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Background and purpose: The process by which family physicians refer patients to specialized levels of the healthcare system is presented. In other words, the referral system can assure us that the clients of health care services are optimally allocated at the specialized level of services. In addition to providing proper time and providing proper health care for health benefits. The referral process is a specialized outpatient consulting process that determines the course and communication of the individual in three levels of the health system to provide the integrity and continuity of services this study aimed to determine the quality of referral and feedback forms in the medical family physician of Mazandaran province in 2019. Materials and methods: This descriptive cross-sectional study was conducted to examine the form of insurance referral of social security insurance by physicians of urban families and feedback from experts. After receiving the code of ethics and obtaining permission from the relevant organization the researcher paid the social security organization 1397 issued by the physicians in the province. The statistical population consisted of all forms of reference and the feedback from experts to the social security insurance organization to get the right According the report of the department of medical record department of the social security insurance organization of Mazandaran province in1397 has been handed over to that organization in a total of 151075 reference sheets completed to obtain the right of the specialists. the collected data were entered into Excel software for statistical analysis was performed in descriptive statistics using central dices (mean, median, mode) and dispersion index(variance, standard deviation, range of changes, coefficients of variation ) for quantitative variables, and index, percentage, and prevalence for qualitative data. The data were analyzed by using spss-25 software. Results: The study of 3200 cases of referral and referral forms of family physicians and specialists showed that among the Physicians 2321(72.5) were male and 879(27.5) were female. The patient's records in 586(%18.3) were incomplete. Clinical findings Were found in 98(2.7%) cases and paraclinical findings were incomplete in 22 cases (0.7%) and complete in 171 cases (5.3%). in 884 cases (27.6%) the papers were illegible the cause of referral was written in 560(17.5%). the reason for further referral in 187 cases (5.8%) was written by experts. In addition, 1454 cases (45.4%) of the return sheets completed by specialists were illegible. Conclusion: The results obtained in this study show that the status of the quality of completion of the referral form by the family doctors and also the status of providing feedback by the specialist doctors are not suitable. to improve this situation the implementation of face-to-face and non-face-to-face training programs for both groups and using electronic referral forms can be put on the agenda.

Background and purpose: Type 2 diabetes is a health problem and is an emergency that has the fastest growth worldwide. Diabetes is one of the priorities of all public health systems this study aimed to determine the quality of diabetes control in urban family physician centers of Sari city in 1382-1398. Materials and methods: This study was a cross-sectional and cross-sectional study. The required sample size was 275 patients who were selected randomly (a total of 300 patients) and 20 clusters (center), each consisting of 15 diabetic patients, were controlled. The population of the study included all patients with type 2 diabetes referred to health care centers of sari. The cases included age, sex, level of FBS, 2 hpp, HbA1c, blood pressure, triglyceride, cholesterol, HDL, LDL, and body mass index as well as eye examination and amputation were also recorded all the information contained the seal of the family physician. In this study, after data collection, the degree of conformity was compared with ADA guidelines. According to the American diabetes association (ADA), the goal of the treatment of this disease is reaching FBS: 90-130, HbA1c below 7%, BS2hpp

Background and Purpose: Several evidences have shown some synergistic effect of diabetes co-morbidity on the tuberculosis (TB) treatment results, while some other studies have not found such associations. This study aimed to investigate the relationship between TB-diabetes co-morbidity and outcomes of TB treatment. Materials and Methods: The research population in this case control study were patients with smear positive tuberculosis. The cases were 158 patients with TB and diabetes selected by consensus method, while controls were 316 patients randomly selected from TB patients without diabetes. Results: Frequency of unfavorable outcome among cases was higher than among controls (7.6% vs 7.3% respectively, p-value =0.901). Multivariate logistic regression models showed that the odds ratios for adverse treatment outcome, death, treatment failure, positive smear after the intensive phase of treatment and high grade positivity (2+ & 3+) were 0.97(0.45- 2.06), 0.97(0.42-2.24), 0.91(0.17-4.85), 1.39(0.79- 2.44) and 2.57(0.83- 7.92) respectively. Moreover, treatment adverse outcomes among patients with drug complications (22.2% vs. 6.5%, p-value =0.010) and rural residents (10% vs 4.9% respectively, p-value =0.037) were significantly higher than those among patients without complication and urban residents respectively. Conclusion: Although we did not observe any significant association between TB-diabetes co-morbidity and treatment results, there was a significant effect measure regarding the effect of smear positivity at the end of the intensive phase of treatment, especially high grade of smear positivity. Because of probable bias in the classification of the exposure, screening of TB patients regarding diabetes mellitus at the beginning of the treatment is recommended.

Abstract Aim A widespread outbreak of COVID‐19 is followed by adverse effects on the mental health of the general population. Therefore, this study is an audit to investigate the activities of various organizations during the COVID‐19 pandemic in Mazandaran Province, Iran. Methods The aim of the study was to collect the data, the relevant officials in various organizations and units were contacted to collect the statistics of actions taken in psychology and psychiatry wards. Moreover, databases such as Google Scholar and Iranian resources were searched. Results According to the results, different healthcare systems worked in parallel during the peak of the COVID‐19 pandemic. For example, Mazandaran University of Medical Science [MAZUMS] Health Vice‐Chancellor performed the following activities during this crisis: establishing a virtual crisis management working group, holding a provincial educational committee to train the crisis management teams, organizing virtual psychological intervention teams in the healthcare systems, and so forth. In addition, the mental health activities by Mazandaran Welfare Organization during the COVID‐19 outbreak included providing hostelry free psychological counseling, quarantine boarding and rehabilitation centers, and providing harm prevention protocols of COVID‐19, especially for marginalized regions. In the third level of medical centers, including hospitals, consultation‐liaison psychiatry or psychiatrists and clinical psychologists, therapeutic interventions for comorbid psychiatric disorders with COVID‐19 disease, and online workshops for mental health were conducted to reduce burnout of medical staff and nurses. Conclusion This study can provide a good guideline for different service providers by using the experiences of other centers to achieve better results.

Background and Aim: Modic changes are alterations in the spine endplates and subchondral bone shock absorption, seen by magnetic resonance imaging (MRI). No studies have investigated the effect of vitamin D and alendronate as oral drugs on reducing and modifying Modic changes after degenerative spine fusion surgery. This study aimed to evaluate the efficacy of oral vitamin D and alendronate administration in patients with low back pain, and Modic changes undergoing lumbar fusion surgery. Methods and Materials/Patients: A total of 81 middle age women with a normal range of serum vitamin d were enrolled in three groups who underwent lumbar fusion surgery according to neurosurgical criteria. Group 1 (n=27) received additional oral alendronate, group 2 (n=27) received oral vitamin D for six months postoperatively, and group 3 (n=27) received no drug (except simple analgesics and antibiotics). The patients were followed up with a visual analog scale (VAS) and Oswestry disability index (ODI). MRI was done before and six months after surgery. Results: There was no significant difference between the three groups in VAS and ODI scores (P=0.416, P=0.601, respectively), but the mean VAS and ODI in all three groups decreased over six months, which was statistically significant (P

Introduction: Cancers are the second cause of death worldwide. Prevalence and incidence of cancers is getting increased by aging and population growth. This study aims to predict the incidence of breast, colorectal and bladder cancers in north of Iran until 2020 using time series models. Methods: The number of breast, colorectal and bladder cancer cases from April 2014 to March 2016 was extracted. The time variable was each month of the study years and using the number of daily registered cancers in each month, the time series of the monthly incident cases was designed. Then, three methods of time series analysis including Box Jenkins, Bayesian and Bootstrap were applied for predicting the incidence of the above cancers until March 2020. Results: The number of bladder cancer cases in March 2014 was 6 cases. This study showed that the number of breast cancer cases in March 2020 will be increased to 15, 15 and 26 cases based on ARIMA, Bootstrap and Bayesian methods respectively. In addition, the incident cases of breast cancer, will be increased from 32 in 2014 to 65 (ARIMA method), 47 (Bootstrap method) and 364 (Bayesian method). The corresponding figure for colorectal cancer was 30, 30 and 95 respectively. Conclusion: The increasing trend of breast, bladder and colorectal cancers will be continued which is considerable based on the Bayesian method results. Considering the limited reliable data used in a short time, it seems that the forecasting results of this model is acceptable.

Abstract Background A protective effect of vitamin D against COVID-19 infection is under investigation. We aimed to analyze the effect of vitamin D sufficiency on the clinical outcomes of patients infected with COVID-19. Methods In this cross-sectional study we analyzed the vitamin D levels of COVID-19 patients who were admitted to Razi Hospital (an infectious disease referral center in Mazandaran province in northern Iran) from February to March 2020. Overall, a cutoff point of 30 ng/mL was used for the definition of vitamin D sufficiency. Results One hundred fifty-three patients were analyzed in this study who had laboratory documentation of a 25(OH) D level at the time of hospitalization. The vitamin D levels of the patients were 27.19 ± 20.17 ng/mL. In total, 62.7% (n = 96) of the patients had a 25(OH) D level of less than 30 ng/mL and 37.25% (n = 57) had a 25(OH) D level of more than 30 ng/mL. In total, 49% (n = 75) of the patients suffered from at least one underlying disease. The univariate and multivariable regression showed that vitamin D sufficiency was not associated with a statistically significant lower risk of adverse clinical outcomes of COVID-19 such as duration of hospitalization and severity of infection (P > 0.05). Conclusions Sufficient vitamin D levels were not found to be protective against adverse clinical outcomes in patients infected with COVID-19. Chronic disorders in COVID-19 patients were found to have greater relevance than vitamin D levels in determining the adverse outcomes of the infection. Further studies are needed to determine the role of vitamin D level in predicting the outcomes of COVID-19 infection.

Abstract Background Iranian children were vaccinated with the scheduled two doses of monovalent measles vaccine (mMV) from 1984. In December 2003, a nationwide campaign of measles-rubella (MR) immunization was established to vaccinate 5–25 year- old individuals. In 2004, the mMV was replaced with measles- mumps- rubella (MMR) vaccine. Despite the high vaccination coverage, the outbreaks of measles still occur in the country. In this Study, the MR immunity status of various age groups, vaccinated with different schedules was investigated, and the immunologic response of seronegative subjects to revaccination was examined. Methods This cross-sectional study was conducted among 7–33-year-old healthy individuals with a documented history of measles vaccination from November 2017 to June 2018. The subjects were categorized as follows: group A, including 20–33 year-old individuals; vaccinated with 1–2 doses of mMV at ages 9 and 15 months, and revaccinated with MR, group B, including 15–19-year-old individuals, vaccinated with two doses of mMV at 9 and 15 months of age, and received additional dose of MMR upon school entrance, group C, including 11–14 year-old individuals, vaccinated with two-doses of MMR at the ages of 15 months and 6 years, and group D, including 7–10 year-old individuals vaccinated with two-doses of MMR vaccine at the ages 12 and 18 months, respectively. Levels of antimeasles- antirubella IgG antibodies in the collected sera were measured. Also antimeasles- antirubella IgM and IgG of seronegative individuals were reexamined at 4–6 weeks after MMR revaccination. The collected data were analyzed using descriptive statistical methods. Results A total of 635 individuals were investigated in this study. Group A, 98; group B, 295; group C, 139; and group D, 103 persons. Overall, 12.3 and 18.4% of the population were seronegative for measles and rubella antibodies. This rate varied greatly between the 4 groups: group A, 0/0–2%; group B,15.2–25.0%; group C,11.5–17.2%; and groupD,14.6–18.4%. After revaccination, 92 and 94.9% of seronegative individuals showed IgG response to measles and rubella vaccines, respectively. Conclusion Despite the high coverage rate of M-R containing vaccines, a significant number of vaccinated subjects were seronegative for measles and rubella, possibly because of secondary vaccine failure; this may negatively affect measles-rubella elimination targets in the country. If these findings are confirmed in similar future studies, a more robust regional/national supplementary immunization activity will be considered.

Background and Aim: Clinical governance is one of the important frameworks for continuous quality improvement and safety in health care systems. Identifying the axes of this approach according to local conditions is one of the important priorities of the health system. The aim of this study was to identify the views of stakeholders on the axes of clinical governance in primary health care based on family physicians in Mazandaran province. Methods: The present qualitative study was conducted using the conceptual framework analysis method in 2018-2019. The study population were key policy makers of Ministry of Health, Health deputy of the University, the county health network, family physicians association, family physicians, and the parliament research center. Participants were selected using purposeful and snowball sampling methods. Data were collected through semi-structured interviews and were analyzed and coded using MAXQDA 11 software. Findings: According to the interviewees' views, the research findings were classified into 4 main dimensions: dimensions of clinical governance, requirements and structures, decision-makers and dimensions of quality and safety assessment. 17 sub-themes including community participation, clinical audit, clinical effectiveness, personnel management, training, information use, risk management, guidelines and procedures, promotion of health indicators, equipment and facilities, referral system, financing, policy makers, effectiveness, efficiency, human aspects of services and justice were identified and extracted. Conclusion: According to the research findings, to facilitate the implementation of clinical governance, solutions such as the existence of appropriate infrastructure, commitment of managers, supportive culture, sufficient knowledge, monitoring and evaluation, appropriate culture building, facilities and equipment and sufficient financial resources are suggested.

Background and purpose: High prevalence of Type 2 Diabetes Mellitus (T2DM) and its demand for regular care have resulted in a massive amount of electronic health records (EHRs). Hemoglobin A1c (HbA1c) and Fasting Blood Sugar (FBS) levels are two widely-used diagnostic measures for evaluation of diabetes care. This study aimed at assessing Family Medicine Plan (FMP) and exploring the trend of changes in FBS and HbA1c levels in patients attending a referral lab affiliated with Mazandaran University of Medical Sciences. Materials and methods: This cross-sectional survey was carried out in 12761 EHRs of a registry database containing the results of blood sugar tests and demographic features selected from over 250 thousand EHRs from 2012-2018. The records were categorized according to normal and abnormal levels of HbA1c (cut-off at 7%). The bivariate logistic regression model was performed by R v.3.6.1 and ggplot2 for data visulazation. Results: Abnormal HbA1c levels were seen in 37.1% of women, 36.7% of men, and 36.7% of the general population. There were significant associations between HbA1c level and age, type of insurance, FMP, kind of care plan, and the year of testing (P0.05). Conclusion: Despite the increasing prevalence of T2DM in Iran, the trend of blood sugar changes during these years showed that changes in HbA1c level was lower than 7% in studied citizens. Considerable attention to self-management in recent years indicates improvements in diagnosis and care of citizens at-risk of diabetes.

Background and purpose: Oral manifestations and their prevalence are of great importance in patients with HIV infection due to their diagnostic value and role on prognosis and monitoring patients’ immunity. All these influence patients' quality of life. The goal of this study was to investigate oral manifestations in patients with HIV/AIDS infection. Materials and methods: This descriptive-cross sectional study was conducted in patients attending counseling center for behavioral diseases in Sari, Iran 2019. Data analysis was done in SPSS V25. Results: Oral manifestations were observed in the majority of patients (96%) ranging from one to six oral lesions. The most common lesions were coated tongue (80.4%), mucosal hyper pigmentation (38.9%), periodontitis (26.8%), frictional hyper keratosis and fissure tongue (24.3%), and gingivitis and erythomatous candidiasis (19.5%). Conclusion: In this study, the prevalence of oral lesions in patients with HIV/AIDS was relatively low, but there were poor periodontal conditions. Hence, appropriate oral hygiene, providing high quality dental services, and prosthodontic care are needed in these patients.

Abstract Objectives The present study was conducted to assess 3(HCWs) during the COVID‐19 pandemic. Methods A total number of 7626 HCWs were included in this web‐based cross‐sectional study, via the convenience sampling technique. To collect the required data, the sociodemographic characteristics information form, the Depression Anxiety Stress Scale‐21 (DASS‐21), and the Corona Disease Anxiety Scale (CDAS) were also employed. In addition, data analysis was performed using the SPSS Statistics software (ver. 24), as well as descriptive statistics, Chi‐square test (χ2), and univariate/multivariate logistic regression models. Results The CDAS results revealed that 47.9% and 70.5% of the HCWs had experienced moderate levels of physical and psychological anxiety, respectively. Based on the DASS results, 44.8%, 43%, and 34.8% of the HCWs had been subjected to depression, anxiety, and stress symptoms during the COVID‐19 pandemic, respectively. The logistic regression models correspondingly showed that depression among the HCWs was significantly correlated with risk factors, such as the age groups of 20–30 years (p = .001), 31–40 years (p = .006), female HCWs (p> .001), history of physical illnesses (p = .004), and history of psychiatric disorders (p> .001). Moreover, factors including the age groups of 20–30 years (p .001), history of physical illnesses (p .001) were assumed as significant predictors of anxiety in these individuals. Besides, factors such as the age groups of 20–30 years (p = .002), 31–40 years (p = .004), female HCWs (p>.001), occupation (p = .016), history of physical illnesses (p .001) could significantly predict the prevalence rate of stress in the HCWs in times of this crisis. Conclusion Given the importance of mental health status among HCWs during the COVID‐19 pandemic, health administrators and policymakers of the Ministry of Health and Medical Education in Iran are suggested to provide psychological screening and supportive care programs for HCWs with the aim of enhancing their mental health and successful coping with critical circumstances.

Background: We aimed to determine the epidemiology of anaphylaxis to bee stings in the rural areas of Gorgan City, Iran. Objectives: Anaphylaxis is a severe, life-threatening, diffuse or systemic hypersensitivity reaction with rapidly progressive problems such as airway (throat or laryngeal edema) or bronchospasm, tachypnea and hypotension .The systemic response to bee stings is 1% in children and 3% in adults. Anaphylaxis due to bee stings is very dangerous in many cases, and may even be fatal at the initial stage. Methods: In this cross-sectional study, we analyzed some of the epidemiological characteristics of the study participants, such as demographic information, bee type, the cause of anaphylaxis, the time of bee sting, the onset of symptoms of anaphylaxis after a bee sting, the number of bee stings, symptoms during anaphylaxis, and therapeutic and prophylactic measures. Results: In total, 201 patients were diagnosed with anaphylaxis caused by bee stings. Of these, 129(64%) were male, and 72(36%) were female with the Mean±SD age of 34.33±32 and 35.25±34 years, respectively. Anaphylaxis incidents occurred in 108 men, and 103 women out of 100000; 169 of whom were adults and 46 were children. Anaphylaxis occurred in 105(52.2%) cases in

Background and purpose: Influenza viruses annually spread around the world in seasonal epidemics. The A/H1N1 virus causes more severe conditions compared to other types of Influenza A. This study is an epidemiological survey of influenza A/H1N1 virus in patients attending health care centers in north of Iran during 2013-2017. Materials and methods: Sampling was done in 3037 patients. Influenza-RNA was extracted from the samples using Viral RNA/DNA Kit PureLinkTM. Identification of influenza A/H1N1 virus was done using special primers and probes (Invitrogen), and Quantitative Real Time PCR System (SuperScript III Platinum). Results: The samples were obtained from both males (39.9%) and females (60.1%). Patients aged 31-40 years of old included the majority of samples. Influenza A/H1N1 positive samples were seen more in patients aged 61-70 (18.51%) (14.55%). Out of the 442 confirmed cases of influenza A/H1N1, 23 (5.88%) deaths were reported. Conclusion: Influenza A virus is constantly evolving by mutation or by reassortment. It evolves rapidly, and new strains quickly replace the older ones, therefore, new vaccines should be developed for immunization against new strains of influenza.

Background and purpose: Couples' communication patterns is of great importance in resolving marital conflicts. These patterns include mutual constructive communication, mutual avoidance communication, and demand-withdrawal communication. The present study aimed at investigating the factors associated with Iranian couples' communication patterns. Materials and methods: A scoping review was performed at five stages; 1-designing the research question 2- searching and extracting research studies 3- selecting relevant studies 4- organizing and summarizing the information, 5. reporting the results. Results: In this scoping review, 18 articles were selected from 130 studies. The factors affecting couples' communication patterns were classified into four categories: 1- spiritual well-being and spirituality, 2- marital and sexual satisfaction, 3- marital compatibility, and 4- love styles. Conclusion: Some factors, including spiritual well-being and spirituality, marital satisfaction and sexual satisfaction, marital compatibility, and love styles were found to affect couples' communication patterns. Seemingly providing ways to enhance couples' communication patterns towards a mutual constructive pattern is necessary to prevent marital problems and conflicts, and experiencing effective and efficient relationships.

Objectives Different factors are responsible for the silent epidemic of diabetes mellitus in developing and developed countries. This study aimed to determine the role of demographic factors, lipid profile, family history (the estimation of genetic association) and anthropometric factors on diabetes onset. Methods Data from the enrolment phase of the Tabari Cohort study was applied for this study and included 10,255 participants aged between 35–70 years. Anthropometric variables were measured by trained staff using standard tools. Blood specimens were collected for lipid profile and blood glucose measurements. Data analyses were performed using SPSS version 24, with univariate and multivariate logistic regression. Results The prevalence of diabetes mellitus was estimated to be 17.2% in the cohort population, 15.6% in men, and 18.3% in women. The adjusted odds ratios (95% confidence intervals) for age groups 40–49, 50–59 and over 60 were 2.58 (2.20–3.69), 5.80 (4.51–7.48) and 8.72 (6.67–11.39), respectively. In addition, the odds ratios (95% confidence intervals) for 2 (or more), and 1 affected family member were 4.12 (3.55–4.90) and 2.34 (2.07–2.65), respectively. Triglyceride concentrations more than 500, and abnormal high-density lipoprotein levels increased the odds of diabetes mellitus by 3.29- and 1.18-fold, respectively. Conclusion The current study showed that old age and a family history were strong predictors for diabetes mellitus.

Background and purpose: Thalassemia is a preventable genetic disorder that is a major health problem. It is now two decades since implementation of the national program for preventing β-thalassemia major in Iran. This study was conducted to compare the costs and results of this program from 2010 to 2014 in Mazandaran University of Medical Sciences. Materials and methods: Economic evaluation was done in this descriptive analytic study. We extracted the data from surveillance reports of health deputy and costs of laboratory services from the private and public sectors and Legal Medicine Organization tariffs. Other cost items were determined using published reports and articles, and interviewing the administrators and researchers. All costs were calculated in Excel 2007 based on the economic value of 2014. Results: The total direct costs of medical services, direct non-medical and non-medical direct costs of implementation of national program for preventing β-thalassemia major in one year were over 18,418,872,744 Rials. The average cost of prevention of a β-thalassemia major birth case was estimated to be be 341,090,236 Rials. The cost ratio of prevention to treatment was 1:12. Five-year implementation of the national program prevented 270 babies born with thalassemia. The success rate of this program was 95% in Mazandaran. Conclusion: Cost benefit analysis showed that the national program for preventing β-thalassemia major was efficient and economically valuable in Mazandaran province.

Background: Given the effect of various factors on the use of communication patterns by couples,this study aimed to determine the most common communication pattern among couples and related factors in Sari, northern Iran. Methods: This cross-sectional study was performed on 520 people (260 couples) in Sari. Data were collected using a demographic–fertility factors questionnaire, Enrich couple scale, communication patterns questionnaire, general health questionnaire (GHQ-28), and NEO personality inventory. Data analysis was performed in SPSS version 25 using descriptive and inferential statistics (multiple regression model). Results: While the mean (standard deviation) age of women included in the study was 34.08 (7.71) years, the mean age of men was 39.13 (9.18) years. The most common communication patterns in both women and men was the mutual constructive communication, whereas the lowest frequent communication pattern was the demand/withdraw communication in both men and women. Marital satisfaction had a significant positive correlation with mutual constructive communication pattern in women and men (P = 0.001). In addition, a significant inverse correlation was observed between the number of marriage to date, women's age, and spouses' demand/withdraw communication pattern with mutual constructive communication pattern in women. Also, a significant inverse correlation was observed between flexibility (P = 0.047), number of marriages (P = 0.013), and the wives' age (P = 0.005) with mutual constructive communication pattern in men. Conclusion: According to the results of the study, it is necessary to recognize the factors related to couples' communication patterns in order to improve the communication patterns so that marital conflicts could be avoided while a more effective communication is established.

Introduction: Fasting has certain effects on metabolic and anthropometric parameters in diabetic patients. It is therefore, necessary for patients to receive proper instructions about their physical activities, eating habits, blood glucose monitoring and medications. Aim: To investigate the effects of fasting on metabolic and anthropometric indices in type II diabetic patients. Materials and Methods: This prospective observational study was performed during Ramadan 2018. The study population consisted of 40 type II diabetic patients (33 females and 7 males) who wished to fast. They started to follow given instructions on their physical activity, eating habits, blood glucose monitoring, and medications before Ramadan. Anthropometric variables were measured pre and post-Ramadan. Fasting Blood/Plasma Glucose (FBG/FPG), Glucose 2 Hour Postprandial (2h PPG), glycosylated haemoglobin (HbA1c), and the lipids profile were assessed before and after Ramadan. FPG and 2h PPG were also evaluated on the fifteenth day of Ramadan. Data were presented as mean±SD. Paired t-test was employed and a p-value of

Background: Chronic obstructive pulmonary disease (COPD) is a global health burden that affects 300 million people worldwide. Globally, COPD was reported as the fourth leading cause of death in 2004 and is projected to occupy the third position in 2030. The goal of the present project is to describe the prevalence and determine the causes and risk factors of COPD in five provinces of Iran. Methods: This study followed a stratified cluster sampling strategy with proportional allocation within strata. The target population is all noninstitutionalized inhabitants, aged 18 and over, who inhabit in different provinces in Iran in the year 2017. The stratification of the sample according to the 31 provinces of Iran is incorporated in the sampling process. The core questionnaire was developed from preexisting validated questionnaires. The single most important outcome measure obtained as part of this protocol was spirometry before and after the administration of 200 mg (two puffs) of salbutamol. Results: The most commonly reported respiratory symptoms were as follows: wheezing (N=217, 20.4%, 95% confidence interval [CI]: 18%–22.8%), sputum production (N=173, 16.5%, 95% CI: 14.3%–18.8%), and dyspnea (N=131, 12.3%, 95% CI: 10.3%–14.3%). The overall COPD prevalence defined by the postbronchodilator spirometric Global Initiative for Chronic Obstructive Lung Disease criteria was 4.9%, higher in men (6.4%) than in women (3.9%). The prevalence of COPD was strongly dependent on smoking status, age, and sex. Conclusion: COPD is considered a preventable disease, and avoidance of exposure to major risk factors can prevent the vast majority of cases. The present study findings add to the literature on the prevalence of COPD in Iran and will help policy-makers, specialists, and all stakeholders to strategize and evaluate medical services required for reducing the prevalence of respiratory diseases. The data from our present study will serve as baseline information for future national and regional studies of COPD.

Background and purpose: Evidence suggest high prevalence of trigger finger (TF) in diabetic patients. Corticosteroid injection in the area of tendon sheath thickening is the first-line treatment of choice for TF. However, some studies indicated low efficacy of this method in diabetic patients. This study aimed at investigating the effectiveness of oral corticosteroids in diabetic patients with TF. Materials and methods: In a clinical trial, 50 diabetic patients with trigger finger (n=106 digits) enrolled. The patients were treated with oral prednisolone 5 mg, three times a day for 2 weeks. They were then followed up based on Quinnell grading at 3 and 6 weeks, and 3 months. Data analysis was done in SPSS V17 applying Repeated measures ANOVA. Results: At the end of the three-month follow-up, 84 fingers (79.3%) of patients who took oral prednisolone improved. The reduction of Quinnell grading was significant after medication (p

Abstract Background The reported positive association between opiatic drug use during pregnancy and adverse pregnancy outcomes might be confounded by other factors related to high-risk behaviors, including the use of other harmful substances. In rural areas of Iran, opium use during pregnancy is relatively common among women who otherwise do not have a hazardous lifestyle, which reduces the risk of residual confounding and increasing the possibility to identify its effects. We aimed to examine the association of antenatal exposure to opium with risks of small for gestational age, short birth length, and small head circumference at birth. Method In this cohort study in the rural area of the Golestan province, Iran, we randomly selected 920 women who were exposed to opium during pregnancy and 920 unexposed women during 2008–2010. Log-binomial regression was used to estimate risk ratios (RR) and 95% confidence intervals (CI) for the associations between prenatal exposure to opium and risks of small for gestational age, short birth length, and small head circumference at birth. Results Compared with non-use of opium and tobacco during pregnancy, using opium only and dual use of opium and tobacco were associated with increased risks of small for gestational age at births (RR = 1.71; 95% CI 1.34–2.18 and RR = 1.62; 95% CI 1.13–2.30, respectively). Compared with non-use of opium and tobacco, exposure to only opium or dual use of opium and tobacco were also associated with more than doubled increased risks of short birth length, and small head circumference in term infants. Conclusion Maternal opium use during pregnancy is associated with increased risks of giving birth to a small for gestational age infant, as well as a term infant with short birth length or small head circumference.

Precocious puberty can cause several adverse effects on final growth and social behavior in girls. Recent studies showed that low serum level of vitamin D might be associated with precocious puberty. The aim of this research was to investigate the association between serum vitamin D level and central precocious puberty in girls. Girls with central precocious puberty under the age of eight were enrolled in the study. Subjects with brain tumor, inherent adrenal hyperplasia, or thyroid dysfunction were excluded from the study. Age, weight, height, serum level of vitamin D, luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, free thyroxin (FT4), bone age, thyroid-stimulating hormone (TSH), and Tanner stages were determined for all the subjects. Healthy girls with no precocious puberty were considered as the control group. Finally, 58 girls (28 with central precocious puberty and 30 healthy) were included in the study. The average levels of serum vitamin D were 12.9 ± 7.8 ng/mL and 15.2±5.9 ng/mL in the case and control groups, respectively (P = 0.02). We found that 37% of girls with precocious puberty were in Tanner stage 2 and 63% in stage 3. The serum vitamin D level had considerable relationship with chronological-bone age difference (P < 0.01). Vitamin D deficiency was more common in girls with central precocious puberty than those with normal sexual maturation. Insufficiency and deficiency of vitamin D were more common in girls who were evaluated in this study in comparison with other studies.

Introduction: The prevalence of type 1 diabetes in all countries throughout the world is different. In this study, an introduction is, therefore, provided for the development of type 1 diabetes in children in Mazandaran province by using all available resources. Methods: In this descriptive cross-sectional study, the prevalence of patients with initial diagnosis of type 1 diabetes mellitus, aging from 6 months to 18 years, was located through contacting and referring to all organizations of insurers and doctors or experts in children endocrinologist and adolescent diseases in Mazandaran province. Results: 289 patients with type 1 diabetes were identified, 138 of whom were male (47.8%), and 151 were women (52.2%) with an overall prevalence of 0.04%, and the rate of this prevalence was 48 cases among 100000 people (50 cases among 100000 girls and 36 cases among 100000 boys). The mean age of the patients was 11.5 years old. In the study of delivery method, 180 patients (62.3%) were diagnosed with cesarean section, and 109 (37.7%) were born through natural delivery method. The mean age of onset of diabetes was 7 years. The minimum and maximum ages were 7 months and 18 years, respectively. 97 (33.6%) of the patients were also hospitalized for the first time due to ketoacidosis, and were diagnosed with diabetes. Conclusion: Type 1 diabetes in Mazandaran province was more prevalent than the similar study in southern Iran and neighboring countries. It is essential to pay greater attention to this disease through studying it in the other parts of the country.

Background and purpose: All pregnant women should be screened for diabetes mellitus. In this regard, two strategies are proposed that superiority of these two is still not clear. The aim of this study was to investigate the prevalence of gestational diabetes mellitus (GDM) according to these recommended strategies, (one-step and two-step glucose tolerance tests) in pregnant women attending health centers in rural areas of Sari, Iran during 2012-2014. Materials and methods: In this cross-sectional study, the medical records of pregnant women were randomly selected using cluster sampling. In Sari rural areas, the gestational diabetes mellitus screening had been done by two-step (50-g and 100-g) and one- step (75-g) tests in 2012 and 2014, respectively. Demographic data and the results of the glucose tolerance tests were extracted from the records and the frequency and odds ratios were calculated with a confidence interval of 95%. Results: Totally, 627 subjects (one-step n= 317 and two-step n=310 patients) were investigated. The mean ages in those screened by one-step and two-step tests were 26.6±4.1 and 26.5±4 years, respectively (P= 0.843). The mean values for BMI, history of pervious gestational diabetes and macrosomal baby delivery and diabetes familial history were not significantly different between the two groups. According to one-step screening, the prevalence of GDM was 38.5% (CI95%:33.1-44.1) while, the two-step test showed a prevalence rate of 4.2% (CI95%:2.3-7.1) (P< 0.0001) OR=14.3 (CI95%: 7.8-26.0). Conclusion: Prevalence of gestational diabetes mellitus is estimated to be much higher in one-step compared with that of the two-step screening. But, maternal and fetal benefits of this method should be assessed more accurately.

Background: Diabetes mellitus, type 1 (T1DM) and celiac disease (CD) are both immune-mediated. The mean rate of clinical overlap is 8%. The aim of this study was to discover the frequency of CD in children with type 1 diabetes in Mazandaran province. Methods: This retrospective descriptive study was performed in the pediatric endocrinology referral center, in Sari from 2012 to 2014. We screened all individuals aged between six months and 18 years with diabetes diagnosis after ketoacidosis, positive anti-GAD 65 antibodies, and insulin therapy. Patients with a positive tissue Transglutaminase Immunoglobulin A (tTG-IgA) antibodies test underwent endoscopic biopsy. Categorical data were tested using chi-square and quantitative data with independent sample T-test in SPSS. Date reported with 95% confidence interval. P

Background: Global experience as well as expert views weight the Family Physician program (FPP) as a primary solution for various problems of healthcare system in Iran. In spite of the valuable information has been collected during conducting FPP, few studies have been done to evaluate the actual performance of this program. This study reviewed the studies related to the evaluation of the FPP systematically. Methods: The authors systematically searched PubMed, Web of Science, Scopus, Embase, Irandoc and SID for articles published in English and Persian until Nov 2017 without limitation for starting time. Selection stages of the articles were done based on PRISMA flow diagram guidelines. Results: Of all articles evaluated, 19 were selected. Four articles were removed due to inadequate quality of the study. Only one article evaluates urban and the rest are about rural. Eight articles were categorized as the process evaluations and 12 outcome assessments (one of them was common). Conclusion: We achieved three main findings. First, the rural FPP has improved access to the healthcare services, but improvement in patient finding and quality of cares remains questionable. Second, there are considerable concerns in the referral system between levels I and II in both urban and rural programs. Third, there was no efficient planning to implement the FP as the gatekeepers of health care system effectively. These issues deprived the efficiency aim of FPP and need serious consideration.

Clinical governance is a systematic approach to enhancing the quality of primary health care and ensuring high clinical standards, responsiveness to performance, and continuous improvement in service quality. The objective of the current study was to investigate the global experiences of clinical governance in primary health care. In the present systematic review, relevant articles from different countries were searched in various databases such as MD PubMed from Medline portal, Emerald Springer link, ProQuest, Cochrane, Scopus, Web of Science, and Consult until April 2019. The searched articles were checked through CASP and PRISMA checklists, and their results were extracted. Of the 17 selected studies, 16 belonged to developed countries, including England (13), Australia, Italy, and New Zealand, and one was from Turkey. The findings were divided into three general categories: (1) principles of effectiveness and risk management, (2) deployment requirements such as structural and organizational needs, resource and communication, and information management, and (3) barriers of clinical governance toward providing primary health care. it is recommended that a suitable framework or model be developed and designed adapted to the local culture and taking into account all effective dimensions for a proper establishment and implementation of clinical governance in primary health care.

Background and Objective. Corpus callosum (CC), the main white matter cable which connects two hemispheres of brain, is important in special procedures such as stereotaxic surgeries vary in size, in different populations. Determination of possible size differences in ethnical groups has special values. Patients and Methods. The size of the CC on midsagittal view was determined in 76 normal male subjects using MRI of brain hemispheres in northern Iran. The size of rostrum, body, splenium, length, and height of CC was measured for each subject. The width of the body of the corpus callosum (B), the anterior to posterior length (L) and the maximum height (H) of the corpus callosum, and ratios B/L and B/H were also calculated. Results. The longitudinal dimensions of the CC were 70.21 mm and 74.05 mm in native Fars and Turkmens, respectively (P

Context: Type one diabetes mellitus (T1DM) is an autoimmune disorder that is yet the most common type of diabetes in children and adolescents. Several genetic risk factors have been associated with T1DM, auto immune thyroiditis and other autoimmune disorder. Among autoimmune disorders, autoimmune thyroid disease (ATD) is the most frequent disorder associated with T1DM. Its prevalence varies depending on age, sex and ethnic origin of the subjects and is considerably higher than the general population and increases with duration of T1DM. The aim of this study was to review the prevalence of ATD in Iranian children with T1DM compared with other countries. Evidence Acquisition: We conducted a review on all papers published on the association between autoimmune thyroiditis and T1DM, which was available on Google Scholar, Scientific Information Database (SID), Magiran and Iran Medex databases up to June 2014. Both Persian and English articles were checked. The searched terms were: diabetes mellitus, autoimmune thyroiditis, prevalence, frequency, Iranian children and adolescents. All papers which were done on patients with age under 20 years old and have used Anti-TPO and Anti-TG to evaluate patients were included. Results: Six papers met all the criteria. A total of 736 participants were included in this review. After review of all the papers, the prevalence of Anti-TPO was reported between 8% and 30% and Anti-TG was reported 6.06% to 23.6% in diabetic children in Iran. Conclusions: Autoimmune thyroid disorders are the most prevalent immunological diseases in patients with type 1 diabetes. All these studies have shown a higher prevalence of the disorder in patients with T1DM compared to the Iranian healthy population. Anti-TPO reported between 8% and 30% and Anti-TG reported 6.06% to 23.6% in diabetic children in Iran that was similar to the studies in other countries.

Characteristics of mosquito larval habitats are important in determining whether they can survive and successfully complete their developmental stages. Therefore, data on the ecological factors affecting mosquito density and abundance especially the physicochemical properties of water of their breeding sites, can possibly be helpful in implementing larval management programs. Mosquito larvae were collected using a standard 350 ml dipper from fixed habitats including: artificial pool, river edge, creek and etc, in 30 villages of 16 counties from May-December 2014. Water samples were collected during larval collection and temperature (°C), acidity (pH), turbidity (NTU), electrical conductivity (μS/cm), alkalinity (mg/l CaCO3), total hardness (mg/l), nitrate (mg/l), chloride (mg/l), phosphate (mg/l) and sulphate (mg/l) were measured using standard methods. Spearman correlation coefficient, Kruskal-Wallis test of nonparametric analysis, Chi-square (χ2) analysis, regression analysis and C8 interspecific correlation coefficient were used for data analysis. A total of 7,566 mosquito larvae belonging to 15 species representing three genera were collected from fixed larval breeding places. Culex pipiens was the dominant species except in four villages where An. maculipennis s.l. and Cx. torrentium were predominant. There was a significant positive correlation between the density of Cx. pipiens and electrical conductivity, alkalinity, total hardness and chloride, whereas no significant negative correlation was observed between physicochemical factors and larval density. The highest interspecific association of up to 0.596 was observed between An. maculipennis s.l/An. pseudopictus followed by up to 0.435 between An. maculipennis s.l/An. hyrcanus and An. hyrcanus/An. pseudopictus. The correlations observed between physicochemical factors and larval density, can possibly confirm the effect of these parameters on the breeding activities of mosquitoes, and may be indicative of the presence of certain mosquito fauna in a given region.

Background: Globally chronic obstructive pulmonary disease (COPD) was reported as the fourth leading cause of death (5.1%) in 2004 and is projected to occupy the third position (8.6%) in 2030. The goal of the present project is to describe the prevalence and risk factors of COPD in a province in the north of Iran. Methods: This study followed a stratified cluster sampling strategy with proportional allocation within strata. The stratification of the sample according to the 31 provinces of Iran is incorporated in the sampling process. The single most important outcome measure obtained as part of this protocol was spirometry before and after the administration of 200 mg (2 puffs) of salbutamol. The descriptive statistics for categorical variables included the number and percent and for continues variables included the mean ± SD. Results: A total of 1007 subjects were included in the study. Among all participants, 46 (5%) subjects had COPD on the basis of symptoms and 43 (8.3%) subjects had COPD on the basis of spirometry criteria. In univariate analysis, urban inhabitants in comparison with rural inhabitants had lower COPD risk (OR: 0.48; 95% CI: 0.24–0.95), smoker had higher risk compared with nonsmokers (OR: 1.97; 95% CI: 1.01–3.82), and subjects with exposure to dust (OR: 2.07; 95% CI: 1.09–3.94) had higher risk compared with contrary status. Conclusions: This study showed that occupational and environmental smoke exposure was associated with COPD. A new design of preventive measures must be taken to control cooking energy and cooking stoves, particularly in rural areas.

Purpose Tubularized Incised Plate (TIP) urethroplasty is a technique for urethral reconstruction of hypospadias although there are some controversies for its use in recurrent cases. The aim of this study was to review the results of TIP technique in various studies and the usage of different flaps for covering the repair site. Material and Methods Extensive Search was performed for articles published between 1994 and 2013 in common electronic databases. The overall TIP complication rates were estimated by a fixed effects model meta-analysis. Results 17 articles of hypospadia repair using the TIP method were reviewed. All studies performed surgery and repair on the basis of the Snodgrass’s method; however, some introduced modifications to the method. The prevalence of complications in repeated TIP surgery was 11.1 to 33.3% and the most prevalent complication in different studies was fistula. Based on the meta-analysis, the overall estimation of complications was 21.8 % (95% CI: 18.3 to 25.5). Conclusion Most studies performed the incision of the urethral plate to create a supportive coverage upon neourethra, and confirmed its success. We recommend further investigation on using different flaps in well-designed randomized controlled trials to choose the best surgical method for repairing recurrent hypospadias.

Numerous methods for repair of hypospadias have been introduced. The technique of Tubularized Incised Plate urethroplasty has gained widespread acceptance. In the classical method of Tubularized Incised Plate urethroplasty, to divert urine flow and preventing urethral stenosis, a stent was used, but its necessity is questionable for some surgeons. In this paper we systematically compared the results of operations in different studies. Searching the databases such as PubMed, SCOPUS, and Google Scholar was done and articles found from January 1994 to September 2013 were included. Then articles about the impact of use or non-use of urinary catheters on surgical outcomes were analyzed. By reviewing 168 studies related to repair of hypospadias with TIP, we selected 11 studies that met our inclusion criteria which did not use a stent. A total of 708 children had urethroplasty using the TIP method without stent. The overall complication rate such as meatal stenosis and fistula compared with stents was not significant. It could tell us that at least in some cases especially in distal types, use of stent can be avoided, because its least benefit would be reduction of bladder spasm and urinary tract infections.

Type 1 Diabetes Mellitus (T1DM) is the most chronic metabolic disorder in children. Celiac disease or gluten-sensitive enteropathy is a genetic and autoimmune disease which results from immune reaction to gluten. Therefore like type 1 diabetes mellitus, celiac disease is triggered by an environmental exposure in genetically susceptible individuals. The aim of this study was to review the articles reporting the prevalence of celiac disease in patients with type 1 diabetes in Iran. The results can be used for comparison with other countries, and also emphasizes the importance of screening for this disease in these patients. In this study, the articles published in PubMed, Google Scholar, Scientific Information Database (SID), Magiran and Iranmedex databases were reviewed. Three published studies (1 cross-sectional and 2 case-control) had been found and described the prevalence of celiac disease in patients aged 2-18 years with type 1 diabetes in Iran. The reported prevalence was between 3.4% and 6.8%. This is similar to reports from other countries however more studies are warranted.

Background and purpose: The basic responsibility of nurses is to maintain patient safety including notifying patients and colleagues about risk and risk reduction methods, supporting the patient safety and reporting events to a responsible person. Without creating a safety culture in all health facilities a sustainable development in the patient care do not occur. This study aims to determine the patient safety culture in teaching hospitals in Gorgan. Materials and methods: In this cross-sectional study, a target group includes nurses at 5 Azar, Taleghani and Deziani Hospitals in Gorgan in 2011. The study population included 348 nurses in these hospitals. The data collection instrument was a questionnaire with 43 questions. Statistical tests were ANOVA and T-Test. Results: Twenty four percent of nurses believed patient safety culture is weak, 46.8% of them, moderate and 30.7% good. The weakest dimension was non-punitive response to error and strongest dimension was organizational education. Statistic test showed significant relationship between patient safety culture and experience (p= 0.021), employment status (p= 0.001), hospital (p= 0.001), ward (p= 0.003). Conclusion: The status of the patient safety culture was related moderate from the nurses' view point but it is necessary it improved in dimensions of the non-punitive response and the staff workload to note that it is highly recommended to take some actions in this regard.

BackgroundUse of narcotic or "recreational" drugs has been associated with adverse pregnancy outcomes such as preterm delivery. However, the associations might be confounded by other factors related to high-risk behaviours. This is the first study to investigate the association between traditional opium use during pregnancy and risk of preterm delivery.Method and findingsWe performed a population-based cohort study in the rural areas of the Golestan province, Iran between 2008 and 2010. We randomly selected 920 women who used (usually smoked) opium during pregnancy and 920 women who did not. Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the associations between the opium use during pregnancy and preterm delivery and adjustment was made for potential confounding factors. This study shows compared with non-use of opium and tobacco, use of only opium during pregnancy was associated with an increased risk of preterm delivery (OR = 1.56; 95% CI 1.05-2.32), and the risk was more than two-fold increased among dual users of opium and tobacco (OR = 2.31; 95% CI 1.37-3.90). We observed that opium use only was associated with a doubled risk for preterm caesarean delivery (OR = 2.05; 95% CI 1.10-3.82) but not for preterm vaginal delivery (OR = 1.25; 95% CI 0.75-2.07). Dual use of opium and tobacco was associated with a substantially increased risk of vaginal preterm delivery (OR = 2.58; 95% CI 1.41-4.71).ConclusionsOpium use during pregnancy among non-tobacco smokers is associated with an increased risk of preterm caesarean delivery, indicating an increased risk of a compromised foetus before or during labour. Women who use both opium and smoked during pregnancy have an increased risk of preterm vaginal delivery, indicating an increased risk of spontaneous preterm delivery.

ABSTRACT The prevalence of asthma is inconsistent in different countries and even in regions of a country. Awareness of this prevalence has favorable impacts on health care system planning. The aim of this literature review and meta-analysis was to estimate the prevalence of pediatric asthma in the Islamic Republic of Iran during two recent decades. A search was done in national (SID, Magiran, Irandoc, Iranmedex) and international databases (PubMed and Google Scholar) to find articles which evaluated asthma prevalence in pediatrics and adolescences, using the international study of asthma and allergies in children written questionnaire. Twenty eight articles between 1992 and 2012 with a total of 96822 participants were found. ‘Asthma ever’ prevalence was 2.7% (95% CI: 1.9 to 3.6) and 3.5% (95% CI: 2.6 to 4.6) in children aged 6-7 and 13-14 years, respectively. ‘Wheezing in the past 12 months’ were 7.6% (5.6 to 9.8) and 10.7% (95%CI: 8.9 to 12.7) in children aged 6-7 and 13-14 years, respectively. The prevalence of asthma had an increasing trend during the last two decades, therefore, the health care system should be alarmed for more meticulous planning and evaluation to control and prevent asthma.

Background: In recent years, epidemiologic and laboratory studies have implied that vitamin D deficiency has a role in the pathogenesis of breast cancer. It has shown that vitamin D can prevent tumor progression induced by carcinogens and inhibit the carcinogenic effects of high fat diet on breast tissue and growth of tumor cells. This study aimed to evaluate serum 25-hydroxyvitamin D level and its role in relation to tumor characteristics and different stages of disease in women with breast cancer. Subject and Methods: This is a cross-sectional study on 200 patients with breast cancer at different stages of the disease. Information on age, menstrual status, BMI, and tumor characteristics were recorded. Serum 25-hydroxy vitamin D concentrations were measured by refigures dioimmunoassay (RIA). Mean and standard deviation were used to describe the data. Meanwhile, T-test and sum of squares test were used to analyze the data. P

Aim The majority of hemodialysis patients are hyperphosphatemic.Hyperphosphatemia in these patients can lead to renal osteodystrophy,vascular calcification, cardiovascular events, and is independently associated with mortality risk. The aim of this study was to evaluate the effect of intravenous vitamin C on phosphorus level in hemodialysis patients. Methods Using a double blind randomized clinical trial, a total of 60 qualified hemodialysis patients were randomly allocated in two intervention and control groups and serum phosphorus, CRP, calcium, albumin and PTH levels were measured. At the end of each hemodialysis session, intervention group received vitamin C vial (500mg/5cc) intravenously three times a week for 8 weeks and control group received normal saline in the same way. Data were collected before and after two months of treatment. Data were analyzed using independent t-test, paired t-test and chi-square test.Results Vitamin C treated group had a significant decrease inphosphorus (p=0.01), CRP level (p=0.01) and Ca×P product(p=0.03). In contrast, there was no significant difference in phosphorous (p= 0.5) and CRP levels (p= 0.6) and Ca×P product (p=0.7) in the control group. In addition, there was no statistically significant change in calcium (p=0.1), PTH (p=0.4) and albumin (p=0.4) levels in both groups. Conclusion Intravenous vitamin C can significantly decrease phosphorus level in hemodialysis patients.

Background. The sequential organ failure assessment (SOFA) score has been recommended to triage critically ill patients in the intensive care unit (ICU). This study aimed to compare the performance of our proposed MSOFA and original SOFA scores in predicting ICU mortality. Methods. This prospective observational study was conducted on 250 patients admitted to the ICU. Both tools scores were calculated at the beginning, 24 hours of ICU admission, and 48 hours of ICU admission. Diagnostic odds ratio and receiver operating characteristic (ROC) curve were used to compare the two scores. Results. MSOFA and SOFA predicted mortality similarly with an area under the ROC curve of 0.837, 0.992, and 0.977 for MSOFA 1, MSOFA 2, and MSOFA 3, respectively, and 0.857, 0.988, and 0.988 for SOFA 1, SOFA 2, and SOFA 3, respectively. The sensitivity and specificity of MSOFA 1 in cut-off point 8 were 82.9% and 68.4%, respectively, MSOFA 2 in cut-off point 9.5 were 94.7% and 97.1%, respectively, and MSOFA 3 in cut-off point of 9.3 were 97.4% and 93.1%, respectively. There was a significant positive correlation between the MSOFA 1 and the SOFA 1 (r: 0.942), 24 hours (r: 0.972), and 48 hours (r: 0.960). Conclusion. The proposed MSOFA and the SOFA scores had high diagnostic accuracy, sensitivity, and specificity for predicting mortality.

Metformin is a dimethyl biguanide oral anti-hyperglycemic agent. Lactic acidosis due to metformin is a fatal metabolic condition that limits its use in patients in poor clinical condition, consequently reducing the number of patients who benefit from this medication. In a double blind randomized clinical trial, we investigated 200 type 2 diabetic patients after coronary artery bypass surgery in the open heart ICU of the Mazandaran Heart Center, and randomly assigned them to equal intervention and control groups. The intervention group received regular insulin infusion along with 2 metformin 500 mg tablets every twelve hours, while the control group received only intravenous insulin with 2 placebo tablets every twelve hours. Lactate level, pH, base excess, blood glucose and serum creatinine were measured over five 12 h periods, with data averaged for each period. The primary outcome in this study was high lactate levels. Comparison between the 2 groups was made by independent Student’s t-test. To compare changes in multiple measures in each group and analysis of group interaction, a repeated measurement ANOVA test was used. There was no significant difference between the 2 groups regarding pH, base excess, or bicarbonate intake (P>0.05). No patient showed lactic acidosis in either group. Lactate levels were 23.0 vs 23.4 in the insulin-metformin and insulin only groups when the study was started, respectively. At the end of the study, those levels were 18.7 vs 18.9, respectively. In addition, the ANOVA repeated measurement test did not show a significant difference in terms of changes in the amount of lactate level between the 2 groups during the five measurement tests of the study period (P>0.05). High-dose metformin (1,000 mg twice daily with insulin) does not cause lactic acidosis in type 2 diabetic patients after coronary artery