Adult emergency department performance in the largest teaching hospital in southern Iran: a 1.5-year cross-sectional study

Background: Emergency department (ED) is one of the most important hospital departments, with significant effects on public health. The aim of this study was to evaluate the adult ED's performance of the largest teaching hospital in southern Iran. Methods: In this retrospective cross-sectional study (March 2017-August 2018), the registered data in the Hospital Information System (HIS) were collected, and the ED’s performance was assessed based on the Iranian emergency performance index. The slopes of the trend lines were calculated for each indicator. Moreover, 2 six-month periods were compared. Results: The data of 104,081 patients were analyzed. The mean (±standard deviation) of visited patients per-month was 5,782.28 (±1258.55). The slope of the trend line was negative for all indicators, except for discharge from ED with personal responsibility. The mean duration of waiting time for the first visit by physician in each triage level slightly decreased. Comparison of the two six-month periods showed a significant difference between the visited patient (P<0.0001). The percentage of patients disposed within six hours (P<0.0001), leaving ED within 12 hours (P<0.0001), as well as the percentage of successful cardiopulmonary resuscitation (P=0.014) in the six-month period of 2018 was significantly lower. The percentage of discharge with personal responsibility significantly increased (P=0.005). Conclusion: Although the number of patients visited in this ED decreased, all indicators had dropped. However, the percentage of discharge with personal responsibility was increased. Moreover, the mean duration of waiting time for the first visit by physician slightly decreased in each triage level

The Relationship between Nutritional Knowledge and Food Habits and Some Cardiometabolic Risk Factors in Patients with Diabetes in Shiraz, Iran

Background: Diabetes is an increasing health problem. Diet and nutritional knowledge are the most important factors in diabetes. This study was done to investigate the association between nutritional knowledge and food habits in relation to cardiometabolic risk factors in the patients with diabetes. Methods: This cross-sectional study was conducted on 260 subjects with diabetes in Motahhari Diabetes Clinic in Shiraz, southern Iran. Dietary intakes were evaluated using a 147-item food frequency questionnaire (FFQ). Also socio-economic, demographic and nutritional knowledge questionnaires were completed. Weight, height and waist circumference were measured. Fasting blood glucose (FBG), low density lipoprotein cholesterol (LDL), high density lipoproteincholesterol (HDL) and triglyceride TG were extracted from patients’ medical records. Results: Of 73 male and 187 female patients, 39.2% were overweight and 33.5% were obese. There was a significant correlation between nutritional knowledge and vegetables intake. Also, getting more dairies and fats were significantly correlated to the levels of FBS. A positive significant correlation was seen between serum HDL and beans and cereals intake. Conclusion: Nutritional awareness cannot lead to a healthy diet alone because socioeconomic status, motivation, and other factors also affect dietary intake. Dietary habits can affect blood lipids and FBG. Therefore, improving the diet of diabetic patients is essential

Mortality rate and predicting factors of traumatic thoracolumbar spinal cord injury: a systematic review and meta-analysis

Objective: To estimate the summation of mortality rate and the contributing factors in patients with traumatic thoracolumbar spinal cord injuries (TLSCI). Methods: A systematic search of observational studies that evaluated the mortality associated with TLSCI in MEDLINE and EMBASE was conducted. The study quality was evaluated using a modified quality assessment tool previously designed for observational studies. Results: Twenty-four observational studies involving 11,205 patients were included, published between January 1, 1997, and February 6, 2016. Ten studies were of high quality, thirteen were of moderate quality, and one study was of low quality. Seventeen reports described risk factors for mortality and eleven of these studies used a multiple regression models to adjust for confounders. The reported mortality rate ranged from 0 to 37.7% overall and between 0 and 10.4% in-hospital. The sum of mortality for in-hospital, 6-month, and 12-month were 5.2%, 26.12%, 4.3%, respectively. The mortality at 7.7 years follow-up was 10.07% and for 14 years follow-up reports ranged from 13.47% to 21.46%. Associated data such as age at injury, male to female ratio, pre-existing comorbidities, concomitant injuries, duration of follow-up, and cause of death have been underreported in studies investigating the mortality rate after TLSCI. Conclusion: Currently no study has accurately assessed mortality in the thoracolumbar spine, while there is general agreement that traumatic thoracolumbar spinal cord injuries are important

A phase III, randomized, two-armed, double-blind, parallel, active controlled, and non-inferiority clinical trial to compare efficacy and safety of biosimilar adalimumab (CinnoRA (R)) to the reference product (Humira (R)) in patients with active rheumatoid arthritis

Background: This study aimed to compare efficacy and safety of test-adalimumab (CinnoRA (R), CinnaGen, Iran) to the innovator product (Humira (R), AbbVie, USA) in adult patients with active rheumatoid arthritis (RA). Methods: In this randomized, double-blind, active-controlled, non-inferiority trial, a total of 136 patients with active RA were randomized to receive 40 mg subcutaneous injections of either CinnoRA (R) or Humira (R) every other week, while receiving methotrexate (15 mg/week), folic acid (1 mg/day), and prednisolone (7.5 mg/day) over a period of 24 weeks. Physical examinations, vital sign evaluations, and laboratory tests were conducted in patients at baseline and at 12-week and 24-week visits. The primary endpoint in this study was the proportion of patients achieving moderate and good disease activity score in 28 joints-erythrocyte sedimentation rate (DAS28-ESR)-based European League Against Rheumatism (EULAR) response. The secondary endpoints were the proportion of patients achieving American College of Rheumatology (ACR) criteria for 20% (ACR20), 50% (ACR50), and 70% (ACR70) responses along with the disability index of health assessment questionnaire (HAQ), and safety. Results: Patients who were randomized to CinnoRA (R) or Humira (R) arms had comparable demographic information, laboratory results, and disease characteristics at baseline. The proportion of patients achieving good and moderate EULAR responses in the CinnoRA (R) group was non-inferior to the Humira (R) group at 12 and 24 weeks based on both intention-to-treat (ITT) and per-protocol (PP) populations (all p values >0.05). No significant difference was noted in the proportion of patients attaining ACR20, ACR50, and ACR70 responses in the CinnoRA (R) and Humira (R) groups (all p values >0.05). Further, the difference in HAQ scores and safety outcome measures between treatment arms was not statistically significant. Conclusion: CinnoRA (R) was shown to be non-inferior to Humira (R) in terms of efficacy at week 24 with a comparable safety profile to the reference product

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

New indications for dabigatran: A suggestion from a drug use evaluation study

Objective: Dabigatran etexilate is a novel oral anticoagulant with several advantages over warfarin such as no need for routine monitoring and fewer drug interactions. This drug was added to our hospital's formulary in 2012. The objective of this study was to assess the rational drug use of dabigatran at a large teaching hospital. Methods: A prospective cross-sectional study was performed from November to June 2015 at Alzahra teaching hospital, Isfahan, Iran. All patients who received at least one dose of dabigatran were eligible for inclusion. Data were collected on patient demographics, indication, dosing regimen, adverse events, concurrent anticoagulant therapy, and laboratory data (including renal function). Findings: A total of sixty patients were included in our study. The majority of patients (n = 40, 66.7%) was prescribed dabigatran for deep vein thrombosis prophylaxis. Only one patient received dabigatran with appropriate indication, dose, and duration. Thirty-six (60%) of our patients had thrombocytopenia at the time of dabigatran initiation. We also detected that ten patients (16.7%) received this drug for heparin-induced thrombocytopenia (HIT). In 32 patients, platelet levels increased after dabigatran initiation. Only seven patients received the appropriate dose of dabigatran (regarding both indication and renal function). Conclusion: Unlabeled use and incorrect dosing of dabigatran in this study emphasize the need to develop a hospital protocol for dabigatran use within our facility. We suggest proper education of clinicians about novel drugs, pharmacist interventions, and further studies about the safety and efficacy of dabigatran for the new indication (such as HIT)

The Effect of Spiritual Skills Training on the Quality of Life of Family Caregivers of Hemodialysis Patients

Background and Objective: The responsibility and concerns of caregivers of hemodialysis patients can impair their quality of life. Since spirituality, as one of the dimensions of human existence, plays an important role in the ability to cope with stress, the present study aimed to determine the effect of spiritual training programs on the quality of life in the caregivers of hemodialysis patients. Materials and Methods: The design of this study was the comparison of outcomes before and after a planned intervention without the use of a control. It was conducted on 30 family caregivers of hemodialysis patients who were referred to the Dialysis Center of Tabas in 2019. The subjects were selected via the convenience sampling method. The intervention was spiritual skills training, which was conducted orally in seven sessions of 45 to 60 minutes once a week. Before and after the intervention, a valid and reliable questionnaire on caregivers' quality of life was completed by the caregivers. The data were analyzed in SPSS software (version 20) using descriptive and inferential statistical tests. Results: There was a statistically significant difference between the overall quality of life and mental concerns before and after the intervention (P0.05). Conclusion: Teaching spiritual skills exerted a positive effect on the quality of life among the caregivers of hemodialysis patients. Therefore, the development of spiritual skills training programs for caregivers can be of great help in improving their quality of life

Effect of marginal design on fracture resistance of IPS e.maxall ceramic restorations: Chamfer versus shoulder finish lines

Background and Aim: One of the problems of all ceramic restorations is their risk of fracture due to occlusal loads. The aim of the present study was to compare the effect of two marginal designs (shoulder and chamfer) on the fracture resistance of IPS-emax all ceramic restorations. Materials and Methods: One extracted maxillary first premolar received chamfer 50' marginal preparation (0.8 mm). Twenty impressions were made using poly vinyl siloxane. Then, chamfer was converted to shoulder 90'(1mm). After impression, epoxy resin dies were fabricated. Impressions of each epoxy resin die were made and poured with die stone. Twenty Press crowns and twenty ZirCAD crowns were made on stone dies and ce-mented on resin dies. Then, samples underwent a fracture test in a universal testing ma-chine. Data were analyzed by one-way ANOVA. Results: The mean fracture resistance was 1426N for the chamfer ZirCAD samples, 1361.3N for the shoulder ZirCAD samples, 1059.9N for the chamfer Press samples and 1295.8N for the shoulder Press samples. One-way ANOVA revealed no difference among groups. (p=0.095). Conclusion: After porcelain application, marginal design does not affect fracture resis-tance of single IPS-emax posterior crowns. Fracture resistance was approximately the same in Press and ZirPress groups probably due to porcelain application, because in Zir-CAD group fractures occurred in the porcelain prior to the cor

Retracted: Stress Distribution in Three-Implant- Retained Mandibular Overdentures Using Finite Element Analysis

Background and Aim: Demand for implant-supported overdentures has increased due to the problems of conventional dentures. Despite the high success rate of implants, implant failure remains a major challenge. Implant overload can cause cortical bone loss and im-plant failure. Using finite element analysis (FEA), this study aimed to find the best design and type of attachments causing minimum stress in the alveolar bone. Materials and Methods: The geometrical model of the mandible was produced using computed tomography (CT) data and three ITI implants were placed in the midline and the location of the first premolar teeth. All conditions were simulated using finite element software. Three bar-ball, bar and ball attachments were considered to support the overdenture. Maximum von Mises stress was calculated in the supporting bone in differ-ent overdenture designs. Results: The greatest amount of stress in bone was around the upper thread and the neck of the implant. The ball and the bar-ball attachments applied the most and the least amount of stress to the peri-implant bone, respectively. Maximum stress was applied to the ball attachment in the bar-ball design. The maximum amount of movement was in bar-ball attachment. Conclusion: The bar-design decreased the stability of overdenture, as well as the stress in the peri-implant bone. Ball design increased concentration of stress in bone around the implant and increased the stability of overdenture