Alcohol treatment systems in Muslim majority countries: Case study of alcohol treatment policy in Iran.

BACKGROUND: Alcohol is a leading risk factor for death and disability globally. Due to the Islamic prohibition of alcohol consumption, alcohol policy is an under-studied and sensitive topic in Muslim majority countries (MMCs). In addition, drinkers in these countries may face barriers to treatment access due to stigma or the legal status of alcohol. Using Iran as a case study this paper explores how alcohol treatment is planned and delivered in the complex environment of an MMC. METHOD: We searched academic and grey literature, clinical manuals, guidelines and policy documents for information on the development and implementation of alcohol treatment policy in Iran. The search was conducted in English, Persian and Arabic. We conducted 6 consultations to verify information obtained. We analysed information based on the Walt & Gilson health policy analysis triangle, which identifies context, process, actors and content as key factors for understanding policy. RESULTS: Iran initiated an alcohol-specific national strategy in 2011-2012 that aims to prevent, reduce and treat alcohol use disorders. This strategy has been designed to be implemented on a multi-sectoral level. Screening and prevention are mainly initiated in primary health care and cases are referred accordingly. Alcohol treatment is provided in specialised outpatient and inpatient settings. Due to contextual factors such as stigma, feasibility and affordability, alcohol outpatient units are planned to be integrated into existing public/ private drug addiction treatment facilities. However, the Ministry of Health has faced many challenges in implementing this pilot project. To date only small numbers of outpatient and inpatient units have formally commenced offering alcohol treatment. CONCLUSION: Implementing alcohol treatment has been challenging for Iran. Approval of new treatment programs may not be seen as a priority because of the low prevalence of alcohol use disorders in the country. Also, policy makers are implementing treatment services with caution due to the existing alcohol prohibition for the country's Muslim majority population. Barriers to treatment seeking need to be addressed at the micro and macro levels. Support from international agencies such as the WHO could assist MMCs to develop appropriate services that are feasible for their unique alcohol policy environment.

Alcohol policy in Iran: Policy content analysis.

BACKGROUND: Muslim majority countries (MMCs) typically have limited alcohol policy development due to Islamic prohibition of alcohol consumption. In response to recent increases in alcohol consumption and related harms, MMCs have introduced civil alcohol policies, ranging from total prohibition to European-style regulations. Using Iran as a case study, we describe how alcohol prohibition is translated into policy in the face of influences from globalisation. METHODS: We collected information from publicly available literature and policy documents, because of the sensitivity of the topic of alcohol in Iran. The search was conducted in English and Persian. We verified information through consultations with policy actors. We also reviewed newspapers over periods just before the 1979 Islamic revolution, and before and after the 2011 alcohol policy (2008-2010; 2014-2016) was introduced. We analysed policy content based on WHO policy recommendations and used the Walt & Gilson health framework to identify policy content, context, actors and process. RESULTS: Despite its broad approach of civil prohibition with concessions for the non-Muslim population, Iran has developed approaches to reduce the harmful impacts of alcohol and adopted nine of ten policy interventions recommended by WHO. Pricing policy was the only intervention not used. We identified contextual challenges, such as resources, stigma and cultural offence that influence policy development. CONCLUSION: MMCs face challenges in creating civil alcohol policies. Iran has taken steps, including a national alcohol strategy, to reduce alcohol-related harms. The socio-cultural, governance and historical context have shaped Iran's adaptation of policy interventions recommended by WHO.

Assessing the Global Burden of Ischemic Heart Disease: Part 1: Methods for a Systematic Review of the Global Epidemiology of Ischemic Heart Disease in 1990 and 2010.

BACKGROUND: Ischemic heart disease (IHD) is the leading cause of death worldwide. The GBD (Global Burden of Disease, Injuries, and Risk Factors) study (GBD 2010 Study) conducted a systematic review of IHD epidemiology literature from 1980 to 2008 to inform estimates of the burden on IHD in 21 world regions in 1990 and 2010. METHODS: The disease model of IHD for the GBD 2010 Study included IHD death and 3 sequelae: myocardial infarction, heart failure, and angina pectoris. Medline, EMBASE, and LILACS were searched for IHD epidemiology studies in GBD high-income and low- and middle-income regions published between 1980 and 2008 using a systematic protocol validated by regional IHD experts. Data from included studies were supplemented with unpublished data from selected high-quality surveillance and survey studies. The epidemiologic parameters of interest were incidence, prevalence, case fatality, and mortality. RESULTS: Literature searches yielded 40,205 unique papers, of which 1,801 met initial screening criteria. Upon detailed review of full text papers, 137 published studies were included. Unpublished data were obtained from 24 additional studies. Data were sufficient for high-income regions, but missing or sparse in many low- and middle-income regions, particularly Sub-Saharan Africa. CONCLUSIONS: A systematic review for the GBD 2010 Study provided IHD epidemiology estimates for most world regions, but highlighted the lack of information about IHD in Sub-Saharan Africa and other low-income regions. More complete knowledge of the global burden of IHD will require improved IHD surveillance programs in all world regions.

Complex reconstruction of supraaortic branches.

OBJECTIVE: The present paper exemplary describes several severe stenoses of supraaortic branches with its symptoms and operative treatments. METHODS: Eight patients, two female (68 ± 5 y), six male (73 ± 4 y), were retrospectively evaluated. Patients showed neurological signs as followed: recurring attacks of vertigo (80%), temporary paresis of extremity (20%), speech disorders (20%) and subclavian and/or carotic-steel-syndrome (15%). Seven patients have already been previously treated with revascularization of the supraaortic branches in the past. The surgical techniques used were thrombendarterectomy of the internal carotid artery, carotid-subclavian bypass and complex aorto-truncal, aorto-carotid and aorto-subclavian-bypass. RESULTS: One patient died nine days postoperatively due to myocardial infarction. Mean duration of stay on intensive care unit was 1.5 days. Mean duration of postoperative ventilation was six hours. Average duration of stay on normal ward was nine days. CONCLUSION: This study presents several complex reconstructions of supraaortic branches, which were indicated in cases with severe stenoses of supraaortic branches. Even though treatment strategies were complex the peri- and postoperative complication rates are quite low. These therapeutic strategies were necessary to avoid severe neurological complications in these patients.

Morphological investigations of type A aortic dissection.

PURPOSE: The aim of this study was to analyze systematically the morphology of aortal segments of Type A dissection. METHODS: Nineteen patients were operated on for Type A dissection in the Department of Thoracic, Cardiac, and Vascular Surgery in Goettingen, Germany, from January 2002 to January 2005. All diagnoses were confirmed by transesophageal echocardiography and computed tomography of the chest. All taken aortic segments were examined by the conventional histological and electron microscopical method. RESULTS: Besides subadventitial hyperplasia of collagen filaments, the preparations showed hyperplasia of endothelial cells with loose cellular junctions, desquamation of endothelial cells, and morphological changes of endothelial cells with villius development, as well as signs of aortitis. CONCLUSION: The present results arouse suspicion of local inflammation of the aortic wall, but with moderate progress under strong hyperplasia. Because of rupture of the intima, the inflammation appears as an acute disease.

[Norman Edward Shumway - pioneer of cardiac surgery (February 9, 1923 to February 10, 2006)]. / Norman Edward Shumway - Pionier der Herzchirurgie (9. Februar 1923 bis 10. Februar 2006).

After a fulfilled life, Norman E. Shumway, the great pioneer of cardiac transplantation, died of lung cancer 1 day after his 83rd birthday in Palo Alto, California, USA. Already at the beginning of the 1960s, he and his colleague Richard R. Lower did revolutionary experimental work on developing and establishing the technique of orthotopic cardiac transplantation in dogs. Several studies on cardiac transplantation were carried out in his department and a few years later, Shumway and his team were on their way to perform the worldwide first human-to-human cardiac transplantation. On December 3, 1967, Christiaan Neethling Barnard, a cardiac surgeon from South Africa, forestalled Shumway and performed this operation in Cape Town, South Africa. This event initiated a global boom of cardiac transplantations in the following years." Many heart centers started their own cardiac transplant programs but high mortality rates led again to stagnancy of transplant activities. Shumway remained stable in believing in good results of cardiac transplantation and continued his program steadily. At the beginning of the 1970s, he and his group were responsible for most cardiac transplantations worldwide.

Hypothermic renal protection using cold histidine-tryptophan-ketoglutarate solution perfusion in suprarenal aortic surgery.

We examined data of 21 patients who were treated with selective perfusion of both renal arteries with 500 mL of 8 degrees C histidine-tryptophan-ketoglutarate (HTK) solution each for renal protection during aortic surgery. Only the data from aortic surgeries with unavoidable suprarenal aortic cross-clamping for juxtarenal or suprarenal abdominal aortic aneurysms (AAAs) or high Leriche syndrome accompanied with stenosis of renal arteries are presented. Five patients underwent immediate surgery because of perforation of an AAA; the other 16 patients went through elective surgeries. In three cases (14%) stenosis of the renal arteries was diagnosed; nevertheless, implantation of an aortorenal bypass was necessary in seven patients. In total, 14 aortorenal bypasses were implanted (five venous grafts and nine prosthesis grafts). Four (19%) patients needed catecholaminergic support to establish stable circulatory conditions; in two (9%) of these cases additional ischemia of the colon was observed and sigmoidectomy was performed. All of these four patients underwent immediate surgery, and one died after surgery because of severe sepsis. In four cases postsurgical renal insufficiency was observed. Three of these patients were admitted for emergency surgery because of their hemodynamic situation due to perforation of the AAA. None of the patients needed chronic dialysis after surgery. Whereas in all patients who underwent elective surgery the renal function remained stable as judged by postoperative serum creatinine values, in five out of seven patients with aortorenal bypass surgery the renal function improved. Perfusion with cold HTK solution offers an additional procedure to protect renal function in patients undergoing elective surgery with suprarenal cross-clamping of the aorta.

Miniaturized HIA microdiagonal pump as left ventricular assist device in a sheep model.

We evaluated the newly developed miniaturized HIA microdiagonal blood pump (MDP) as a continuous flow left ventricular assist device. In a sheep model (n = 6), the MDP was implanted through left lateral thoracotomy and placed paracorporeally with inflow conduit to left atrium and outflow conduit to descending aorta. The sheep were pumped at a mean flow rate of 2.5 L/min for 7 days. Anticoagulation was applied by intravenous heparin administration. Postoperatively, activated clotting time was held stable with values of 200 seconds. During follow-up, blood samples (creatinine kinase, creatinine, glutamic-oxaloacetic transaminase (aspartate aminotransferase) (GOT), glutamate dehydrogenase (GLDH), gamma-GT, plasma-free hemoglobin, and hemoglobine) were taken daily. After 7 days, the sheep were killed for macroscopic examination. Systemic artery pressures remained stable during the whole test period. Because of operative reasons, the hemoglobin value (7.5 +/- 0.61 g/dl) decreased perioperatively, but recovered within the test period, whereas creatinine kinase increased initially after thoracotomy, but decreased to normal within days. Renal and liver functions were slightly impaired perioperatively, indicated by temporarily enhanced values of GOT, gamma-GT, GLDH, and creatinine. The MDP did not produce significant hemolysis as measured by plasma-free hemoglobin levels. Wound infections did not occur. We conclude that the MDP ran successfully as an left ventricular assist device for 7 days in sheep has potential for long-term support, and may serve as an alternative to current technologies. Presented data were not obtained in a clinical trial; however, the results are promising enough to proceed with longer duration animal studies.

A new storage solution for porcine aortic valves.

The aim of this study was to assess the calcification tendency of two biovalves manufactured by different fixation techniques and compare their biocompatibility when implanted subcutaneously in rats. Two biological valve types (Intact) and Mosaic, stored in either glutaraldehyde or in a solution recently developed in our department, were investigated ultrastructurally and their calcium content was measured following 12 weeks subcutaneous implantation in rats. All valves tested in this study showed a considerable loss of the endothelial cover, as judged by scanning electron microscopy. Independent of fixation conditions, the bioprostheses demonstrated a partial destruction of collagen fibers and a rearrangement of the extracellular matrix. The calcium content of Intact valves was significantly higher than that of Mosaic valves (66+/-2.6 versus 3.6+/-0.6 mg/g dry tissue, p<0.0001). Low calcium content of the bioprostheses is considered to result from effective anti-calcification treatment. Ultrastructural changes of prosthetic tissue seem to promote degenerative calcification. The valves stored in the new storage solution exhibited a calcium content which was reduced by approximately 50% compared to those stored in glutaraldehyde. The percentage of reduction in calcification of the valves stored in our newly developed solution is independent of the fixation conditions (p=0.886). The advantage of the new storage solution is based on the fact that rinsing is unnecessary before implantation and, most importantly, a clear reduction in the calcification tendency is achieved.

Myocardial ischemia tolerance in the newborn rat involving opioid receptors and mitochondrial K+ channels.

Neonatal rat hearts are more tolerant to ischemia compared to adult rat hearts. We hypothesized that opioid receptors and mitochondrial potassium channels are involved in the elevated ischemia tolerance of neonatal rats. Newborn rats were treated by an intraperitoneal injection with sodium chloride (placebo, Pla; n = 7), naloxone (Nal; n = 8), or K+ (ATP) channel blocker 5-hydroxydecanoate (HD; n = 8), or were left untreated (sham; n = 8). Thirty minutes after injection, the rats were sacrificed and hearts were arrested cardioplegically and fixed with aldehyde fixative 90 min after global ischemia at room temperature. For control, newborn rat hearts were fixed immediately after sacrifice. Ventricular tissue blocks were prepared for electron microscopy. Mitochondrial (volume-weighted mean volume of mitochondria) and cardiomyocyte volume (cellular edema index, CEI) were estimated to quantify the ischemic injury. Compared to control myocardium, CEI was increased by 244% +/- 39% in sham, 173% +/- 28% in Nal, 142% +/- 25% in HD, and 101% +/- 24% in Pla (P < 0.05 between groups). Volume-weighted mean volume of mitochondria was increased by 514% +/- 235% in sham, 341% +/- 110% in Nal, 458% +/- 149% in HD, and 175% +/- 70% in Pla. Differences between Pla and other groups were significant (P < 0.01 for all). No significant difference was observed between the other groups. Thus, ischemic injury was smallest with placebo, indicating a mechanism similar to preconditioning induced by the intraperitoneal injection. This response was attenuated by blockade of opioid receptors and mitochondrial potassium channels, suggesting their involvement in the elevated ischemia tolerance of newborn rat hearts.

Manejo cirúrgico de doenca oclusiva aorto-ilíaca na presenca de rim em ferradura: relato de um caso / Operative management of aortoiliac occlusive disease in presence of horseshoe kidney: report of a case

Neste trabalho é apresentado um caso de coexistência de aterosclerose aorto-ilíaca com rim em ferradura, em um homem com 57 anos de idade. O diagnóstico desta combinacão rara foi feito pouco antes da cirurgia, com a angio-ressonância magnética constituindo o método diagnóstico pré-operatório mais importante para o planejamento cirúrgico. A abordagem transabdominal proporciona uma exposicão excelente da aorta abdominal em pacientes com rim em ferradura, sem risco de lesão das artérias renais acessórias ou de ureter em posicão anômala. A reconstrucão foi feita com a implantacão de uma prótese de Dacron em Y em posicão aorto-bifemoral e, por causa da lesão aterosclerótica difusa e na presenca do rim em ferradura, foi optado por anastomose proximal término-lateral.

Evidence of woven bone formation in heart valve disease.

The pathogenesis of acquired cardiac valve disease still remains a matter of controversy. In this work, scanning electron and polarised light microscopic investigations in addition to energy dispersive X-ray microanalyses (EDAX) were carried out on explanted human aortic and mitral valves to determine the morphology and element composition of calcified areas in valvular lesions. Biopsies were taken from aortic valves removed from 28 male patients (average age, 75+/-1 years) and 46 females (68+/-3 years) and from mitral valves obtained from 18 male patients (72+/-3 years) and 8 females (71+/-6 years). By means of scanning electron microscopy, multiple foci of calcified areas were identified. Endothelial cells in these areas appeared swollen and displayed reduced cell-cell contacts. The calcium deposits were separated from the adjacent tissue by layers of collagen fibers. Often a layer of woven bone tissue separated intravalvular inclusions from hyperplastic collagen fibers. Using EDAX analysis, calcium and phosphorus were detected in these valvular lesions. The major finding of our study is the presence of woven bone tissue in explanted cardiac valves, which may result from pathological strains or mechanical overloading of the collagen fibers.

Pulmonary Langerhans' cell histiocytosis (histiocytosis X) following metastasizing malignant melanoma.

BACKGROUND: Pulmonary Langerhans' cell histiocytosis (histiocytosis X) is an uncommon, diffuse interstitial lung disease of unknown cause, mostly presenting in young smokers. Association of pulmonary Langerhans' cell histiocytosis with a malignant neoplasm is rare. CASE DESCRIPTION AND RESULTS: We present and discuss the case of a 48-year-old man (ex-smoker) with metastasising malignant melanoma. A few months after chemotherapy and a modified Whipple procedure for retroduodenal metastasis of a malignant melanoma, computer tomographic scans revealed intrapulmonary "ring-shaped structures". Endobronchial biopsies and bronchioalveolar lavage showed no evidence of neoplasm or inflammation. Open-lung biopsy was performed and revealed pulmonary Langerhans' cell histiocytosis. CONCLUSION: To our knowledge this is the first reported case of pulmonary Langerhans' cell histiocytosis in association with malignant melanoma. Chemotherapy for malignant melanoma may be related to the development of pulmonary Langerhans' cell histiocytosis.

Orthotopic SCID mouse model with two newly established human lung squamous carcinoma cell lines.

The objective of this study was to present an orthotopic SCID mouse model using two newly established human cell lines derived from squamous cell carcinomas of the lung. GO-LCC1 cells (1 x 10(6)) and GO-LCC2 cells (3 x 10(6)) were implanted orthotopically into the right lungs of 10 C.B. 17 scid/scid mice. In both groups, aggressive tumor growth with partial infiltration of the thoracic wall, heart and diaphragm was observed. In only one case distant metastases in the contralateral lung were detected, while all animals developed tumors at the site of inoculation. Xenografted GO-LCC1 cells showed enhanced tumor propagation compared to GO-LCC2 cells. Our data underscore the usefulness of the SCID mouse model to study the biological behaviour of cultuved human tumor cells and furthemore demonstrate the clinical applicability of xenograft techniques using human tumor cell lines derived from pneumonectomy specimens of squamous lung carcinomas.

Ultrastructural alterations in acquired aortic and mitral valve disease as revealed by scanning and transmission electron microscopical investigations.

Scanning and transmission electron microscopical investigations were carried out on explanted human aortic and mitral valves to study the prevalence of hyperplastic and degenerative lesions in acquired valvular dysfunction. Biopsies were taken from 67 aortic and 23 mitral valves. All of the valves examined showed degenerative lesions including a loose binding of the endothelial cells, a partial denudation of the endothelial cover and areas of fibrous hyperplasia surrounded by calcium deposits. Additionally, the formation of various excrescences was detected by means of scanning electron microscopy. Of all excrescences identified, 90% were localized at the free margin of the leaflet, 3% in the subnodular region and 7% in the nodule of Arantius. The ratio of filiform to lamellar forms of hyperplastic lesions was approximately 80% in most of the samples examined. The results presented demonstrate the complex ultrastructural features of surgically explanted human valves showing both degenerative and hyperplastic lesions in the same valve.