Management of ST-segment-elevation myocardial infarction during the coronavirus disease 2019 (COVID-19) outbreak: Iranian"247" National Committee's position paper on primary percutaneous coronary intervention.

World Health Organization has designated coronavirus disease 2019 (COVID-19) as a pandemic. During the past several weeks, a considerable burden has been imposed on the Iranian's healthcare system. The present document reviewed the latest evidence and expert opinion regarding the management of ST-segment-elevation myocardial infarction during the outbreak of COVID-19 and outlines a practical algorithm for it.

Whether vitamin A supplementation is effective in T-bet and IFN-É£ gene expression reduction?

BACKGROUND: The aim of present study is evaluation of vitamin A supplementation efficacy on IFN-ɣ and T-bet gene expression in atherosclerotic patients. METHODS: Thirty-one patients and 15 healthy controls participated in this study. Healthy control and patients in Vitamin A group received 25 000 IU retinyl palmitate daily for 4 months. Control patients also received 1 pearl of placebo per day up to 4 months. Gene expression levels were assessed by real-time PCR using SYBR green detection method. RESULTS: IFN-γ gene expression in fresh cells of patients taking vitamin A declined slightly (0.85-fold, p = 0.068), whereas the expression of this gene was increased in patients taking placebo, and in healthy control subjects 1.2-fold (p = 0.267) and 1.7-fold (p = 0.580), respectively. There were no significant difference (p = 0.159) between 3 groups in terms of IFN-γ gene expression in cells stimulated with PHA. In order to determine whether PHA stimulation of PBMCs in vitro had an effect on T-bet expression, we measured the difference between the 3 groups of studied. The results showed significant differences between the groups (p = 0.046). IFN-γ gene expression in cells activated with ox-LDL in healthy control subjects and patients taking vitamin A, was reduced 0.43 (p = 0.0001) and 0.41 (p = 0.001) respectively, but in placebo patients was increased 2.2-fold (p = 0.959). CONCLUSION: Considering role of vitamin A on suppression of Th1 cells in atherosclerotic patients, it can be concluded that vitamin A supplementation may be advantageous for these patients.

Anthropometric and Biochemical Measures in Bariatric Surgery Candidates: What Is the Role of Inflammatory Potential of Diet?

BACKGROUND: The present study aimed to assess dietary total antioxidant capacity (TAC), dietary phytochemical intake (PI), and dietary inflammatory index (DII) in patients with morbid obesity who are candidates of bariatric surgery and their association with anthropometric and biochemical parameters. METHODS AND MATERIALS: One hundred seventy patients with morbid obesity who were referred to surgery clinic of Firoozgar Hospital were enrolled in the study. Ideal body weight and adjusted ideal body weight were calculated. The dietary data were collected using a food frequency questionnaire. Anthropometrics and biochemical parameters were assessed. A p-value of <0.05 was considered significant. RESULTS: The strongest correlations of DII with dietary intakes and anthropometric and biochemical biomarkers were found for iron (p<0.0001). Significant association was also observed for ferritin (p=0.02) and transferrin (p=0.02). In terms of PI, The strongest associations were also found for iron (p<0.0001). Additionally, the value of body mass index (BMI) showed significant correlation with PI (p=0.04). The correlations of dietary total antioxidant indices with dietary intakes and anthropometric and biochemical biomarkers were assessed. Non-significant correlation was found between fasting blood sugar (FBS), hemoglobin A1C (HbA1C), vitamin B12, and vitamin D3 with ORAC index. Significant strong correlation showed for the value of iron in both ferric reducing ability of plasma (FRAP) and Oxygen Radical Absorbance Capacity (ORAC) indices (p<0.0001). CONCLUSION: We find statistical significance correlation for dietary PI and BMI. The inflammatory and antioxidant properties of diet were not related to biochemical markers associated with obesity. Graphical abstract.

Intermediate versus standard-dose prophylactic anticoagulation and statin therapy versus placebo in critically-ill patients with COVID-19: Rationale and design of the INSPIRATION/INSPIRATION-S studies.

BACKGROUND: Microvascular and macrovascular thrombotic events are among the hallmarks of coronavirus disease 2019 (COVID-19). Furthermore, the exuberant immune response is considered an important driver of pulmonary and extrapulmonary manifestations of COVID-19. The optimal management strategy to prevent thrombosis in critically-ill patients with COVID-19 remains unknown. METHODS: The Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) and INSPIRATION-statin (INSPIRATION-S) studies test two independent hypotheses within a randomized controlled trial with 2 × 2 factorial design. Hospitalized critically-ill patients with reverse transcription polymerase chain reaction confirmed COVID-19 will be randomized to intermediate-dose versus standard dose prophylactic anticoagulation. The 600 patients undergoing this randomization will be screened and if meeting the eligibility criteria, will undergo an additional double-blind stratified randomization to atorvastatin 20 mg daily versus matching placebo. The primary endpoint, for both hypotheses will be tested for superiority and includes a composite of adjudicated acute arterial thrombosis, venous thromboembolism (VTE), use of extracorporeal membrane oxygenation, or all-cause death within 30 days from enrollment. Key secondary endpoints include all-cause mortality, adjudicated VTE, and ventilator-free days. Key safety endpoints include major bleeding according to the Bleeding Academic Research Consortium definition and severe thrombocytopenia (platelet count <20,000/fL) for the anticoagulation hypothesis. In a prespecified secondary analysis for non-inferiority, the study will test for the non-inferiority of intermediate intensity versus standard dose anticoagulation for major bleeding, considering a non-inferiority margin of 1.8 based on odds ratio. Key safety endpoints for the statin hypothesis include rise in liver enzymes >3 times upper normal limit and clinically-diagnosed myopathy. The primary analyses will be performed in the modified intention-to-treat population. Results will be tested in exploratory analyses across key subgroups and in the intention-to-treat and per-protocol cohorts. CONCLUSIONS: INSPIRATION and INSPIRATON-S studies will help address clinically-relevant questions for antithrombotic therapy and thromboinflammatory therapy in critically-ill patients with COVID-19.

Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: the Iranian Project for Assessment of Coronary Events 2 (IPACE2).

OBJECTIVES: To assess contemporary data on characteristics, management and 1-year postdischarge outcomes in Iranian patients hospitalised with acute coronary syndrome (ACS). SETTING: 11 tertiary care hospitals in 5 major cities in the Islamic Republic of Iran. PARTICIPANTS: Patients aged ≥ 20 and ≤ 80 years discharged alive with confirmed diagnosis of ACS including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and high-risk unstable angina (HR-UA). PRIMARY AND SECONDARY OUTCOME MEASURES: Patients were followed up regarding the use of medications and the end points of the study at 1 month and 1 year after discharge. The primary end point of the study was 1-year postdischarge major adverse cardiac and cerebrovascular events (MACCEs), defined as mortality (cardiac and non-cardiac), ACS and cerebrovascular attack (stroke and/or transient ischaemic attack). The secondary end points were hospital admission because of congestive heart failure, revascularisation by coronary artery bypass grafting surgery or percutaneous coronary intervention (PCI), and major and minor bleeds. RESULTS: A total of 1799 patients (25.7% STEMI and 74.3% HR-UA/NSTEMI) discharged alive with confirmed diagnosis of ACS were included in the final analysis. During hospitalisation, the majority of the patients received aspirin (98.6%), clopidogrel (91.8%), anticoagulants (93.4%), statins (94.3%) and ß-blockers (89.3%). Reperfusion therapy was performed in 62.6% of patients with STEMI (46.3% thrombolytic therapy and 17.3% primary PCI). The mean door-to-balloon and door-to-needle times were 82.9 and 45.6 min, respectively. In our study, 64.7% and 79.5% of the patients in HR-UA/NSTEMI and STEMI groups, respectively, underwent coronary angiography. During the 12 months after discharge, MACCEs occurred in 15.0% of all patients. CONCLUSIONS: Our study showed that the composition of Iranian patients with ACS regarding the type of ACS is similar to that in developed European countries and is unlike that in developing countries of the Middle East and Africa. We found that our patients with ACS are treated with high levels of adherence to guideline-recommended in-hospital medications.

The influence of vitamin A supplementation on Foxp3 and TGF-ß gene expression in atherosclerotic patients.

The aim of this study was to investigate the role of vitamin A in Foxp3 and TGF-ß gene expression in atherosclerotic patients. Patients and healthy controls in the vitamin A group received 25,000 IU retinyl palmitate per day, while patients in the placebo group took one capsule of placebo per day for 4 months. Gene expressions of regulatory T cells were studied by real-time PCR. The levels of Foxp3 expression in phytohemagglutinin-activated cells were much higher in the patients who received vitamin A than in placebo-treated patients and healthy controls, while Foxp3 gene expression in oxidized low-density lipoprotein-activated cells showed no significant differences between all groups (p=0.357). A significant difference in the expression level of TGF-ß gene in fresh cells was observed between patients and healthy controls (p=0.009). TGF-ß gene expression in oxidized low-density lipoprotein-activated cells increased in all groups; however, these changes were not statistically significant (p=0.65); the changes obtained were 2.8-, 2.2- and 3.9-fold in the vitamin A, placebo, and control groups, respectively. Based on suppressing actions of regulatory T cells on effector T cells and findings that show that vitamin A has the effect of increasing expression of regulatory T cells, it can be concluded that supplementation with vitamin A in atherosclerotic patients may be effective in slowing disease progression.

The in vitro effect of oxidized LDL and PHA on proliferation and gene expression of regulatory T cells in patients with atherosclerosis.

Atherosclerosis is a chronic inflammatory condition that affects the arterial wall. Oxidized low-density lipoprotein (ox-LDL) seems to have an important role in atherosclerotic plaque formation.This study was performed to investigate the effects of ox-LDL as well as PHA on proliferation and gene expression of peripheral blood mononuclear cells (PBMCs) in patients with atherosclerosis compared to healthy controls. Proliferation of PBMCs was assessed by BrdU assay, while gene expression was assessed by real-time PCR. Both PHA and ox-LDL significantly induced proliferation of PBMCs of patients and controls. PBMCs from controls showed significantly higher proliferation when stimulated with ox-LDL compared to patients. Expression of TGF-ß was significantly lower in PBMCs from patients compared to healthy controls (p<0.001). Following simulation with PHA, TGF-ß and Foxp3 gene expression levels in patients and controls were significantly decreased (p<0.001). Expression of Foxp3 in PBMCs treated with ox-LDL was significantly decreased in patients and controls.Decreased expression of TGF-ß and Foxp3 genes after ox-LDL stimulation may be due to more sensitivity of Treg cells than effector T cells to ox-LDL. Presence of ox-LDL within atheroma could be associated with the diminished population of Treg cells in the atherosclerotic patients.

Low-dose oral contraceptive to re-induce menstrual bleeding in amenorrheic women on DMPA treatment: a randomized clinical trial.

BACKGROUND: Depot medroxy progesterone acetate (DMPA) is one of the most reliable contraceptive methods with a failure rate less than 0.3 percent. It is injected every three months and Although it has many advantages over many other hormonal contraceptives, But a major disadvantage of it is bleeding disorders which comprise most of the discontinuance reasons. Our Aim was to study bleeding complications of DMPA when used as a contraceptive in Ardabil district and clinical trial of LD and Ethynil oestradiol in controlling these complications. MATERIAL/METHODS: All the 917 women who referred to ardabil's health centers for having a DMPA injection for the first time, were entered into a longitudinal study. Those complaining of menstrual cessation were entered into a double blinded randomized clinical trial. Data were collected by means of 9 questionnaires 7 of them used for descriptive and 2 for clinical trial study. Data was analyzed by SPSS statistical package. RESULTS: Those DMPA users with a cesarean section history had a higher chance of bleeding complications. Four hundred forty-four of the 917 women receiving the injection discontinued using it before the end of the study period. The main reason for discontinuation (in 70%) was irregular menstrual bleedings and menstrual cessation. In the clinical trial of women with bleeding cessation, 70% of those receiving the LD-OC pill experienced menstrual bleedings again, compared with only 22.7% in the placebo group. The discontinuation rate in the drug group was lower than in the placebo group as well (p < 0.05). CONCLUSIONS: Treating menstrual cessation caused by DMPA with LDs, improves the complication and decreases the discontinuance rate.