Coenzyme Q 10 Administration in Community-Acquired Pneumonia in the Elderly

Background: Community-acquired pneumonia (CAP) is generally considered a major cause of morbidity and mortality in the elderly. Objectives: This study aimed to assess the efficacy of adjunctive coenzyme Q 10 (CoQ 10 ) in the treatment of elderly CAP. Patients and Methods: Hospitalized elderly patients with CAP (diagnosed by using defined clinical and radiological criteria) were randomized to receive oral CoQ10 (200 mg/d) or placebo for 14 days, along with antibiotics. Primary and secondary outcomes on days 3, 7, and 14 were measured. Disease severity was scored using CURB-65 index. Statistical analysis was performed using SPSS and P value < 0.05 was considered significant. Results: We enrolled 150 patients for this research. Then, 141 patients, including 70 patients in the trial group and 71 patients in the control group were analyzed. Mean age of the trial and control groups were 67.6 ± 7.2 years and 68.7 ± 7.9 years, respectively. Clinical cure at days 3 and 7 were 24 (34.3%) and 62 (88.6%) in the trial group (P value = 0.6745) and 22 (31%) and 52 (73.2%) in the placebo group (P value = 0.0209). Patients on CoQ10 had faster defervescence (P value = 0.0206) and shorter hospital stay (P value = 0.0144) compared with the placebo group. The subgroup analysis of the patients with severe pneumonia showed differences in clinical cure at day 14. Treatment failure was less in CoQ10 group than in the placebo group (10% versus 22.5% and P value = 0.0440). Adverse events in two groups were few and similar. Conclusions: CoQ10 administration has no serious side effects and can improve outcome in hospitalized elderly CAP; therefore, we recommend it as an adjunctive treatment in elderly patients

Age‑standardized mortality rate and predictors of mortality among COVID‑19 patients in Iran

BACKGROUND: To have a thorough understanding of epidemic surveillance, it is essential to broaden our knowledge of death tolls worldwide. This study aimed to determine the age‑standardized mortality rate (ASMR) and predictors of mortality among coronavirus disease 2019 (COVID‑19) patients. MATERIALS AND METHODS: In this cross‑sectional design, all COVID‑19 patients with a positive polymerase chain reaction test in the population covered by Arak University of Medical Sciences (AUMS) were entered to the study. Data collection was conducted by phone interview. The study variables comprised age, sex, coronary heart diseases, diabetes, and some symptoms at admission. The adjusted odds ratio (OR) and 95% confdence intervals (CIs) were obtained by logistic regression. The direct method was applied to calculate ASMR (per 100,000) of COVID‑19. The analysis was applied by STATA software 12.0. RESULTS: A total of 208 cases of COVID‑19 (out of 3050 total infected cases) were dead and 2500 cases were recovered. The mean age of dead patients was 70 years. The COVID‑19 fatality rate in the population equaled 6.8%; in those patients who were 70 years old or more, however, the case fatality rate was 16.4%. The ASMR of COVID‑19 was 12.9 (CI 95%: 11.2, 14.8). The odds of COVID‑19‑related death in the age over 60 were 10.87 (CI 95%: 6.30, 18.75) times than lower 45 years old. Moreover, it was observed that COVID‑19 signifcantly increased the odds of COVID‑19‑related death in diabetes patients (OR = 1.45, CI 95%: 1.02, 2.06, P = 0.036). CONCLUSION: The ASMR of COVID‑19 was relatively higher in males than females. In general, the COVID‑19 fatality rate was relatively high. We found that older age and diabetes can have impact on the death of COVID‑19, but the headache was found to have a negative association with the COVID‑19‑related death Age‑standardized, COVID‑19, epidemiology, Iran, mortalit

The Evolution of Hepatitis C Treatment

Hepatitis C is one of the important causes of liver disease in the world. It seems that HCV will emerge as the leading cause of viral hepatitis-related advanced liver diseases and death in the near future. There are approximately 71 million chronically infected individuals worldwide, many of whom are unaware of their infection (1). It has been estimated that the prevalence of HCV in the Iranian general population is less than 0.5%. In Iran, the average prevalence of HCV is among thalassemia patients (16.6%), hemophilia patient (54%), individuals under dialysis (8.3%) and among injection drug users (51.4 percent). After screening of blood donors for HCV in Iran, the burden of HCV infection decreased significantly in hemophilia, thalassemia and patients on hemodialysis. Unfortunately, injecting illicit drugs still continues to be a major source of infection in Iran (2, 3). Iran has the lowest prevalence for HCV infection in the Middle East. Countries such as Pakistan and Azerbaijan with high prevalence of HCV infection are neighbors of Iran (2). The main populations at risk of HCV infection in Iran include intravenous drug users (IDUs) followed by people with tattoos, use of common razor, multi partner, homosexuality, receiving blood, and patients on hemodialysis (2). Clinical care for patients with hepatitis c infection has advanced considerably thanks to an enhanced understanding of the pathophysiology of the disease and because of developments in diagnostic procedures and improvement in therapy and prevention, and HCV elimination has been considered by the World Health Organization till 2030 (2,3). Screening and treating patients is necessary to eradicate HCV, So, EIA test is used for initial screening and detecting antibody against hepatitis C. Rapid diagnostic tests (RDTs) using serum, plasma, finger stick, whole blood or saliva as matrices can be used for initial screening. If anti-HCV antibodies are detected, the presence of HCV RNA or alternatively HCV core antigen in serum or plasma should be determined to identify patients with ongoing infection. Although the sensitivity of the core antigen assay is less than HCV RNA assay, but because of low cost and good sensitivity, it is a valuable test for HCV. The positive Anti HCV by EIA and negative PCR may be occurred by following reasons: 1-false positive 2-spontaneous viral clearance 3- treatment –induced viral clearance, 4- low levels of virus DNA in the Blood that is not determined by PCR. Following spontaneous or treatment –induced viral clearance, anti HCV antibodies may be persist lifelong. Thus, the follow of treated patient use of PCR or core Ag is necessary (1). HCV has a high rate of genetic heterogeneity (1-7 genotype), therefore, no vaccine to prevent this infection today. Genotype 1a and 3a are the most prevalent genotypes in Iran. HCV reinfection can occur after spontaneous or treatment induced viral clearance, essentially if patient at high risk of infection and re exposure (4). Strategies to promote diagnosis, screening, and treatment should be targeted to high-risk groups rather than the general population. Annual screening is recommended for Individuals with a history of injecting illicit drug. In the past, treatment of HCV was interferon and ribavirin for 24 to 48 weeks. This treatment regimen associated with low response to treatment, high drug complication and high drug cost. In 2011, protease inhibitors, the first generation of DAAs (Telaprevir and Boceprevir), were emerged as the third component of the standard of care. These drugs had a lot of complications such as drug-drug interactions, severe skin rashes/pruritus and anemia. In 2013, Sofosbuvir, a new DAA, was introduced for treatment of HCV infection. SOF-containing regimens had a shorter duration of therapy, with fewer side effects in comparison with protease inhibitor-based triple therapy (5). At present, in Iran, the basis of treatment is sofosbovir 400 milligram that combined with second drug daclatasvir (60 mg) or velpatasvir in pan genotype and or ledipasvir (90 mg) in genotype 1a. These drugs exist in separated or combination form with different brand names. In fact, the patient with hepatitis C in both treatment-naive and non-cirrhotic, taking a combination pill daily for 12 weeks associated with high treatment response. However, in cirrhotic patients or patients with previous treatment experience, treatment prolongs 24 weeks or ribavirin (1000 -1200 mg, 5-6 200mg tablets) is added to 12 weeks of treatment according patient weight. Accurate assessment of liver fibrosis and cirrhosis is essential for predicting prognosis and for planning treatment duration and adding RBV to the standard therapy of patients with chronic HCV infection. So, percutaneous liver biopsy or elastography non-invasive methods have been considered as the gold standard for assessing hepatic fibrosis. If biopsy or elastography not available, platelet count, liver sonography and liver enzyme level is helpful for determination of liver fibrosis (6). In EASL Recommendations on Treatment of Hepatitis C 2018, other drugs of DAAs like pibrentasvir, glecaprevir, elbatasvir and grazoprevir are recommended. Also 8, 16 and 28 weeks of treatments are suggested in special cases and treatment without sofosbovir is mentioned (1). Determination of viral load by quantitative PCR and genotyping of HCV recommend before the treatment, if viral load and genotyping is not available, qualitative PCR without genotyping is sufficient for treatment with pan genotyping drugs (1, 5). New treatments are free-INF and these drugs have low cost and low adverse effect (5, 7). Todays, HCV is treated very simply by consuming only one pill daily for 12 weeks. Sustained viral response (SVR) that defined negative PCR 12-24 weeks after discontinuing treatment occurred in more than 90% of patients (1, 4). In patients with cirrhosis, despite SVR, sonography of liver and αFP level test for screening of liver malignancy is recommended every 6 months (1). It seems that the best strategy for HCV prevention in the community is increasing case finding and therapy with the ultimate goal of stopping the vicious cycle in the community. Todays, there is no vaccine for HCV prevention yet. The incidence of HCV infection should be reduced by providing safe blood transfusion and medical procedures in hospitals and out-patient clinics, increasing people awareness and public education regarding the risks of exposure such as unsafe tattooing and unsafe sexual contacts and finally implementation of harm reduction for IDUs (1, 5)

DNA Fingerprinting of Resistant Mycobacterium tuberculosis Isolates in Iran by IS6110-RFLP Method

The objective of the research was to identify resistant Mycobacterium tuberculosis strains and recognize their molecular epidemiology and how they are disseminated in order to determine the cause and the effect of drug resistance and the process of its development.          Materials and methods. Genomic deoxyribonucleic acid obtained from 37 drug-resistant Mycobacterium tuberculosis isolates were examined and fingerprinted by the IS6110- restriction fragment length polymorphism method. The data obtained were then analyzed using SPSS statistics software.          Results. The mean patients’ age was 51 ± 15.5 years. There were 46% of male patients, 67.6% of the patients from urban areas, 86.5% of Iranians, 21.6% of relapsed cases, 8.1% of human immunodeficiency virus-positive patients, and 10.8% of the patients with a history of contact with tuberculosis patient. Based on IS6110 - restriction fragment length polymorphism, 30 different genetic types were observed which indicated a significant variation of this pathogen in Markazi province, Iran. The number of cluster genotypes was determined by 6 clusters; the number of unique types was 24. There were no relationships between age, gender, nationality, residence, close contact with tuberculosis patients, recurrence of tuberculosis, positive human immunodeficiency virus status and clustered or non-clustered strain genotype.          Conclusions. Considering the high genetic diversity in Mycobacterium tuberculosis strains, it can be concluded that, based on IS6110 - restriction fragment length polymorphism, about 65% of cases occurred due to reactivation, and 35% of the cases were due to recent transmission. The information obtained through the molecular typing method can be very effective in future planning for tuberculosis control in Iran

Arginine Adjunctive Therapy in Active Tuberculosis

Background. Dietary supplementation has been used as a mechanism to augment the immune system. Adjunctive therapy with L-arginine has the potential to improve outcomes in active tuberculosis. Methods. In a randomized clinical trial 63 participants with smear-positive pulmonary tuberculosis in Markazi Province of Iran were given arginine or placebo for 4 weeks in addition to conventional chemotherapy. The final treatment success, sputum conversion, weight gain, and clinical symptoms after one and two months were considered as primary outcomes and secondary outcomes were ESR, CRP, and Hg. Data were collected and analyzed with SPSS software (ver. 18). Results. Arginine supplementation reduced constitutional symptoms ( = 0.032) in patients with smear-positive TB at the end of the first month of treatment. Arginine treated patients had significantly increased BMI at the end of the first and second months of treatment ( = 0.032 and = 0.04) and a reduced CRP at the end of the first month of treatment ( = 0.03) versus placebo group. Conclusion. Arginine is useful as an adjunctive therapy in patients with active tuberculosis, in which the effects are more likely mediated by the increased production of nitric oxide and improved constitutional symptoms and weight gain. This trial is registered with Clinical Trials Registry of Iran: IRCT201211179855N2

Laboratory features of patients with Brucellosis and its association with titer of Wright agglutination test

Background: One of the features of Malta fever is diversity of hematologic manifestations. The Aim of This study was to evaluate hematologic findings of brucellosis and its association with titer of wright agglutination test. Materials & Methods: This study was a cross - sectional and analytical study that was conducted on 189 patients with brucellosis in the Arak in 2011. The diagnostic criteria of the disease were the Wright test and 2-Mercaptoethanol (2ME) agglutinin assay with titers greater than 1:160 and 1:80, respectively, and clinical symptoms compatible with brucellosis. Data were obtained from patient records and were analyzed with SPSS version 16. Results: From 189 patients with Brucellosis who were enrolled in study 67.8% was male, Mean age in men was 37.8±23.3 years and in women 36.9±15.3 years. Erythrocyte sedimentation rate in 44.5% was between 21- 40 and in 2.1% was above 60. 45% of patients had qualitative CRP levels higher than +2. Leukopenia in 9%, anemia 19%, thrombocytopenia 7.4% was seen. In 27.8% the lymphocyte cell count was predominant. 7.5% of patients had eosinophilia of more than 5% and 4.8% with bicytopenia and 1.6% had pancytopenia. The association between titer of wright test and sex, ESR, leucopenia, thrombocytopenia and anemia was not observed, (P>0.05) but with CRP>1+ (P=0.0001) and age over 45 years (P= 0.017 association was significant. Conclusion: Brucellosis should be considered as a differential diagnosis among patients whose blood picture reveals anemia, leukopenia, thrombocytopenia or pancytopenia. There is no relation between wright titer and hematologic manifestation. In comparison with similar studies in other countries, hematologic abnormality is lower in our patients

Arginine Adjunctive Therapy in Active Tuberculosis

Background. Dietary supplementation has been used as a mechanism to augment the immune system. Adjunctive therapy with L-arginine has the potential to improve outcomes in active tuberculosis. Methods. In a randomized clinical trial 63 participants with smear-positive pulmonary tuberculosis in Markazi Province of Iran were given arginine or placebo for 4 weeks in addition to conventional chemotherapy. The final treatment success, sputum conversion, weight gain, and clinical symptoms after one and two months were considered as primary outcomes and secondary outcomes were ESR, CRP, and Hg. Data were collected and analyzed with SPSS software (ver. 18). Results. Arginine supplementation reduced constitutional symptoms (P=0.032) in patients with smear-positive TB at the end of the first month of treatment. Arginine treated patients had significantly increased BMI at the end of the first and second months of treatment (P=0.032 and P=0.04) and a reduced CRP at the end of the first month of treatment (P=0.03) versus placebo group. Conclusion. Arginine is useful as an adjunctive therapy in patients with active tuberculosis, in which the effects are more likely mediated by the increased production of nitric oxide and improved constitutional symptoms and weight gain. This trial is registered with Clinical Trials Registry of Iran: IRCT201211179855N2

Adverse Reactions to Antituberculosis Drugs in Iranian Tuberculosis Patients

Background. Antituberculosis multidrug regimens have been associated with increased incidence of adverse drug reactions (ADRs). This study aimed to determine the incidence and associated factors of ADRs due to antituberculosis therapy. Methods. This is a retrospective cross-sectional study on tuberculosis patients who were treated in tuberculosis clinics in Markazi province in Iran. The information contained in the medical files was extracted and entered into the questionnaire. Data was descriptively analyzed by using statistical package for social sciences (SPSS 18). Results. A total of 940 TB patients of 1240 patients’ medical records available in 10 medical offices were included in this study. Of the 563 ADRs found in this study, 82.4% were considered minor reactions and 17.6% were major reactions. No death from antituberculosis ADR was observed. We found that the risk of major ADRs was higher in females (P  value=0.0241), age >50 y (P  value=0.0223), coinfection with HIV (P  value=0.0323), smoking (P  value=0.002), retreatment TB (P  value=0.0203), and comorbidities (P  value=0.0005). Conclusions. This study showed that severe side effects of anti-TB drugs are common in patients who have risk factors of ADRs and they should be followed up by close monitoring

Serological response to one intradermal or intramuscular hepatitis B virus vaccine booster dose in human immunodeficiency virus-infected nonresponders to standard vaccination

Purpose : Hepatitis B virus (HBV) vaccination is recommended for all human immunodeficiency virus (HIV)-infected patients without HBV immunity. However, serological response to standard HBV vaccination is frequently suboptimal in this population and the appropriate strategy for revaccination of HIV-infected nonresponders remained controversial. We aimed to determine the serological response to one booster dose of HBV vaccine given by intradermal (ID) or intramuscular (IM) route in HIV-positive nonresponders to standard HBV vaccination. Materials and Methods : In this study, 42 HIV-infected nonresponders were enrolled. We randomized them to receive either 10 μg (0.5 mL) for ID (20 cases) or 20 μg (1 mL) for IM (22 cases) administration of HBV vaccine as a one booster dose. After 1 month, anti-HBs titer was checked in all cases. A protective antibody response (seroconversion) defined as an anti-HBs titer ≥10 IU/L. Results: Seroconversion was observed in 47.6% of subjects after 1 ID dose. A total of 30% showed antibody titers above 100 IU/L. Except one case, all responders had CD4 + >200 cells/mm 3 . Mean anti-HBs titer was 146.5 ± 246 IU/L. After the one IM booster dose, seroconversion was observed in 50% of cases. A total of 36.3% of subjects had anti-HBs ≥100 IU/L. All responders had CD4 + >200 cells/mm 3 , except one case. Mean anti-HBs titer was 416.4 ± 765.6 IU/L. Responders showed significantly higher CD4 + cell counts, in comparison to nonresponders (P < 0.001). Conclusions: One booster dose administered IM or ID to HIV-infected nonresponders resulted in similar rates of seroconversion, overall response rate 50%. However, higher anti-HBs titers observed more frequently in IM group