gene in patients with multiple sclerosis. The blood samples were collected from 140 multiple sclerosis (MS) patients (including 51 untreated and 89 treated patients) and 140 healthy subjects as a control group. The serum levels of IL-35 were measured by ELISA. The DNA was analyzed for SNP rs3761548 in FOXP3 gene using SSP-PCR. There was no significant difference between untreated MS patients and control group regarding the mean serum levels of IL-35, although this parameter was higher in untreated patients. However, the mean serum level of IL-35 in treated MS patients was significantly higher than that in the control group (P < 0.008). The mean serum levels of IL-35 in patients who were treated with interferon-ß, methylprednisolone, or with the both interferon-ß and methylprednisolone were significantly higher than that in the healthy group (P < 0.01, P < 0.01, and P < 0.2, respectively). The frequencies of AA and AC genotypes at rs3761548 in the FOXP3 gene were significantly higher in MS group as compared with healthy subjects (P < 0.05). The frequency of CC genotype at rs3761548 was significantly lower in the MS group in comparison with healthy control subjects (P < 0.001). Moreover, the frequency of A allele was significantly higher whereas the frequency of C allele was significantly lower in MS patients in comparison to healthy subjects (P < 0.001). The mean serum level of IL-35 was significantly lower in MS patients or healthy subjects with AA genotype as compared with those with CC genotype at rs3761548 in FOXP3 gene (P < 0.01 and P < 0.001, respectively). These results showed higher serum levels of IL-35 in treated MS patients representing that the benefit effects of treatment may in part performed through the upregulation of the IL-35 production. The SNP rs3761548 may influence the susceptibility to MS disease and the serum levels of IL-35.

A distinct autosomal recessive ocular anomaly in Chaharborj, Islamic Republic of Iran.

In Chaharborj, a village in north-eastern ofthe Islamic Republic of Iran, a high prevalence of congenital blindness (1.1%) has been reported. The clinical findings have not been fully described. We therefore assessed the clinical aspects of this condition in a case series of 20 congenitally blind patients and 24 of their parents. All patients had been blind since birth. There was anterior segment dysgenesis and retinal non-attachment in all patients. There were no systemic anomalies. Histopathologically, there was iridocorneal adhesion, normal angle structure and retinal dysplasia. No significant difference was found in the frequency of different HLA class I alleles compared with the general population. The anomaly causing congenital blindness in these patients has components of both anterior and posterior segment dysgenesis. It appears to be a distinct entity with an autosomal recessive pattern of inheritance.

A distinct autosomal recessive ocular anomaly in Chaharborj, Islamic Republic of Iran

In Chaharborj, a village in north-eastern of the Islamic Republic of Iran, a high prevalence of congenital blindness [1.1%] has been reported. The clinical findings have not been fully described. We therefore assessed the clinical aspects of this condition in a case series of 20 congenially blind patients and 24 of their parents. All patients had been blind since birth. There was anterior segment dysgenesis and retinal non-attachment in all patients. There were no systemic anomalies. Histopathologically, there was iridocorneal adhesion, normal angle structure and retinal dysplasia. No significant difference was found in the frequency of different HLA class I alleles compared with the general population. The anomaly causing congenital blindness in these patients has components of both anterior and posterior segment dysgenesis. It appears to be a distinct entity with an autosomal recessive pattern of inheritance

Determination of aflatoxin M(1) in breast milk samples in Tabriz-Iran.

The aim of this study was to examine the exposure of lactating mothers to aflatoxins using aflatoxin M(1) in breast milk as a biomarker for exposure and to detect its determining factors and possible effects on child growth. A 9% sample of 2022 lactating women who exclusively breastfed their infants, including 91 lactating women of urban areas of Tabriz city and 91 lactating women of its rural areas were recruited by a geographical clustered sampling method. Breast milk samples and information on food intake were collected from subjects using structured food-frequency questionnaire. Extraction of AFM(1) was performed with the ELISA test procedure. Aflatoxin M(1) was detected in breast milk of 20 out of 91 mothers (22%) in concentrations of 6.96 +/- 0.94 (pg/ml) in rural areas. Aflatoxin M(1) contamination was not present in samples of urban areas. The presence of aflatoxin M(1) was significantly associated with consumption of local milk (beta = 0.71, P < 0.001) and stunted growth in children (beta = -0.31, P < 0.015). These findings emphasize the need for developing strategies to reduce exposure to aflatoxin, possibly involving interventions targeted at reducing contamination of foods.

Association between fat content of breast milk and maternal nutritional status and infants' weight in tabriz, iran.

The aim of this study was to investigate the relationship between breast milk fat content with maternal anthropometric status, energy and macronutrient intake and weight for age Z-score of exclusively breastfed infants. Breast milk samples and information on energy and macronutrients intake (using 24-hour recall method for 3 days) were collected from 182 lactating women. Weight and height of mothers and infants were measured and the body mass index (BMI) and weight for age Z-score (WAZ) were calculated. The fat content of the milk samples was measured by the Gerber method. The mean daily energy intake was 2390 ± 405 kcal which was lower than the recommended values for mothers. The mean fat content of the milk samples was 3.52 ± 1.41 g/dl, which was significantly associated with dietary carbohydrate consumption (ß= 0.39, P<0.004) and BMI (ß= 0.28, P<0.02). A significant association between the WAZ of infants and maternal BMI (ß= 0.36, P<0.001) was recorded. The WAZ of infants whose mothers' breast milk lipid content was more than 3 g/dl was significantly higher than those whose mothers had lower breast milk lipid content (P<0.031). Further studies need to be done on the effect of fat content of breast milk on infant's weight and how maternal factors regulate the composition of breast milk.

Determination of free L-carnitine levels in type II diabetic women with and without complications.

BACKGROUND: Studies on the determination of carnitine levels and nutritional status in patients of type II diabetes. OBJECTIVE: We designed this study to determine changes of serum-free L-carnitine in type II diabetic women. DESIGN: A cross-sectional study (case-control study). SETTING: Clinical of Endocrinology and Metabolism, Sina Hospital, Pharmacological Research Center, Tabriz Medical university, Iran. PATIENTS AND METHODS: Taking into account the importance of the control of diabetes, in the present case-control study, the levels of serum-free L-carnitine, blood glucose and lipids, systolic and diastolic blood pressure, body mass index (BMI) and nutritional status assessed in the case and control groups which were selected by the simple sampling method. The control group (n=18) included patients with no complications and the case group (n=33) was grouped into three subgroups including patients with retinopathy, hyperlipidemia and neuropathy. RESULTS: Study results indicated that the mean serum-free L-carnitine concentration in the case group was significantly lower than its mean concentration level in the control group, 39.63+/-8.99 vs 53.42+/-0.93 micromol/l, respectively (P<0.001). Serum-free L-carnitine in retinopathy, hyperlipidemia and neuropathy case subgroups were 39.03+/-9.89, 39.63+/-8.99 and 40.44+/-12.50 micromol/l, respectively (P>0.05). No significant difference was found between the serum-free carnitine levels of the case subgroups. The mean blood glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol levels and systolic and diastolic blood pressure were significantly higher in the case group than in the control group. CONCLUSION: In this study, the mean serum-free L-carnitine levels in diabetic patients with complications was almost 25% lower than in diabetic patients with no complications. On the basis of the study results, carnitine supplementation in diabetic patients, especially in patients with diabetes complications, might be useful.

Preparing live donor for kidney donation.

PURPOSE: In order to select the most appropriate donor and minimize psychological and physical complications in the kidney donors, it is of high importance to prepare the donor meticulously. The essential respective items are reviewed in this study. MATERIALS AND METHODS: The available published literature and papers presented in Medline from 1983 to 2003 were reviewed. RESULTS: One the sources of sources of kidney donation is the live donor which is mostly used in Iran. Similarly, due to long waiting lists of kidney recipients, live donor kidney transplantation have been increasingly used in developed countries. Consequently, several aspects of this issue have been considered and specific recommendations have been discussed; anatomy of the donor's kidney, age, ABO blood group, viral infections, weight, HLA type compatibility, psychological status, and diseases such as diabetes, ADPKD, and Alport syndrome should be evaluated in donation candidates. CONCLUSION: Live donor kidney donation has the advantage of elective and programmed transplantation over cadaveric transplantation. However, removal of an intact organ from the body of a normal individual may lead to complications, as it may so in any other major surgical operation. Thus, it is strongly recommended to select the most appropriate donor patiently by a series of accurate evaluations.

Incisional hernia after renal transplantation and its repair with propylene mesh.

PURPOSE: Kidney recipients are susceptible to incisional hernia. We studied predisposing factors for incisional hernia in our patients and the results of its repair with propylene mesh. MATERIALS AND METHODS: From 1989 to 2002, 589 patients had undergone kidney transplantation in our hospital. Of these, patients who developed incisional hernia were evaluated in this study. The following data were collected from their records: age, gender, weight, age at graft rejection, surgical complications, treatment method, and the treatment results with propylene mesh. RESULTS: Of 589 recipients, 16 (3%) developed incisional hernia in surgical site. The median interval between kidney transplantation and developing of incisional hernia was 48 (range 12 to 425) days. Predisposing factors were overweight, age over fifty years, and female gender (P <0.005). In four patients, hernia was small, and the repair was performed without using mesh. Three patients were reluctant to hernia repair, and in 9, due to the large size of hernia, repair was done using propylene mesh. Having these 9 patients treated with propylene mesh, 2 developed serous collection in surgical site, which were managed successfully with multiple punctures. Hernia recurrence or infection was not noted in these patients during 3 to 36 months follow-up periods. CONCLUSION: Incisional hernia is not a rare entity after kidney transplantation. Predisposing factors, such as overweight, age over 50 years, and female gender have a role in its development. Also, repeated surgeries in kidney recipients can increase the risk of incisional hernia. Managing this complication with propylene mesh is a safe and effective method.

Epididymo-orchitis risk factors in traumatic spinal cord injured patients.

STUDY DESIGN: Retrospective audit and interview-based study of a traumatic spinal cord injured cohort, assessing the incidence and risk of epididymo-orchitis (E-O). OBJECTIVES: Assess the potential risk factors for E-O in this cohort (spinal cord injured patients). SETTING: Janbazan Clinic for Spinal Cord Injuries, Mashad, Iran. METHODS: A retrospective notes audit of 169 male traumatic spinal cord injured (SCI) patients was performed. In addition, interviews were performed to confirm any equivocal data. The following risk factors were assessed: history of recurrent urinary tract infections (UTIs), urethral stricture, urethral diverticuli, urinary fistula, urinary calculi, spinal injury type, neurogenic bladder type, autonomic dysreflexia, vesico-ureteral reflux, sphincterotomy, vasectomy, marriage status, bladder residual and emptying method, ejaculation, spinal injury level, micturation control, and muscular spasm, which included detrusor, external sphincter or lower limb spasm. RESULTS: A total of 65 patients from our group (38.5%) had suffered E-O at least once. E-O presented on average, 3.9 years after the SCI. Patients with a history of muscular spasm appeared less likely to develop E-O (P<0.05). None of the vasectomised patients developed E-O. The relation between all the other factors and E-O were not significant. CONCLUSIONS: Our study has shown that the presence of muscular spasm decreases the risk of E-O, although the mechanism remains unclear. Surprisingly, the other historical risk factors showed no clear relation with E-O occurrence.

Covered exstrophy and visceral sequestration with complete double bladder.

A 13-year-old boy had a complete double bladder and urethra associated with an inferior abdominal lesion, which on histological examination proved to be a colonic remnant with no communication to the underlying bowel. This entity is one of the exstrophy/epispadias complex variants known as covered exstrophy with sequestered bowel. Although 4 cases of this anomaly have been reported in the literature, to my knowledge this is the first such case with a double bladder. Excision of the lesion and the incontinent bladder was performed, and the ureter was reimplanted in the contralateral continent bladder.