ARCHIVES OF IRANIAN MEDICINE
Year:2013 | Volume:16 | Issue:3|Papers Count:17

This issue of AIM focuses on studies from Isfahan Cardiovascular Research Institute. This institute is a pioneer of research on lifestyle modification for prevention of cardio- vascular disease (CVD) in middle-east. During the last few decades, most developing countries have witnessed noticeable improvements in general health. Infectious diseases, formerly the prime reason for mortality, are becoming less and less common leading to significant improvements in various health indexes such as infant mortality rate and life expectancy. The life expectancy at birth in Iran has rose to above 73 years in 2010.

INTRODUCTION: Accurate estimates of the incidence of cardiovascular diseases (CVD) comprising of acute myocardial infarction (AMI), unstable angina pectoris (UAP), sudden cardiac death (SCD), and stroke are very important for public health. However, such information is scarce, especially for middle- and low-income countries.METHODS: The Isfahan Cohort Study (ICS) prospectively followed up 6504 individuals, 51.8% women, aged 35 years and over, 6323 initially free of CVD, from urban and rural areas in three districts in central Iran including Isfahan, Najafabad, and Arak. A panel of specialists in cardiology and neurology decided on the diagnosis of the occurred events based on patients’ hospital records, verbal autopsy, and death certificates.RESULTS: After 32893 person-years of follow-up, 427 new cases of CVD events (229 in men) were registered. Confirmed cases of AMI, stroke, UAP, and SCD were 57, 43, 93, and 36 in men and 32, 48, 100, and 18 in women, respectively. The corresponding crude incidence rates were 352, 265, 352, and 220 per 100000 person-years in men and 186, 279, 584, and 104 in women, respectively. No significant differences were found in age at the time of events occurrence between men and women and between different event types except for SCD and stroke in women that in average the former occurred nine years later. CVD mortality rate was 331 per 100000 person-years in men and 203 in women.CONCLUSION: We found substantially high incidence rates for almost all CVDs and mortality. These findings need urgent consideration by health policy makers specifically for women.

BACKGROUND: Stress has been considered as a highly common disorder that has a complicated relation with dietary intake and has been linked with both increased and decreased dietary intake.OBJECTIVE: This study was conducted to assess the association between food consumption and stress levels in an Iranian adult population.METHODS: In this cross-sectional study, data from the third phase of Isfahan Healthy Heart Program (IHHP) that was conducted for cardiovascular diseases prevention and health promotion were used. Nine thousand five hundred forty-nine adults aged ≥18 years participated in the study. Dietary habits were assessed by a 49- item Food Frequency Questionnaire (FFQ). Stress levels were assessed by General Health Questionnaire-12 (GHQ-12). The participants were separated on the basis of their stress levels into two groups as the low- and high- stress groups.RESULTS: Individuals in the low- stress group were significantly younger and tended to have higher physical activity and education level, lower LDL cholesterol, and were less likely to be current smokers. Dietary intake of unsaturated oils, grains, fruits, vegetables, meat, and dairy products was significantly higher in the low- stress group whereas dietary intake of saturated oils was significantly lower; moreover, Global Dietary Index (GDI) was lower in the low- stress group. We found a significant positive association between stress level, GDI (OR: 1.24; 95% CI: 1.14-1.35), and saturated oils (OR: 1.17; 95% CI: 1.08-1.28) and inverse association between stress level and intake of unsaturated oils (OR: 0.84 ; 95% CI: 0.77-0.91), fruits and vegetables (OR: 0.83; 95% CI: 0.76-0.90), meat (OR:0.88; 95% CI:0.82-0.97),and dairy products (OR: 0.88 ; 95% CI: 0.81-0.96) after adjustments based on sex, age, smoking, and physical activity.CONCLUSION: Our results showed a significant positive association between dietary intake and stress. We must have a special attention to dietary intake in stress management program of high- stress individuals, and in dietary recommendations, psychologic aspects should be considered. However, prospective longitudinal studies are needed to assess the causal relationship between stress and dietary factors.

OBJECTIVE: To investigate the association between obesity indices, abdominal fat distribution, and lipid profile in patients with stable angina (SA).METHODS: Body weight, height, waist circumference (WC), body mass index (BMI), and waist /height ratio (WHtR) of 123 patients with SA who underwent coronary angiography were measured. Fasting blood samples were taken to measure the levels of fasting blood sugar (FBS), total cholesterol (TC), low- and high-density lipoprotein cholesterol (LDL-C, HDL-C), apolipoproteins A and B (apo A and apo B), and triglycerides (TG). According to angiography reports, the participants were divided into patients with or without coronary heart disease (CHD). All patients underwent an abdominal computerized tomography (CT) scan to measure the visceral, superficial, and deep subcutaneous fat.RESULTS: The mean ages of the patients with CHD (n=73) and without CHD (n=50) were 50.5±7.6 and 53.7±7.6 years, respectively (P=0.03). The patients with CHD had significantly higher levels of TC, TG, and superficial subcutaneous fat, while the patients without CHD had higher levels of apo A (P≤0.05). Multivariate analyses showed a significant association of visceral fat with TC, LDL-C, TG, and apo B, in the patients without CHD, while significant inverse associations were found between WC and HDL-C, WHtR, and apo A as well as visceral fat and LDL-C in the patients with CHD.CONCLUSIONS: Among anthropometrics and imaging indices of obesity, WC and WHtR have shown better association between central obesity with dyslipidemia in the patients with CHD, while CT-measured visceral adipose tissue area was the best correlate of dyslipidemia in the patients without CHD.

BACKGROUND: Opium dependence is a recognized individual and public health threat, but little is known about its association with acute myocardial infarction (AMI) or sudden cardiac death (SCD).METHODS: In a cross-sectional study followed by a one-year matched longitudinal cohort, all 569 men hospitalized with AMI in all Cardiac Care Units (CCU) of Isfahan, Iran, were recruited in a six-month period. In addition, 123 out-of-hospital deaths were included that were diagnosed as SCD at the same duration. Among those discharged alive, 126 opium dependents were matched with 126 nondependents (mostly nonusers) according to age and smoking status, and were followed for one year. Opium dependence was measured using the ICD10 criteria and Severity of Dependence Scale (SDS) questionnaire. The method was validated by morphine blood levels. Biochemical measurements, blood pressure, blood cell counts, anthropometrics, and ejection fraction were measured at baseline and repeated at the end of follow-up.RESULTS: There were 118 (17.1%) patients with an average of 17.4±10.4 years of abuse who met the criteria for opium dependency. Opium dependence decreased the age at event by 3.6 (95% CI: 1.2-6.0) years and was independent of smoking (P=0.003). In terms of cardiovascular risk factors such as ejection fraction, in addition to post-AMI mortality and morbidity, no significant associations were noted at baseline or after one year of follow-up. The odds ratio of sustained smoking after AMI was 1.92 (95% CI: 1.04-3.52) in opium dependents (P=0.033).CONCLUSION: Despite public opinion, opium did not improve cardiovascular risk factors, or post-AMI mortality and morbidity. Conversely, there were irrefutable findings regarding the detrimental effects of opium dependence.

BACKGROUND: The incidence of cardiovascular disease (CVD) and its risk factors increase after menopause, thus realizing that the effect of menopause on women’s health is becoming ever more vital.OBJECTIVE: The aim of this study was to investigate the menopausal effect on cardiovascular risk factors in elevated triglycerides (TG) and waist circumference (WC) phenotype, and to compare this phenotype among pre- and postmenopausal women.METHODS: A total of 4146 women were randomly selected for this study from three districts of Isfahan, Arak, and Najafabad in Isfahan Healthy Heart Program (IHHP). Anthropometric, physical, and biochemical factors were assessed using standard methods. All variables were studied based on the menopause status and the levels of TG and WC.RESULTS: Twenty-five point three percent of the postmenopausal women and 9.5% of the pre-menopausal women were hyper-TG/WC phenotype; however, the highest percent (77.1%) belonged to high-WC women in the postmenopausal group. In comparison with the postmenopausal women, the premenopausal women were more physically active, with higher education level, but lower BMI, WC, waist to hip ratio, and less likely to be smoker. In postmenopausal women, biochemical factors including fasting blood sugar and lipid profiles were significantly higher than the premenopausal women. There was no significant difference for multivariate-adjusted means of cardiovascular risk factors for menopause in different phenotypes of the WC and TG groups after adjustment for age and BMI.CONCLUSION: Hyper- TG/WC phenotype was more prevalent in postmenopausal women and menopause is not independently associated with CVD risk factors.

OBJECTIVE: To assess the amount of salt intake among normotensive (NT) and prehypertensive (PHT) subjects and to determine whether the association between salt intake and blood pressure is correlated with body weight and waist circumference (WC) or is independent.METHODS: A total of 806 NT and PHT subjects from Isfahan Healthy Heart Program (IHHP) were enrolled in the study. A standard questionnaire was used to assess sociodemographic characteristics. The amount of salt intake was measured by the 24-hour urine collection method. Blood pressure, height, weight, and WC were measured based on standard protocols.RESULTS: The mean ages (±SD) of NT and PHT subjects were 35.9 (±11.9) and 44.7 (±12.5) years, respectively (P<0.001). The mean values of body mass index (BMI) and WC were greater among PHT than NT subjects (BMI: 27.9±3.8 vs. 25.1±4.3 kg/m2; P<0.001 and WC: 90.2±8.6 vs. 81.2±11.2 cm; P<0.001, respectively). PHT subjects had higher amount of salt intake than NT ones (10.3±6.2 vs. 12.7±7.1 g/d, respectively; P=0.003). Odds ratio (OR) for being PHT increased significantly across the tertils of salt intake in crude model and sociodemographic- adjusted model. Further adjustment for BMI and WC values weakened the OR for being PHT and showed nonsignificant trend (OR (and 95% CI) for BMI across tertiles of salt intake: 1, 1.26 (0.59-2.69), 1.89 (0.93-3.81); P=0.063 and OR (and 95% CI) for WC across tertiles of salt intake: 1, 1.22 (0.58-2.57), 1.79(0.89-3.56); P=0.082).CONCLUSION: The findings of this study suggest that the association between salt intake and blood pressure is related to body weight and WC.

BACKGROUND: Potato, a high- glycemic index (GI) food, is one of the most widely used starchy foods worldwide. Previous studies on the association of dietary intakes with stroke have mostly focused on the dietary GI and there is no information regarding the association between potato consumption and risk of stroke. This case-control study was conducted to evaluate the association between potato consumption and risk of stroke in an Iranian adult population.METHODS: In this case-control study, 195 patients with stroke, hospitalized in the Neurology Ward of Alzahra University Hospital and 195 controls from other wards of the hospital with convenience non-random sampling method were enrolled. To assess participants'' dietary intakes, a validated food frequency questionnaire was used. Information on socioeconomic and demographic variables, physical activity pattern, and smoking were collected by the use of questionnaires. Logistic regression method in different models was applied to explore the associations between potato intake and stroke. First quartile of potato intake was used as a reference in all models. Mantel-Haenszel extension chi-square test was used to assess the overall trend across quartiles of potato consumption.RESULTS: Individuals with stroke were more likely to be male (60% vs. 46%, P<0.05) and older (68.0±1.0 vs. 61.5±0.8 y, P<0.001) as compared with controls. They had lower body mass index (BMI) (25.2±0.3 vs. 28.5±1.0 kg/m2, P<0.05), and were less likely to be obese (11.3% vs. 29.2%, P<0.001) compared with controls. The mean potato consumption was 31.1±3.4 and 23.4±1.3 g/d for cases and controls, respectively. Participants with the highest potato consumption were younger and more likely to be physically active. High potato consumption was associated with higher intakes of energy, fruits, vegetables, pulses, and grains. After adjustment for age, sex, and total energy intake, we found that individuals with the highest potato consumption were more likely to have stroke as compared with those with the lowest consumption (OR: 1.9; 95%CI: 1.0-3.6). The correlation between physical activity and potato consumption was 0.03, P = 0.54 and that of smoking and potato intake was -0.004, P=0.94. Even after additional control for smoking and physical activity, the association remained significant (OR: 1.9; 95% CI: 1.0-3.6). Further adjustment for dietary intakes made the associations non significant (OR: 1.1; 95%CI: 0.5-2.5). However, when BMI was taken into account in the final model, we found that individuals in the third quartile of potato consumption were significantly more likely to have stroke (OR: 2.2; 95%CI: 1.0-4.7).CONCLUSION: We found evidence indicating that there is a marginally significant independent association between potato consumption and risk of stroke. Prospective studies are required to confirm this finding.

BACKGROUND: The incidence of idiopathic pulmonary fibrosis (IPF) appears to be increasing. In the western literature, the average age of presentation is in the seventh decade of life while it has been reported to be earlier in the Middle East and India. Given that a paucity of epidemiological data exists in Iran, we sought to describe the clinical pattern and course of the disease at a large Iranian referral center.METHODS: A retrospective review was conducted of 132 patients diagnosed with IPF at the National Research Institute of Tuberculosis and Lung Diseases (NRITLD) in Tehran, Iran from 1988 through 2008. Data were collected from the medical records which consisted of demographics, clinical history, laboratory tests, pulmonary function tests (PFT), radiographic and pathology findings, treatment, and outcomes of the disease.RESULTS: The mean age at diagnosis was 56.6 years (95% CI: 53.8-59.4) with no significant sex predilection. Common presenting symptoms included dyspnea and cough, which occurred for a mean period of 21 months prior to diagnosis. Common signs included end-inspiratory crackles and digital clubbing, which were found in 85.6% and 55.3% of the patients, respectively. Radiographically, reticular and reticulonodular opacities were seen in 47.3% and 20.9% of the patients, respectively on high resolution computed tomography (HRCT). In patients who underwent lung biopsy, diffuse interstitial fibrosis was seen in 91.1%. The mean follow-up time for all patients was 32.8 months (95% CI: 23.2-42.4, range: 1-257 months). There were 16 patients who died during the study period. The mean age of death was 56.8 years (95% CI: 46.2-67.4), which is significantly lower than the life expectancy in Iran (P-value: 0.017). The mean survival time for patients who died was 1.1 years (95% CI: 0.5-1.7) after diagnosis. The one- and three- year overall survival rates for all patients were 88% and 79%, respectively.CONCLUSION: The clinical characteristics of IPF in Iran are similar to those in the western literature. However, Iranian patients appear to be developing the disease a decade earlier than western patients.

With the imminent threat of a global health crises of obesity and diabetes or “diabesity” as it is referred to today, healthcare professionals urgently need an effective range of treatment options for management of these two epidemics. After many decades in obscurity, bariatric surgery has emerged as an impressive treatment of obesity and type 2 diabetes. The field of bariatric surgery has seen a rapid evolution over the last 30 years and current procedures are safe, effective, less invasive, and relatively cost- effective. Bariatric procedures produce durable weight loss, long -term remission of type 2 diabetes, and beneficial effects on other comorbidities; they lead to a significant reduction in mortality in the long term. The adverse events after surgery are not uncommon but in majority of cases are not fatal. Bariatric surgery is costly, but cost-efficacy analysis consistently shows that the additional years of lives gained through bariatric surgery can be obtained at a reasonable and affordable cost. However, universal surgical treatment of obesity is not achievable with the world’s current healthcare and surgical resources.The conclusion of this review is that although bariatric surgery is a good addition to management of obesity and diabetes, these epidemics must be addressed by more comprehensive and long- term health policy efforts and appropriate research to determine the most effective ways of prevention and nonsurgical alternatives to treat obesity and type 2 diabetes.

BACKGROUND: The prevalence of the palmaris longus agenesis (PLA) has been variously reported to be from 1.5% to 64% in different ethnic groups. Lack of reliable information about the state of the PLA in Iran made us to design a study on the agenesis of the palmaris longus (PL) among Iranian population during 2009.MATERIALS AND METHODS: One thousand participants were included in this descriptive study. Subjects were patients and personnel of a sample of a major orthopedic surgery center in Iran. The Schaeffer test was used to detect the presence or absence of the PL. An orthopedic resident conducted the test (observer reliability 98%). The prevalence of agenesis was determined in the sample and its actual prevalence was estimated for the whole population. The role of gender and handedness was also considered in the presence or absence of the PLA.RESULTS: The prevalence of the PLA was estimated to be 22.8%; 10.2% agenesis on the right side, 5.9% on the left side, and 6.7% bilateral PLA. The relationship between PLA and gender didn’t appear to be significant. Among people with PLA 43% and among people without PLA 17% were left handed (P<0.05, odds ratio [OR]: 3.7).CONCLUSION: The prevalence of the PLA in Iranians seems to be comparable with the average Caucasian values which is estimated to be 22.4%. Furthermore, significant relationship exists between the PLA and left hand dominance.

Littoral- cell angioma (LCA) is a rare vascular tumor of the spleen. It was thought to be a benign, incidental lesion. However, many recent reports have described it to be a malignant lesion with congenital and immunologic associations. We report a case of LCA of the spleen, which has been infrequently communicated in the literature. A 41-year-old female patient was admitted to our hospital with a three-week history of weakness, weight loss, anorexia, and intermittent upper abdominal pain which improved slightly with antacid medication. Imaging studies, including computed tomography (CT) and magnetic resonance imaging (MRI), showed multiple lesions in the spleen. Laparoscopic splenectomy was performed.

Nocardia cerebral abscesses are rare intracranial lesions. They account for only 1% to 2% of all brain abscesses. They are important in immunocompromised patients, but rarely occur in immunocompetent hosts. Here, we present a case of multiple primary brain abscesses with Nocardia in an immunocompetent patient, who was treated successfully with oral antibiotic therapy.

Stiff man syndrome is a rare disease characterized by painful chronic spasms in the muscle and skeletal system. This syndrome is an autoimmune neurologic disorder which is associated with thymoma. We treated a 32-year-old male patient with a type C thymoma (based on the World Health Organization classification) who had stiff man syndrome. The patient underwent an extended thymectomy which brought about alleviation of his symptoms.

A 35- year-old female patient was presented to our hospital with complaints of wheezing and dyspnea on efforts of three years duration. She did not have any personal history of atopy and never smoked. Her physical examination was normal. The chest X-ray demonstrated an abnormality in the right paratracheal region with absence of the aortic knuckle on the left side.

A 30-year-old female presented with headache and gait disturbance which were gradually progressive for the past three months. On T1 weighted magnetic resonance imaging (MRI), it appeared to be a 35mm´25mm´20mm hyperintense mass in the left cerebellar hemisphere encroaching on the vermis and causing compression of the fourth ventricle.

Recent excavations provided many documents regarding the application of medical instruments, surgical and even reconstructive procedures during the pre-historic and ancient periods. Actually, there is no historical definite time-zone separating general and cosmetic operations in the pre-modern time; however, historically there have been many surgeons who tried to perform reconstructive procedures during their usual medical practice. This article presents a brief look at the history of plastic surgery form the ancient to the contemporary era, with a special focus on Iran.