Does a medical management program for CKD patients postpone renal replacement therapy and mortality? A 5-year-cohort study.

BACKGROUND: Many countries have started screening and prevention programs for chronic kidney disease (CKD). However, one of the main concerns of health authorities is whether management strategies for diagnosed CKD patients can decrease mortality or morbidity. This study aimed to investigate the effect of two competing clinical strategies of treatments under nephrologists' supervision compared with no treatment on the frequency of the need to start renal replacement therapy (RRT) and mortality in CKD patients. METHODS: Our cohort comprised consecutive newly diagnosed patients with CKD in an outpatient clinic in Tehran between October 2002 and October 2011. CKD Patient enrollment occurred if two criteria of high plasma creatinine level and chronicity of renal disease by at least 3 months of clinical history or small sized kidneys in ultrasound findings were met. Demographic data and time of RRT or mortality in patients who had been followed up regularly were compared with those in the control group. The control group included those patients who did not attend a nephrology clinic to receive CKD management package for at least 1 year during the study period. RESULTS: The cohort included 76 patients in the control group and 389 patients in the supervised group. The mean age of the patients was 61.33±14.9 years (16-95 years). The ratio of males/females was 1.47 (277/188). The mean follow-up in the control and supervised groups was 33.29±20.50 (7-111) and 36.03±25.24 (6-124) months , respectively, and the total patient years of follow-up was 1382.3. A substantial number of patients survived without RRT until the first year of follow up (96%) in both groups, but afterward, those in the control group had more deaths or need to start RRT in comparison with those who received medical advice (20 vs. 67 months; p= 0.029). This cohort also showed a higher survival and a longer time to show a GFR of less than 15 cc/min (84 vs 34 months, p<0.0001) in patients who had been under physician supervision compared with the control group. CONCLUSIONS: Active follow-up of CKD patients appears to significantly decrease the risk of death or progression to end-stage renal disease and the requirement to start renal replacement therapy.

A Systematic Review of Systematic Reviews on the COVID-19 Pandemic.

COVID-19 a systemic inflammation involving multiple organs, affecting all age groups, with high mortality rate, severe adverse outcomes, and high economic burden need to be described. A systematic review of systematic reviews conducted. We searched PubMed, OVID Medline, Cochrane library, COVID-19 resource centers of N Engl. J Med, AHA, and LITCOVID. Certainty of evidences was evaluated by GRADE approach. Meta-analysis according to random effects model was conducted. Seventy-one eligible systematic reviews are included in the study. A total of 86.5% of them had high quality, and 13.5% had medium quality. Meta-analysis results are presented in tabular format, and the remaining results are presented in narration fashion. COVID-19 involves blood vessels, lung, heart, nervous system, liver, gastrointestinal system, kidney, eyes, and other organs and infects adult and children, neonates, pregnant women, and elderly, transmitted via air born and droplet. Comorbidities associated with COVID-19 are HTN 20.7%, CVD 9.6%, DM 9.55%, respiratory diseases 7%, and 9% of cigarette smoking. Prognostic factors for mortality among COVID-19 cases are acute cardiac injury, diagnosed CVD, DM, respiratory disease, and HTN. Prognostic factors for disease severity are CVD and HTN. Prognostic factors for disease progression were fever, shortness of breath, and smoking. There is no specific antiviral treatment. Preventive measures including physical distancing of 2 m and more, using PPE, avoiding social gatherings, quarantine, and isolation have been recommended. Encouraging telemedicine, online training, and homeschooling are highly recommended. Vaccine is approaching, and concerns exist about vaccine with a high efficacy. Modification of CVD and cardiometabolic risk became the cornerstone for sustainable control of pandemic.

Multiple inflammatory prognostic factors in acute coronary syndromes: a prospective inception cohort study.

Inflammatory basis in pathopoiesis of coronary artery disease (CAD) have been demonstrated in recent decades. Elevated C-Reactive Protein (CRP) and leukocytosis were associated with an elevated risk for acute coronary syndrome (ACS). To evaluate the relationship between quantitative CRP and cardiac troponin I in conjunction with white blood cell (WBC) count and 30 days outcomes and treatment planning in patients with ACS. A concurrent inception cohort study was designed involving 200 patients as exposed and 200 patients as non exposed groups. We evaluated the relationship between baseline CRP and WBC count and cardiac troponin I , other risk factors and biomarkers, angiographic and other para-clinical tests and clinical outcomes with ACS. Higher CRP and WBC count were associated with additional coronary care unite (CCU) admission days (P = 0.002), hospitalization days (P = 0.007), arrhythmia type (P = 0.007), receiving streptokinase (P = 0.001), angiographic findings (P = 0.003), final myocardial infarction versus unstable angina (P = 0.001), date of complication (P = 0.001) and the date of cardiopulmonary resuscitation (if incident) (P = 0.015). In a multivariate Cox proportional hazard model high CRP and WBC count remained strong predictor of mortality (P = 0.028), angiography findings (three Vessel disease (3VD) and left main (LM) disease) (P = 0.001), and readmission in CCU (P = 0.002). A cardiac troponin I above 0.1 microg/lit was considered elevated. Elevated troponin level, demonstrated a significant relationship with MI incidence between two groups (P = 0.001) (89% in troponin positive group versus 11% in troponin less than 0.1 microg/lit). Inflammatory markers including, CRP and WBC count can be used to predict mortality, readmission, 3VD and LM disease in patients with ACS. In a Cox Proportional Hazard Model cardiac troponin above 0.1 microg/lit was significant predictors of MI (P = 0.003) and CPR (P = 0.044) at 30 days follow up period.

Iranian school teachers: knowledge and attitude toward ecstasy.

UNLABELLED: The drug ecstasy has been increasingly used for recreational purposes, especially among students. Teachers play an important role in altering student attitudes toward ecstasy. OBJECTIVE: The aim of this study was to access teacher knowledge and attitude toward ecstasy and its side effects. METHODS: In a cross-sectional study, 460 teachers from 20 public and 10 private schools were randomly invited to participate in the study between April 2005 and April 2006 and their knowledge and attitudes toward ecstasy were collected on the basis of a designed questionnaire. RESULTS: No significant correlation was found between knowledge about ecstasy and gender, whereas, there was a positive relation between knowledge and education level of the teachers (P = .033). Attitude was higher in female participants (P = .012), but was not related to the age of the teachers. We found no relation between attitude toward ecstasy and the teachers' education levels. CONCLUSION: Knowledge about ecstasy and its side effects was dependant on the teachers' education level, whereas their attitude toward ecstasy was dependent on the teachers' gender.

The Relationship Between Premature Myocardial Infarction with TC/HDL-C Ratio Subgroups in a Multiple Risk Factor Model.

INTRODUCTION: So far, there is no evidence available to demonstrate the relationship between five subgroups of total cholesterol/high density lipoprotein cholesterol (TC/HDL-C) ratio with premature myocardial infarction (MI). OBJECTIVE: We conducted a case control study to probe more features of the relation between TC/HDL-C ratio and the five subgroups of the ratio with myocardial infarction under 55 years and above it. METHOD: A hospital based case control study with incident cases was designed. Cases and controls were comprised of 523 under 55-year and 699 above 55-year documented newly diagnosed MI cases, respectively. Standardized clinical and para clinical method were used to ascertain disease and risk factors. Independent sample t-test, Pearson chi square test, Odds ratios and Mantel-Haenszel test and logistic regression analysis conducted to evaluate relationships. RESULTS: This study enrolled 1222 MI cases. Patients with very low risk category of TC/HDL-C ratio estimated OR=0.18 with 95% confidence interval (CI) (0.04-0.72) for developing MI under 55 years. Patients who had low risk category of TC/HDL-C ratio having OR=0.26 95% CI (0.07-0.89). Low risk and very low risk categories of the TC/HDL-C ratio compare to high risk subgroup of the ratio demonstrate decreased risk of developing MI under 55 years p<0.05. CONCLUSION: Our study results can be translated as an aggressive treatment for lowering TC/HDL-C ratio in both general population and victims of coronary events. Mitigation of the level of TC/HDL-C ratio from low risk to very low risk category will attenuate the risk of MI under55 years about 8% which is the immediate clinical implication of our findings.

Outcome of coronary artery bypass grafting in patients without major risk factors and patients with at least one major risk factor for coronary artery disease.

BACKGROUND: Coronary artery bypass grafting (CABG) has become a safer procedure in recent years. AIMS: We aimed to compare complications and early outcome of CABG in patients without history of general risk factors with those in patients with at least one general risk factor for coronary artery disease (CAD). SETTINGS AND DESIGN: Cross-sectional study. MATERIALS AND METHODS: Postoperative in-hospital complications, 30-day mortality rate and length of stay in hospital of 708 patients without preoperative general risk factors undergoing CABG in three university hospitals were assessed and compared with 10,844 patients undergoing CABG with at least one general risk factor as controls. In addition, the association of the studied variables with patients' early outcome was evaluated. STATISTICAL ANALYSIS: SPSS software with Pearson's chi2 test; independent sample t test, Mann-Whitney test and univariate analysis were used. RESULTS: All studied in-hospital complications were similar between the two groups. Thirty days mortality rate (0.7% in study group and 1.4% in control group) was similar between groups, whereas prolonged length of stay (>12 days) was more frequent in control group (61.33% vs. 71.36%, P<0.0001). Atrial fibrillation (P<0.0001) was a strong predictor for prolonged length of stay in hospital. CONCLUSION: Most aspects of early complications after CABG, as well as 30-day mortality rate, were similar between patients with and without general risk factors for coronary artery disease undergoing CABG.

Ankle-Brachial Index as a Prognostic Factor and Screening Tool in Coronary Artery Disease: Does it Work?

BACKGROUND: Given the lack of consistency in the literature regarding the reliability of the ankle-brachial index (ABI) as a valid screening tool and an independent risk indicator of cardiovascular events and mortality, we compared it with angiography as a reference standard test. METHODS: This case-control study, conducted between 2010 and 2011 in Tehran Heart Center, recruited 362 angiographically confirmed cases of coronary artery disease (CAD) and 337 controls. A standard protocol was used to measure the ABI and different CAD risk factors. RESULTS: A low ABI had specificity of 99.7%, positive predictive value of 95.8%, negative predictive value of 49.8%, sensitivity of 64%, likelihood ratio of 24.07, and odds ratio (OR) of 22.79 (95%CI: 3.06-69.76). The role of the associated risk factors was evaluated with OR (95%CI), with the variables including gender 3.15 (2.30-4.30), cigarette smoking 2.72 (1.86-3.99), family history 1.72 (1.17-2.51), diabetes 1.66 (1.15-2.4), and dyslipidemia 1.38 (1.02-1.88). In a multivariate model, the following variables remained statistically significantly correlated with CAD [OR (95%CI)]: ABI 13.86 (1.78-17.62); gender 3.69 (2.43-5.58); family history of CAD 2.18 (1.41-3.37); smoking 1.69 (1.08-2.64); age 1.04 (1.02-1.06). CONCLUSIONS: A low ABI had specificity of 99.7%; however, because of its low sensitivity (64%), we should consider CAD risk factors associated with a low ABI in order to use it as a first-line screening test.

Medical student's benefit rates from the clinical teaching rounds and its associated factors in Tehran University of Medical Sciences in the year 2010.

Among the various methods of clinical teaching, rounds and grand rounds are considered as the gold standards. Clinical round includes some standard components and it plays an effective role in student's learning process. The aim of this study was to evaluate the content of teaching rounds in 40 clinical wards in 4 medical teaching hospitals affiliated to Tehran University of Medical Sciences in Tehran, Iran, and also to assess the learners benefit rate from these programs and determine the factors affecting those. This is a cross sectional, descriptive and analytical study conducted on 318 medical learners in different grades, about the content of clinical rounds. The data collection tool was a questionnaire made by researchers. The validity of the questionnaire according to experts opinions and the reliability with a pilot study conducted on 30 cases were confirmed (α=0.826). Data entered into the SPSS software and for analysis Chi-square, Student's t-test, ANOVA and linear regression analysis tests were used. In this study 20 subjects related to clinical rounds content were assessed. The highest score was related to the subject of diagnosis and the lowest one was related to legal issues. Overall, the mean score of the learner's benefit rate to this method was 3.52 out of five. The level of learner's benefit rate was above the average and the benefit rates according to educational grade, number of the students and faculties were significantly different (P<0.05). Average of the benefit rate among residents were significantly higher than the other medical trainees (P<0.05). In conclusion, in understudied clinical rounds, there has been more emphasized on history taking, clinical examinations and diagnosis subjects, and Issues like: accountability, health economy, patient's nutrition, non-drug treatments and medical legal issues are less considered in the studied rounds.

Pattern of coronary artery disease risk factors in population younger than 55 years and above 55 years: a population study of 31999 healthy individuals.

More than eighty percent of patients with coronary heart diseases (CHD) have conventional risk factors. Prevalence of well known risk factors seems to show a different pattern in younger patients and individual above 55 years. To evaluate the pattern of conventional CHD risk factors in healthy individuals in two different age groups. A large scale population based survey of 31999 individuals from ten medical centers was designed. Screening of risk factors was performed upon these protocols: taking medical history, physical examination and blood tests of complete blood cell counts, fasting blood sugar, lipid profile, urinalysis and creatinine. Prevalence of the risk factors in healthy people aged above 55 years were: 8.1% for systolic blood pressure (SBP)>140 mmHg, 3.8% for diastolic blood pressure (DBP)>90 mmHg, 13.9% for fasting blood glucose (FBS)≥126 Mg/dl, 36.9% for total cholesterol>200 Mg/dl, 19.2% for triglyceride (TG)>200 Mg/dl, 67.8% for HDL-c<40 Mg/dl, 27.2% for LDL-c>130 Mg/dl, 4.72 for TC/HDL-c ratio, 2.88 for LDL-c/HDL/c ratio and 4.24 for TG/HDL-c ratio. Prevalence of risk factors in individuals younger than 55 years were: 1.7% for SBP>140 mmHg, 1.2% for DBP>90 mmHg, 5.2% for FBS≥126 Mg/dl, 31.3% for TC>200 Mg/dl, 21.5% for TG>200 Mg/dl, 69.4% for HDL-c<40 Mg/dl, 23.2% for LDL-c>130 Mg/dl, 4.7 for TC/HDL-c ratio, 2.83 for LDL-c/HDL-c ratio and 4.43 for TG/HDL-c ratio. In univariate model of analysis: prevalence of the risk factors were significantly higher in age above 55 years than in people younger than 55 years except for hypertriglyceridemia and HDL-c<40 Mg/dl. In a multivariate model of logistic regression, pattern of following CHD risk factors remained to demonstrate a statistically significance difference between two age groups: FBS≥126 Mg/dl P=0.006, TG>200 Mg/dl P= 0.002, HDL-c<40 Mg/dl P= 0.019, education status P=0.001, sex P=0.012, and SBP>140 mmHg P=0.001. Pattern of such a CHD risk factors of FBS≥126 Mg/dl, TG>200 Mg/dl, HDL-c<40 Mg/dl, education status, sex and SBP>140 mmHg demonstrated a statistically significant difference in the age above 55 years to the healthy people younger than 55 years. These results cab be implicated to set up prediction models for stratifying individuals at higher risk of CHD.

Trend of lipid ratios associated with well known risk factors of coronary artery disease in different age: a population based study of 31,999 healthy individuals.

BACKGROUND: Developing current evidence in order to better assess the rates and pattern of the CAD risk factors among populations is pivotal in CAD risk stratification. METHODS: A large scale population based survey involving 31,999 healthy people was designed. Risk factors information was provided from medical history, physical examination and laboratory assessments. RESULTS: Increasing linear trend was observed for: cigarette smoking (CS) (P=0.001), systolic blood pressure (SBP)> 140 mmHg (P=0.001), diastolic blood pressure (DBP)> 90 mmHg (P=0.001), SBP> 120 mmHg (P=0.001), DBP> 80 mmHg (P=0.001), fasting blood glucose (FBS)> 126 Mg/dl (P=0.001), total cholesterol (TC)>200Mg/dl (P=0.001), triglyceride> 200 Mg/dl (P=0.001), TC> 170 Mg/dl (P=0.001), and LDL-c> 130 Mg/dl (P=0.001). Multivariable adjusted magnitudes of associations for risk factors across age groups were statistically different, thus in an age group of 30-40 years: cigarette smoking, high DBP, increased body mass index (BMI), high level of FBS and lower level of education demonstrated strongest associations. In an age group of 40-50 years: CS, high level of DBP, increased BMI, FBS> 126 Mg/dl, and SBP> 120 mmHg, in an age group of 50-60 years: SBP> 120 mmHg, CS, higher level of DBP, and FBS> 126 Mg/dl, and in above 60 years: SBP> 120 mmHg, HDL-c< 45 Mg/dl, C/S and FBS have demonstrated the strongest associations. CONCLUSIONS: Trends of increment in the mean levels of SBP, DBP, TC, LDL-c and FBS are statistically significant across age decades. Multivariate strength of associations for CAD risk factors demonstrates significant differences across age groups.

Relationship between the pattern of coronary artery disease risk factors and lipid ratios with five groups of body mass index in 28566 healthy adults.

Pattern of the coronary artery disease (CAD) risk factors across body mass index (BMI) categories remains uncertain. There is a different threshold of obesity for increasing cardiovascular hazard across populations, accordingly recognition and management of obesity and overweight can guide better control of CAD epidemic in the national level. To determine the discrepancy in the prevalence of CAD risk factors across five BMI categories. A population based survey of 28566 participants recruited to medical screening of taxi drivres in Tehran (MSTDT) was designed. According to a standardized protocol data on CAD risk factors were obtained by taking medical history, examination and laboratory tests. After adjustment for age, sex, literacy, smoking, systolic blood pressure (SBP), fasting blood sugar (FBS), and LDL-C/HDL-C ratio, these CAD risk factors of diastolic blood pressure (DBP)>90 mmHg, hypertriglyceridemia, high triglyceride/ HDL-C ratio, hypercholesterolemia, and high cholesterol/HDL-C ratio were increased significantly across five incremental categories of BMI. Prevalence of DBP> 90 mmHg, hypertriglyceridemia, hyper cholesterolemia and ratios of cholesterol/ HDL-C and TG/HDL-C increased considerably across five groups of BMI. This pattern is different from previous research and our results endorsed more features of pattern of CAD risk factors across BMI categories.

Teaching evidence-based medicine more effectively.

UNLABELLED: Evidence-based Medicine (EBM) is becoming an integral component of graduate medical education competency and a requirement for grad medical education practice-based learning core competency. This study tries to compare the efficacy of conferences utilizing small-group discussions with the traditional conference method in enhancing EBM competency. The participants in this randomized controlled trial (RCT) were 170 members of the medical faculty who were divided into two groups of 86 (intervention) and 84 (control). Following the intervention, EBM competency was assessed by a written examination. statistical analysis made use of chi-square test, independent sample t-test and relative risks for univariate analysis. Mantel-Hanszel was used for bivariate analysis. Cox proportional hazard models were used to evaluate multivariate-adjusted associations between EBM educational intervention and EBM knowledge, attitude and skills. A new indicator of number needed to intervention (NNI) was defined and computed. RESULTS: The results proved conference along with small-group discussion to be a more effective teaching method with P=0.001 on knowledge, P<0.001 for attitude and skills P<0.001 in an EBM exam when compared with medical faculty members who did not participate in EBM educational intervention (n=84). Moreover, they had also increased confidence with critical appraisal skills, and searching EBM resources. CONCLUSIONS: Conferences followed by small-group discussions significantly enhance EBM knowledge, attitude, critical appraisal skills and literature review skills.

Overweight and obesity and their associated factors in adolescents in Tehran, Iran, 2004-2005.

OVERVIEW: Obesity is a significant health crisis around the world. Of great concern are the data pointing to the recent increase in the prevalence of obesity irregardless of age group and country. Overweight and obesity in adolescence are markers of overweight and obesity in adults, respectively. Very little data are currently available on the prevalence of childhood obesity in Iran, and more research on the risk factors is required before preventive public health programs can be formulated and put into practice. OBJECTIVE: The objective of this study was to quantify the prevalence of overweight and obesity and their associated factors in adolescent children living in Tehran. MATERIALS AND METHODS: During a multistage stratified cluster sampling, 2900 students (1200 males and 1700 females) aged 11-17 years were selected from 20 secondary schools in the school year of 2004-2005. A questionnaire was filled, and weight and height were measured. DISCUSSIONS AND CONCLUSIONS: The body mass index (BMI) was calculated and adjusted for age and sex. Prevalences of overweight and obesity were 17.9 and 7.1%, respectively. BMI increased with age, and it was higher in those who had lower levels of physical activity. Age at menarche was negatively associated with BMI. There was no relationship between macro- and micronutrient intake and overweight and obesity. This study highlights the high prevalence of overweight and obesity in adolescent children in Tehran.

Outcome of coronary artery bypass grafting in patients without major risk factors and patients with at least one major risk factor for coronary artery disease.

BACKGROUND: Coronary artery bypass grafting (CABG) has become a safer procedure in recent years. AIMS: We aimed to compare complications and early outcome of CABG in patients without history of general risk factors with those in patients with at least one general risk factor for coronary artery disease (CAD). SETTINGS AND DESIGN: Cross-sectional study. MATERIALS AND METHODS: Postoperative in-hospital complications, 30-day mortality rate and length of stay in hospital of 708 patients without preoperative general risk factors undergoing CABG in three university hospitals were assessed and compared with 10,844 patients undergoing CABG with at least one general risk factor as controls. In addition, the association of the studied variables with patients' early outcome was evaluated. STATISTICAL ANALYSIS: SPSS software with Pearson's chi2 test; independent sample t test, Mann-Whitney test and univariate analysis were used. RESULTS: All studied in-hospital complications were similar between the two groups. Thirty days mortality rate (0.7% in study group and 1.4% in control group) was similar between groups, whereas prolonged length of stay (>12 days) was more frequent in control group (61.33% vs. 71.36%, P<0.0001). Atrial fibrillation (P<0.0001) was a strong predictor for prolonged length of stay in hospital. CONCLUSION: Most aspects of early complications after CABG, as well as 30-day mortality rate, were similar between patients with and without general risk factors for coronary artery disease undergoing CABG.