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Abstract There is limited information about the relationship between diabetes mellitus (DM) and ALT to HDL-C ratio. This study aims to investigate this relationship for the first time in Iran. The data of this study were taken from the third phase of the Shahroud Eye Cohort Study, which was conducted in 2019 with the participation of 4394 people aged 50–74. ALT and HDL-C levels were measured using a BT-1500 autoanalyzer. The mean ALT/HDL-C ratio was reported along with 95% confidence intervals (CI). The multiple logistic regression was used to examine the association between this ratio and DM, while controlling for the effects of other independent variables. The mean and standard deviation of the ALT/HDL-C ratio in all participants were 16.62 ± 11.22 (95% CI 16.28–16.96). The prevalence of DM was 34.7% and individuals with DM had a mean ALT/HDL-C ratio that was 1.80 units higher than those without diabetes (P

Abstract Sleep plays an essential role in improving the quality of life of people living with HIV (PLWH); however, sleep traits in this population are not well studied. This study aims to evaluate the sleep traits and related associated factors among PLWH in Iran. A nationwide cross-sectional study was conducted with 1185 PLWH who attended Voluntary Counseling and Testing centers in 15 provinces in Iran between April 2021 and March 2022. The Berlin Obstructive Sleep Apnea questionnaire, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and Insomnia Severity Index were used. A two-step clustering method was employed to identify the number of sleep clusters in PLWH. Prevalence of poor sleep quality, sleepiness and insomnia were 49.6%, 21.15% and 42.7% respectively. Three sleep trait clusters were identified: I. minor sleep problems (45.6%); II. Snoring & sleep apnea (27.8%), and III. poor sleep quality and insomnia (26.7%). Age (Odds Ratio (OR) 1.033, 95% Confidence Interval (CI) 1.017–1.050), academic education (OR 0.542, 95% CI 0.294–0.998) and HIV duration were associated with being in Snoring & sleep apnea cluster, while age (OR = 1.027, 95% CI 1.009–1.040) was associated with being in Poor sleep quality and insomnia cluster. PLWH with depression had higher odds of being in Poor sleep quality and insomnia cluster, and those with anxiety had higher odds of being in Snoring & sleep apnea cluster and Poor sleep quality and insomnia cluster. A significant proportion of PLWH have poor sleep quality, sleepiness, and insomnia. The identification of three distinct sleep trait clusters underscores the need for increased attention and tailored interventions to address the specific sleep issues experienced by PLWH.

Background. The Urban Family Physician Program (UFPP) has been implemented in Fars and Mazandaran provinces of Iran since 2013 with the aim of improving access and utilization of health services, with a particular focus on children and adolescents. In order to evaluate the effectiveness of the program in achieving this goal, this study aimed to compare the access and utilization of health services among children living in areas covered by the UFPP with those living in other regions of Iran. Methods. A secondary analysis was performed using data from the 2015 National Health Utilization Survey. The data of people aged under 18 were extracted and indicators on the use of health services based on three main models of health service provisions were compared: (1) cities in Fars and Mazandaran provinces (UFPP implemented); (2) cities in other Iranian provinces (excluding Fars and Mazandaran); and (3) villages and cities with a population under 20,000. Results. The study included 20,689 children. The outpatient and inpatient visits in children living in Fars and Mazandaran provinces were higher than in children from other provinces and smaller towns (11.89 vs. 7.92 and 7.21 for outpatient and 4.74 vs. 3.51 and 4.27 for inpatient, respectively). Furthermore, UFPP was found to be associated with a higher utilization of health services in children residing in cities (odds ratio=1.50 (1.98-1.15)). Additionally, the cost of outpatient and inpatient health services in areas where the UFPP was implemented was lower compared to other parts of the country. Conclusion. The urban family physician program has been successful in increasing the access to health services and reducing health costs in children. Practical Implications. The findings suggest that the urban family physician program can be an effective strategy for improving healthcare access and reducing costs, especially in areas with high population density. Policymakers and healthcare providers can use the results of this study to inform the development and implementation of similar programs in other countries, with the aim of improving healthcare access and reducing healthcare costs in children and adolescents.

Abstract This study aimed to evaluate the association between iris color and refractive errors in children aged 6–12 years. This cross-sectional study was based on data obtained from the first phase of the Shahroud Schoolchildren Eye Cohort Study. The target population was 6 to12 year-old students living in urban and rural areas. Iris colors were classified by comparing eye colors with close-up images of iris colors. Myopia was defined as a spherical equivalent (SE) ≤ − 0.5 diopter and hyperopia was defined as SE ≥ 2 diopter in cycloplegic refraction. The association of iris color with hyperopia and myopia was investigated by fitting two separate multiple logistic regression models adjusted for place of residence, age, sex, and times for outdoor activity and near work. Among the 5394 participates with the mean age of 9.7 year, the prevalence of myopia and hyperopia was 4.8% and 4.7% respectively. The number and proportion (in parentheses) of amber, light blue, light brown, dark brown, gray, green and hazel iris colors were 19(0.4%), 26(0.5%), 645(12.0%), 4517(83.7%), 4(0.1%), 59(1.1%), and 124(2.3%) respectively. Compared to dark brown, the odds ratios and 95% confidence intervals (in parentheses) of myopia were 4.8(1.2–18.7), 0.8(0.1–5.8), 1.0(0.7–1.5), 0.4(0.1–2.7) and 0.6(0.2–1.8) for amber, light blue, light brown, green and hazel iris colors in multiple logistic regression model. No significant association was observed between iris colors and hyperopia. This study shows that amber iris is significantly associated with higher odds of myopia. These children should be further monitored and examined. More studies with higher sample size in all iris colors are recommended.

Abstract Objective This study aimed to investigate the association between depression and self-care in diabetic patients potentially influenced by biases in depression measurement using weighting the positive and negative predictive values. Methods In this cross-sectional study, 1050 patients informedly consented to participate in the study. Using a WHO-5 well-being index, the participants were examined for depressive mood as exposure. The sensitivity and specificity of this index in a systematic review study were 0.86 and 0.81, respectively. Self-care (that is outcome) was assessed using the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire. To correct the misclassification bias of exposure, the predictive weighting method was used in the multivariable logistic regression model adjusted for covariates. Bootstrap sample with replacement and simulation was used to deal with random error. Results The mean age of patients was 42.8 ± 7.5 years. In this study, 70.1% of diabetic patients (n = 720) were depressed based on the questionnaire score and only 52.7% (n = 541) of them had appropriate self-care behaviors. Our study revealed a close relationship between self-care and covariates such as gender, depression, having comorbidities, abdominal obesity, economic status and education. The odds ratio of the association between depressive mood and lack of self-care in primary multivariable logistic regression was 2.21 (95% CI: 1.62-3.00, p

AIM: To determine the agreement of ocular biometric indices including axial length, keratometric readings, anterior chamber depth, and horizontal corneal diameter between the Pentacam AXL and IOL Master 500. METHODS: The study was a large cross-sectional population-based study (Tehran Geriatric Eye Study) conducted from Jan 2019 to Jan 2020. A total of 160 clusters were randomly selected proportional to size (each cluster contained 20 individuals) from 22 strata of Tehran city. All people aged 60y and above were invited to participate in the study. For all participants, preliminary ocular examinations were performed including the measurement of uncorrected and best-corrected visual acuity, objective and subjective refraction, anterior and posterior segment examinations. All participants underwent an ocular biometry using the Pentacam AXL and IOL Master 500. RESULTS: The 95% limits of agreement (LoA) between the two devices were -0.13 to 0.19, -0.15 to 0.17, and -0.13 to 0.19 in normal, pseudophakic, and cataractous eyes, respectively. With increasing the axial length, the difference between the two devices significantly increased in all three groups of normal, pseudophakic, and cataractous eyes (P

Abstract Purpose: To assess the repeatability of Pentacam AXL as a Scheimpflug-based system or measuring axial length according to the age, sex, lens type, axial length value, and type of cataract. Methods: The present study was conducted using multistage cluster sampling in Tehran, Iran. Ocular biometry was performed, using the Pentacam AXL, by an experienced optometrist on all the participants. The axial length (AL) measurements were taken thrice, with a gap of 10 minutes. To evaluate the repeatability, the intraclass correlation coefficient (ICC) and the repeatability coefficient (RC) were calculated. To determine the significant difference in the repeatability index among study variables, the tolerance index (TI) was calculated. Results: In this report, 897 eyes of 677 individuals aged between 20 and 91 years (mean ± SD: 64.90 ± 13.62 years) were reported. The ICC of the axial length measurements was 0.981 for all cases. Based on the within-subject standard deviation, the RC was 0.401. The ICC was 0.976 and 0.985 in men and women, respectively. The TI showed better RC of measurements among females. The ICC decreased from 0.999 in participants under 40 years to 0.973 in individuals over 60 years of age. The TI showed a decrease in RC with advancing age. The RC was worse in eyes with nuclear cataracts; the RC was also worse in the first quartile of the signal-to-noise ratio (SNR) compared to the other SNR quartiles. Conclusion: The Scheimpflug-based systemPentacam AXL had high repeatability in measuring axial length. Some variables such as male gender, older age, and nuclear cataract were associated with reduced repeatability of the measurements. A higher SNR was associated with better repeatability of the axial length measurements.

Abstract Background First permanent molars (FPM) play an important role in the masticatory function and oral health. This study aimed to assess the economic inequalities of FPM health indices among schoolchildren in the northeast of Iran. Methods A total of 4051 children aged 8–12 years old were included in the analyses of this cross-sectional study in 2015. Economic status was measured using the principal component analysis on home assets. Concentration index (C) was used to measure economic inequality in FPM health indices, and its contributing factors determined by Wagstaff decomposition technique. Results The prevalence of having decayed, missing, and filled FPMs among children was 40.9% (95% CI: 38.8–43.0), 1.2% (95% CI: 0.8–1.6%), and 7.8% (95% CI: 6.7–8.9%), respectively. Missing FPM was generally more concentrated among low-economic children (C=-0.158), whereas, filled FPM was more concentrated on high-economic children (C = 0.223). Economic status, mother education, having a housekeeper mother, and overweight/obesity, contributed to the measured inequality in missing FPM by 98.7%, 97.5%, 64.4%, and 11.2%, respectively. Furthermore, 88.9%, 24.1%, 14.5%, and 13.2% of filled FPM inequality was attributable to children’s economic status, father education, residence in rural areas, and age, respectively. Conclusion There is a significant economic inequality in both missing and filled FPM. This inequality can be attributed to the economic status of individuals. To reduce FPM extraction, it is important to target low-income and rural children and provide them with FPM restoration services. Additionally, it is necessary to provide training to less-educated parents and housekeeper mothers to address the observed inequalities.

IntroductionMonitoring social inequalities in dental caries is crucial for establishing priorities in oral health systems. This study aimed to assess economic inequalities in dental caries and its contributing factors among Iranian schoolchildren.MethodsData were obtained from the first phase of the Shahroud Schoolchildren Eye Cohort Study in 2015. A total of 4992 children aged 6-12 years old were included in the analysis. Dental examinations were conducted following the diagnostic methods and standards of the Oral Health Examination Survey, as recommended by the World Health Organization. The concentration index (C) was utilized to assess economic inequalities in dental caries. Additionally, the decomposition of C was employed to explain the determinants of the measured inequalities.ResultsIn total, 71.4% of the schoolchildren had dental caries in primary dentition (dft≥1), and 41.6% of the schoolchildren had dental caries in permanent dentition (DMFT≥1). The Cs of dft≥1, primary decayed teeth (pdt≥1), and permanent missing teeth (PMT≥1) were -0.136 (95% CI: -0.167, -0.104), -0.164 (95% CI: -0.194, -0.134), and -0.208 (95% CI: -0.262, -0.153), respectively, which indicates their more concentration among low-economic children. Conversely, pft≥1 and PFT≥1 had Cs of 0.327 (95% CI: 0.292, 0.361) and 0.218 (95% CI: 0.179, 0.256), showing more concentration among high-economic children. Basic health insurance coverage and age were the main contributors that explained 28.6% and 19.2% of the economic inequality in dft≥1, and 25.7% and 16.6% of the pdt≥1 inequality, respectively. Economic status, residence in rural areas, mother education, father education, and age were the main contributors to the measured inequality in pft≥1 by 80.5% and 26.5%, 21.9%, 22%, and -18.3%, respectively. Economic status, having a housekeeper mother, residence in rural areas, having basic health insurance coverage, mother education, and father education positively contributed to the measured inequality in PMT≥1 by 45.4%, 42.4%, 37.8%, 35.1%, 21.3%, and 15.2%, respectively, while age had a negative contribution of -19.3%. For PFT≥1, economic status, age, and father education accounted for 76%, 25.4%, and 20.3% of the measured inequality, respectively.ConclusionPro-rich economic inequalities were observed in children's primary and permanent teeth caries. Thus, government interventions to reduce these inequalities should aim to expand the coverage of basic and supplementary health insurance in line with increasing the coverage of dental health costs in these plans, training and providing access to required dental health services for low-socioeconomic children, including the poor, rural, and those who have low-educated parents and a housekeeper mother, especially at younger ages.

Abstract Background By the lengthening of life span, the incidence of chronic diseases such as hypertension and uncontrolled hypertension has increased. This study aims to determine the prevalence of uncontrolled hypertension and its related factors in the age group of 50–74 years in Shahroud, northeast Iran. Methods The data of the third phase of the Shahroud Eye Cohort Study were used in this study. This phase of the cohort study included 4394 participants aged 50 to 74 years from the previous phases. In addition to ophthalmological and optometric examinations, demographic characteristics, blood biochemistry tests, and blood pressure measurements were performed in this phase. Individuals with a blood pressure ≥ 140/90 mm/Hg (being treated or not treated with antihypertensive medicines) were defined as uncontrolled hypertension. In patients with diabetes and chronic kidney disease, blood pressure equal to or higher than 130/80 mm/Hg was considered uncontrolled hypertension. Descriptive statistics and multiple logistic regression were used to analyze the data. Findings Overall, the prevalence of uncontrolled hypertension out of all the participants was 61.7% (95% CI: 60.3–63.2). Multiple regression results showed that the male gender (OR: 2.1, 95% CI: 1.5–2.9), patients with diabetes (OR:3.2, 95% CI: 2.4–4.3), and patients with chronic kidney disease (CKD) (OR: 3.2, 95% CI: 2.5–4.1) increased the risk of uncontrolled hypertension while in patients with cardiovascular disease (OR: 0.6, 95% CI: 0.4–0.8) and polypharmacy (OR: 0.2, 95% CI: 0.1–0.2) reduced the risk of uncontrolled hypertension. Conclusion The present study showed that uncontrolled hypertension has a high prevalence, and factors such as male gender, diabetes, and CKD are associated with this disorder. So, it is recommended to take the necessary measures to formulate and implement immediate actions to prevent or control hypertension.

Aims: Sleep duration and quality are increasingly recognized as potential contributors to cardiovascular disease risk, with serum lipids playing a crucial role in this relationship. However, the results regarding this association have been inconsistent across different ethnic groups. This study aims to investigate this association in an Iranian elderly population. Methods: Totally 1392 people 60 to 69 years old were included in this study. Sleep duration and quality were assessed by the Pittsburgh sleep quality index (PSQI). Logistic and linear regression models were employed to determine the association of sleep duration and quality with serum lipid levels; moreover, the effects of other potential confounders were also controlled. Findings: Most of the participants had low sleep quality (70.47 %), which was more notable in males (80.08 %), compared to females (59.15 %), and most of the participants slept 6–7 h per day (42.2 %). No association was observed between sleep quality and serum lipid levels including HDL (OR = 1.12; P = 0.871), LDL (OR = 0.80; P = 0.451), total cholesterol (OR = 0.89; P = 0.702) and triglyceride (OR = 1.13; P: 0.477). As well as, no association between sleep duration and LDL; (β = 0.35; P = 0.094), total cholesterol (β = 0.02; P = 0.918), triglycerides (β = −0.02; P = 0.846), and HDL (β = −0.06; P = 0.534). Conclusion: In the elderly population, poor sleep quality is typical, particularly among males. Sleep quality and duration were not associated with serum lipid profiles, including TG, TC, LDL, and HDL.

Abstract Background Isolated systolic hypertension (ISH), is the most common form of hypertension in older adults. However, the ISH prevalence is not well known in many developing countries such as Iran. This study was conducted to determine the ISH prevalence and its related risk factors in an Iranian population. Methods Data were obtained from the second phase of the Shahroud eye cohort study (ShECS) in 2014. ShECS is a longitudinal population-based study which the first phase had been conducted in 2009 using the stratified multistage cluster sampling design on 5190 people aged 40 to 70 years. The ISH prevalence was determined based on the eighth Joint National Commission guidelines for different demographic variables. The associated risk factors were estimated by multiple logistic regression and a two-tailed p-value less than 0.05 was considered significant. Results The ISH prevalence was 15.89% (95% CI: 14.88–16.96). It was 15.68% (14.12–17.39) and 15.87% (14.54–17.29) for men and women, respectively. The prevalence of ISH increased significantly with increasing age. The 65–70 compared to 45–69 year age group (OR = 4.21), body mass index (OR = 1.03), diabetes (OR = 1.64), retirement, compared to practitioner job (OR = 1.53), and waist to hip ratio (WHR) (OR = 9.81) were significantly associated with ISH prevalence. Conclusions ISH is highly prevalent among the older adult population in Iran. Given the risk of cardiovascular disease associated with ISH, it is recommended to conduct education and public health interventions to improve the detection, prevention, and treatment of ISH.

Abstract Aim To determine the prevalence of ocular trauma in Iranian children aged 6–12 years. Methods This population-based cross-sectional study, comprised the first phase of the Shahroud Schoolchildren Eye Cohort Study on primary school children using cluster sampling in urban areas and census in rural areas. The students underwent the measurement of uncorrected and corrected visual acuity as well as non-cycloplegic, cycloplegic, and subjective refraction. The history of trauma, hospitalization, and surgery due to trauma was collected from parents using a questionnaire. Results The data of the trauma history was recorded for 5267 out of 5620 students. The mean age of the students was 9.7 ± 1.7 years (range: 6–12 years), 53.7% of them were boys, and 79.3% were from urban areas. A positive history of ocular trauma was found in 285 participants, and the lifetime prevalence of ocular injury (95% CI) was 5.2% (4.6–5.9). Blunt trauma was the most common ocular injury with a prevalence of 66.2%. There was a significant positive assocation between ocular trauma and living in rural areas (OR: 1.49, p: 0.012), older age (OR: 1.17, p

BackgroundConsidering the importance of cardiovascular disease (CVD) risk prediction for healthcare systems and the limited information available in the Middle East, we evaluated the SCORE and Globorisk models to predict CVD death in a country of this region.MethodsWe included 24 427 participants (11 187 men) aged 40-80 years from four population-based cohorts in Iran. Updating approaches were used to recalibrate the baseline survival and the overall effect of the predictors of the models. We assessed the models’ discrimination using C-index and then compared the observed with the predicted risk of death using calibration plots. The sensitivity and specificity of the models were estimated at the risk thresholds of 3%, 5%, 7%, and 10%. An agreement between models was assessed using the intra-class correlation coefficient (ICC). We applied decision analysis to provide perception into the consequences of using the models in general practice; for this reason, the clinical usefulness of the models was assessed using the net benefit (NB) and decision curve analysis. The NB is a sensitivity penalized by a weighted false positive (FP) rate in population level.ResultsAfter 154 522 person-years of follow-up, 437 cardiovascular deaths (280 men) occurred. The 10-year observed risks were 4.2% (95% CI: 3.7%-4.8%) in men and 2.1% (1.8-2%.5%) in women. The c-index for SCORE function was 0.784 (0.756-0.812) in men and 0.780 (0.744-0.815) in women. Corresponding values for Globorisk were 0.793 (0.766-0.820) and 0.793 (0.757-0.829). The deviation of the calibration slopes from one reflected a need for recalibration; after which, the predicted-to-observed ratio for both models was 1.02 in men and 0.95 in women. Models showed good agreement (ICC 0.93 in men, and 0.89 in women). Decision curve showed that using both models results in the same clinical usefulness at the risk threshold of 5%, in both men and women; however, at the risk threshold of 10%, Globorisk had better clinical usefulness in women (Difference: 8%, 95% CI: 4%-13%).ConclusionOriginal Globorisk and SCORE models overestimate the CVD risk in Iranian populations resulting in a high number of people who need intervention. Recalibration could adopt these models to precisely predict CVD mortality. Globorisk showed better performance clinically, only among high-risk women.

Abstract Background Vision-related quality of life is related to severity of visual impairments and show the impact of eye diseases on daily activities. This study aims to assess visual functions and disability and its association with age, gender, education, marital status, and economic status in adults aged 45–69 years. Methods Data in this population-based study were from the second phase of the Shahroud eye cohort study and collected by using a Short-Form Visual Functioning Scale. The scores of visual function and disability were calculated based on Rasch-transformed scores of the National Eye Institute visual functioning questionnaire, where a more negative score indicates a better situation. Multiple linear regression was used to investigate the factors associated with visual functions. Results Among 4737 participants the visual function data for 4715 people were analyzed. The visual function of 75.3, 17.1 and 7.5% of participants were “ideal and good”, “moderate”, and “bad and very bad”, respectively, while 0.06% were unable for vision. The running mean of the visual function was calculated to be − 3.95 ± 0.02. The visual performance was worse in females than the males (β = 0.14, p = 0.005). Visual function improved with increasing levels of education (β = − 1.06, p

Abstract In this study, corneal findings regarding keratoconus (KC) and early KC among mothers with Down syndrome children (MDS) and a group of age-at-delivery-matched mothers with normal children (MNC) were compared. KC was diagnosed based on the presence of a clinical sign and at least one abnormal tomographic or biomechanical criterion. Early KC was defined as having no clinical sign in the presence of at least one abnormal tomographic or biomechanical criterion. The normal subgroups in each group were compared in terms tomographic and biomechanical parameters. In MDS and MNC, the prevalence rates were 6.5% and 1.6% for KC (P = 0.047), and 30.9% and 14.3% for early KC (P = 0.014), respectively. Comparison between the two normal subgroups showed significant differences in mean index of height asymmetry, irregularity index, anterior asphericity, pentacam random forest index, corneal stiffness parameters at first applanation, deformation amplitude ratios, integrated radius-1 mm, highest concavity deflection amplitude, biomechanical corrected IOP, peak distance, and radius (all P

Abstract Objectives To develop and to propose a machine learning model for predicting glaucoma and identifying its risk factors. Method Data analysis pipeline is designed for this study based on Cross-Industry Standard Process for Data Mining (CRISP-DM) methodology. The main steps of the pipeline include data sampling, preprocessing, classification and evaluation and validation. Data sampling for providing the training dataset was performed with balanced sampling based on over-sampling and under-sampling methods. Data preprocessing steps were missing value imputation and normalization. For classification step, several machine learning models were designed for predicting glaucoma including Decision Trees (DTs), K-Nearest Neighbors (K-NN), Support Vector Machines (SVM), Random Forests (RFs), Extra Trees (ETs) and Bagging Ensemble methods. Moreover, in the classification step, a novel stacking ensemble model is designed and proposed using the superior classifiers. Results The data were from Shahroud Eye Cohort Study including demographic and ophthalmology data for 5190 participants aged 40-64 living in Shahroud, northeast Iran. The main variables considered in this dataset were 67 demographics, ophthalmologic, optometric, perimetry, and biometry features for 4561 people, including 4474 non-glaucoma participants and 87 glaucoma patients. Experimental results show that DTs and RFs trained based on under-sampling of the training dataset have superior performance for predicting glaucoma than the compared single classifiers and bagging ensemble methods with the average accuracy of 87.61 and 88.87, the sensitivity of 73.80 and 72.35, specificity of 87.88 and 89.10 and area under the curve (AUC) of 91.04 and 94.53, respectively. The proposed stacking ensemble has an average accuracy of 83.56, a sensitivity of 82.21, a specificity of 81.32, and an AUC of 88.54. Conclusions In this study, a machine learning model is proposed and developed to predict glaucoma disease among persons aged 40-64. Top predictors in this study considered features for discriminating and predicting non-glaucoma persons from glaucoma patients include the number of the visual field detect on perimetry, vertical cup to disk ratio, white to white diameter, systolic blood pressure, pupil barycenter on Y coordinate, age, and axial length.

Abstract Background Metabolic syndrome is a combination of metabolic risk factors causing a pathological condition that increases the risk of non-communicable diseases, such as diabetes and cardiovascular diseases. A variety of dietary approaches have been examined to halt this rapid trend; however, the effects of modified-Paleo diet and medium-carbohydrate diet on inflammation, adipokines, hepatokines, and the profile of endothelial microparticles in individuals with metabolic syndrome have not been investigated in detail. The present study is designed to examine the effect of modified-Paleo and moderate-carbohydrate diet with two delivery modes: “fixed diet plan” vs “calorie counting” on weight, body composition, serum levels of some hepatokines and adipocytokines, and flow cytometric analysis of endothelial microparticles in adults with metabolic syndrome. Methods Eighty metabolic syndrome patients will be recruited in this study. They will be randomly allocated to one of the following 4 groups: (1) receiving a modified-Paleo diet with calorie counting, (2) receiving a modified-Paleo diet with a fixed diet plan, (3) receiving a medium-carbohydrate diet with calorie counting, and (4) receiving a medium-carbohydrate diet with a fixed diet plan for 10 weeks. Weight, height, waist circumference, and body composition will be assessed at the study baseline and at the end of the trial. Serum insulin, asprosin, chemerin, FGF-21, CTRP-1, PYY, ghrelin, plasma EMPs (CD31+/CD42b− and CD144+/CD42b−), lipid profile, glycemic indices, hs-CRP, leptin, vitamin C, creatinine and satiety, hunger, fullness, and desire to eat (via visual analog scales) will be measured at the study baseline and at the end of the trial. Insulin resistance and insulin sensitivity will be determined using the HOMA-IR and QUICKI equations. Discussion To the best of our knowledge, this is the first randomized controlled trial that will determine the effect of modified-Paleo and moderate-carbohydrate diet on weight, body composition, serum levels of some hepatokines and adipocytokines, and the profile of EMPs in adults with metabolic syndrome. Moreover, the effects of different diet delivery modes, including “fixed diet plan” and “calorie counting” will also be analyzed. The results of this trial can provide clinical witnesses on the effectiveness of carbohydrate-restricted diets in ameliorating metabolic status and prevent the development of chronic diseases. Trial registration Iranian Registry of Clinical Trials IRCT2016121925267N4 . Registered on 26 July 2017

AIM: To investigate the patterns and outcomes of open globe injuries in the elderly population in Iran. METHODS: In this retrospective cross-sectional chart review, medical records of 248 patients (aged 60y and more) with the diagnosis of open globe injury from 2006 to 2016 were reviewed. Demographic features, type, and mechanism of open globe injury, ocular trauma score (OTS), visual acuity before and after treatment, the zone of injuries, and the associated injuries found at the presentation or thereafter were documented. RESULTS: A total of 248 eyes of 248 patients were included. The mean age was 69.2±5.8y (range: 60-90y). Male/ female ratio was about 3:1 (187 vs 61). The three most common causes of injury were falling (25.2%), sharp objects (18.9%), and tree branches (13.9%). Penetrating injury accounted for most of the geriatric ocular trauma (50.4%), followed by globe rupture (40.3%), intraocular foreign body (IOFB; 7.3%), and perforating injury (2.0%). The median raw OTS for the population was 60.5 and the most common OTS class was 3. The injuries tend to affect zone I more than zone II and zone III. The only predictor of final visual acuity was the class of OTS (P

Objective Malaria remains endemic in most of sub-Saharan Africa and has a negative impact among pregnant women, resulting in morbidity and poor birth outcomes. The purpose of this study was to assess the relationship between malaria and adverse birth outcomes among prenatal women in the Northern Region of Ghana.Design This is a prospective cohort study of singleton pregnancies at 28 weeks of gestational age and above recruited between July 2018 and May 2019 from four public hospitals in the Northern Region of Ghana.Outcome measures Low birth weight (LBW), preterm birth and perinatal death.Results A total of 1323 pregnant women completed the study out of the 1626 recruited, with an average age of 27.3±5.2 years. The incidence of malaria in this population was 9.5% (95% CI 7.9 to 11.1). After adjusting for newborn admissions to the neonatal intensive care unit, parity, maternal age and glucose-6-phosphate dehydrogenase, women who were exposed to malaria during the third trimester of pregnancy had 2.02 times (95% CI 1.36 to 2.99) higher odds of premature delivery. Furthermore, they had 2.06 times (95% CI 1.09 to 3.93) higher chance of giving birth to babies with LBW, irrespective of their socioeconomic status. With an OR of 1.02 (95% CI 0.26 to 4.01), there was no difference in perinatal mortality between pregnant women with malaria and those without malaria after adjusting for caesarean section.Conclusion This study confirms that prenatal malaria increases the odds of both preterm and LBW deliveries. A decisive policy to eradicate or minimise perinatal malaria is needed to contribute to the prevention of LBW and adverse pregnancy outcomes.

Abstract Background Previous studies have reported a high prevalence of hypertension in Iranian students, especially in rural areas. The aim of this study was to investigate the daily intake of salt in students and its association with high blood pressure. Methods A random sub-sample was selected from the participants of the second phase of Shahroud schoolchildren eye cohort study and then a random urine sample was tested for sodium, potassium and creatinine. Urine electrolyte esexcretion and daily salt intake were calculated by Tanaka et al.’s formula. Results Among 1455 participants (including 230 participants from rural area and 472 girls), the mean age was 12.9 ± 1.7 year and the mean daily salt intake was 9.7 ± 2.6 g (95% CI 9.5–9.8). The mean salt consumption in rural areas [10.8 (95% CI 10.4–11.2)] was higher than urban areas [9.4 (95% CI 9.3–9.6)], in people with hypertension [10.8 (95% CI 10.3–11.3)] was more than people with normal blood pressure [9.4 (95% CI 9.3–9.6)], and in boys [9.8 (95% CI 9.7–10.0)] was more than girls [9.3 (95% CI 9.1–9.6)]. Higher age, BMI z-score, male sex and rural life, were associated with increased daily salt intake. Increased salt intake was associated with increased systolic and diastolic blood pressure. Conclusion Daily salt intake in Iranian adolescents was about 2 times the recommended amount of the World Health Organization, was higher in rural areas and was associated with blood pressure. Reducing salt intake should be considered as an important intervention, especially in rural areas.

AIM: To evaluate the diagnostic ability of topographic and tomographic indices with Pentacam and Sirius as well as biomechanical parameters with Corvis ST for the detection of clinical and subclinical forms of keratoconus (KCN). METHODS: In this prospective diagnostic test study, 70 patients with clinical KCN, 79 patients with abnormal findings in topography and tomography maps with no evidence on clinical examination (subclinical KCN), and 68 normal control subjects were enrolled. The accuracy of topographic, tomographic, and biomechanical parameters was evaluated using the area under the receiver operating characteristic curve (AUC) and cross-validation analysis. The Delong method was used for comparing AUCs. RESULTS: In distinguishing KCN from normal, all parameters showed statistically significant differences between the two groups (P0.05). CONCLUSION: In clinical KCN, all topographic, tomographic, and biomechanical indices have acceptable outcomes in terms of sensitivity and specificity. However, in differentiating subclinical forms of KCN from normal corneas, curvature-based parameters (SIb and IS value) followed by integrated indices (PRFI and TBI) are the most powerful tools for early detection of KCN.

OBJECTIVES This study compared the vaccination coverage rate (VCR) in children under 5 years old in Nasiriyah, Iraq before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS This cross-sectional study was conducted in the city of Nasiriyah in southeastern Iraq, with data collected from 79 primary healthcare facilities. This study evaluated the VCR in 3 periods (2018, 2019, and 2020) using multi-level random sampling. Pertinent data were extracted from the vaccination records of 598 children for Bacillus Calmette-Guérin (BCG); pentavalent 1, 2, and 3; measles; and activated oral poliovirus vaccine 1 and 2. Missing data were completed by telephone calls to participants’ parents. Logistic regression was applied to compare and estimate the odds ratios (ORs) with 95% confidence intervals (CIs) for the association between VCR and related factors. RESULTS The data showed the greatest decline in the studied vaccines in 2020. Among the vaccines studied, BCG had the highest rate in all 3 periods (100% VCR) and measles had the lowest rate (83.7%), reaching 63.6% in 2020 (p

Abstract Background Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood mental health disorders. Stimulant drugs as the most commonly used treatment and first-line therapy for ADHD have side effects. One of the newest approaches to select the best choices and optimize dosages of medications is personalized medicine. Methods This historical cohort study was carried out on the data taken from the period of 2008 to 2015. Eligible subjects were included in the study randomly. We used mixed-effects logistic regression models to personalize the dosage of Methylphenidate (MPH) in ADHD. The patients’ heterogeneity was considered using subject-specific random effects, which are treated as the realizations of a stochastic process. To recommend a personalized dosage for a new patient, a two-step procedure was proposed. In the first step, we obtained estimates for population parameters. In the second step, the dosage of the drug for a new patient was updated at each follow-up. Results Of the 221 children enrolled in the study, 169 (76.5%) were male and 52 (23.5%) were females. The overall mean age at the beginning of the study is 82.5 (± 26.5) months. In multivariable mixed logit model, three variables (severity of ADHD, time duration receiving MPH, and dosage of MPH) had a significant relationship with improvement. Based on this model the personalized dosage of MPH was obtained. Conclusions To determine the dosage of MPH for a new patient, the more the severity of baseline is, the more of an initial dose is required. To recommend the dose in the next times, first, the estimation of random coefficient should be updated. The optimum dose increased when the severity of ADHD increased. Also, the results show that the optimum dose of MPH as one proceeds through the period of treatment will decreased.

Abstract Background Emerging evidence showed promising effects of vitamin D on headaches characteristics. Thus, it seems there is still a need for more researches to clarify the mechanisms by which this vitamin exerts anti-migraine effects. Methods The present study was conducted as a 16-week randomized double-blind placebo-controlled trial on 80 episodic migraine patients allocated in 2 parallel groups each consisted of 40 patients who received vitamin D 2000 IU/d or placebo. At baseline and after the intervention completion, headache diaries and migraine disability assessment questionnaire (MIDAS) were used to assess migraine related variables in patients. Also, interictal serum concentration of calcitonin gene-related peptide (CGRP) (as the dominant mediator of migraine pain pathogenesis) was evaluated using ELISA method. Results The mean (SD) of age in the vitamin D and placebo groups was 37 (8) and 38 (12) years, respectively. ANCOVA test adjusted for baseline values, and confounders showed vitamin D supplementation resulted in a significant improvement in MIDAS score after 12 weeks in the intervention group (21.49 (16.22–26.77)) compared to placebo (31.16 (25.51–36.82) P value: 0.016). Moreover, after controlling for baseline levels, and other variables using ANCOVA, CGRP level was appeared to be significantly lower following vitamin D supplementation (153.26 (133.03–173.49) ng/L) than the patients in the placebo arm (188.35 (167.15–209.54) ng/L) (P value = 0.022). Conclusion According to the current findings, vitamin D supplementation in episodic migraineurs, particularly in those with migraine with aura, may potentially improve migraine headache characteristics and disability probably through attenuating CGRP levels. Therefore, these results could provide a new insight into anti-nociceptive effects of vitamin D; however, more studies are required to confirm our findings. Trial registration The trial is registered in the Iranian registry of clinical trials (IRCT) at 11 July 2018, with IRCT code: IRCT20151128025267N6 .

Purpose: To study the anterior chamber (AC) dimensions, angles and pupil diameter (PD) in patients with Down syndrome compared to normal controls. Methods: Prospective study is comparing the AC parameters in patients with Down syndrome aged 10-30 years and age-matched controls. Extracted indices included average anterior chamber depth on the 2-mm ring (ACD-2 mm), 4-mm ring (ACD-4 mm), at the corneal apex from the endothelium (endo-ACD), at the corneal apex from the epithelium (epi-ACD), anterior chamber volume (ACV), mean anterior chamber angle (ACA), and PD measured by Pentacam. Results: Data from 202 patients with Down syndrome (age 17.2 ± 4.8 years) were compared with 190 normal controls (age 17.2 ± 4.5 years). In Down and normal groups, mean ± SD were 2.51 ± 0.31 and 2.83 ± 0.34 mm for ACD-2 mm, 1.65 ± 0.30 and 1.93 ± 0.31 mm for ACD-4 mm, and 3.03 ± 0.29 and 3.24 ± 0.26 mm for endo-ACD, 3.54 ± 0.29 and 3.80 ± 0.26 mm for epi-ACD, mean 169.31 ± 30.38 and 200.17 ± 33.20 mm3 for ACV, 40.69 ± 4.50 and 39.97 ± 4.12° for ACA, and 2.79 ± 0.62 and 3.59 ± 0.80 mm for PD, respectively (all P < 0.001). None of the studied indices significantly correlated with age, except for ACA (P = 0.011). All parameters, except for PD, were significantly higher in males compared to females (all P < 0.001). Temporal ACA was significantly wider in male subjects (44.61 ± 6.52 vs. 42.24 ± 6.52°; P < 0.001). Conclusion: The AC in patients with Down syndrome is smaller than normal individuals. AC in females with Down syndrome is smaller than males, and the narrower ACA is attributable to the difference in the temporal angle and not the ACA in other meridians.

Objective/background: There have been conducted few studies in Iran on the quality of sleep in the general population. This study aimed to use the item response theory (IRT) model to examine the accuracy of the seven components of the Pittsburgh Sleep Quality Index (PSQI) and to provide an appropriate cut-off point for population-based studies. Methods: This study was performed using the data of the second phase of the Shahroud Eye Cohort Study (ShECS) in 2014. The sleep quality of 4710 participants was measured through PSQI. Using an IRT model, the seven components of the index are considered as indicators and sleep quality as the latent variable in the measurement model. This model supposed that there is only one hidden component to explain the respondent's behavior to a number of items. Results: Results of analyzing different components of PSQI showed that component 6 (using sleep medication) and 7 (daytime dysfunction disorder) had the lowest values of discrimination parameter and component 4 (habitual sleep efficiency) and 1 (sleep quality) had the highest value of discrimination parameter. Persons with an expected sleep quality score of less than or equal to 6.5 will be defined as good sleep quality pattern. Conclusions: Since discrimination values for components 6 and 7 are less than the values for other components, the use of the standardized latent scores is emphasized for assessing the quality of sleep in the population.

Background: We aimed to assess prevalence and predictors of pre-existing hypertension in pregnant women in three districts of Northern region, Ghana. Methods: This cross-sectional study was conducted among 1626 women in the third trimester of pregnancy across four antenatal centers in 2018. A questionnaire was used to collect medical information including weight and height. We used descriptive statistics to characterize all qualitative variables and performed logistic regression analyses to estimate association of hypertension and other risk factors. Results: We included 1626 women; mean age standard deviation (SD) of pregnant women was 27.4 (5.1) years. About 4.5% (95% confidence interval [CI]: 3.6-5.7) of pregnant women reported they had earlier been diagnosed of having hypertension by a doctor or midwife, before pregnancy. Obese pregnant women had 2.9 times increased adjusted odds of having hypertension relative to non-obese pregnant women (Odds Ratio (OR))=2.9, 95% [CI]: 1.39-5.85, P=0.004). Further, gestational diabetes was a predictor of pre-existing hypertension at an increased odds of 4.9 times relative to those without gestational diabetes (OR= 4.9, CI: 0.92-26.75, P=0.061). Women with two or more children had 3.2 times the adjusted odds of having hypertension (OR=3.2 CI: 1.59-6.69, P=0.001). Conclusion: Although the prevalence pre-existing hypertension was not too high, obesity, gestational diabetes and number of children were independent predictors of pre-existing hypertension in pregnant women.

Purpose: To measure Horizontal Inequity Index (HI) of unmet refractive error and its changes between 2009 and 2014 in Iran. Methods: The data used in this study was taken from population-based study, Shahroud Eye Cohort Study. The number of participants analyzed in first (2009) and second phases of study (2014) were 5190 and 4737, respectively, and individuals between 40 and 64 years were included. The HI was determined by using the Concentration Index (C) based on the nonlinear (Probit) model, and C was decomposed to identify and quantify the contribution of each factor. Results: After adjusting for need variables, the results demonstrated that the HI in unmet refractive need decreased from −0.288 (95% CI: 0.370, −0.206) in the 2009 to −0.132 (95% CI: 0.290, −0.028) in 2014. Decomposition of the C showed that level of education and economic status were the greatest contributors with shares of 26.2% and 17.9%, respectively, in reducing the amount of HI in unmet refractive error between 2009 and 2014. Conclusions: The current study demonstrated that unmet refractive error did not have an equal distribution among economic quintiles, despite the same need for correcting refractive errors. Reducing the amount of HI in unmet refractive error between 2009 and 2014 indicated an improvement in the unmet need in the five years period between two phases of study. Keywords: Horizontal inequity, Concentration Index, Unmet need, Refractive errors, Population-based study

Purpose: To determine the central corneal thickness (CCT), apex, and paracentral thicknesses and their determinants in children aged 6–12 years. Methods: The present study was part of the phase 1 of Shahroud School Children Eye Cohort Study in 2015. Cluster sampling was done in urban areas while all children were invited to participate in the study in rural areas. The Pentacam HR was used for measurements. CCT was measured within the central 3 mm zone of the cornea, and corneal thickness 3 mm further from the center was considered paracentral thickness. Results: Of 6624 students who were selected, 5620 (84.8%) participated in the study. Among 4956 students, studied in this report, 52.2% were boys, and the mean age of the study participants was 9.75 ± 1.71 years (6–12). The mean CCT and apical thickness was 556.29 ± 34.04 and 557.43 ± 34.03 μm, respectively. The mean paracentral thickness was 657.62 ± 39.11 μm in the superior, 632.65 ± 37.63 μm in the inferior, 648.64 ± 38.75 μm in the nasal, and 617.36 ± 37.19 μm in the temporal region. A multiple regression model showed that CCT decreased by 4.70 μm with every 1 diopter increase in the mean keratometry and increased by 20.06 μm with every 1 mm increase in the anterior chamber depth (ACD) (Both P-Value

Background and purpose: Nowadays, immobility is known to be the fourth risk factor for mortality. The aim of the present study was to investigate the relationship between fall experience over the previous year and levels of physical activity in the elderly. Materials and Methods: The study was performed with 1616 participants of 60≤ years. The relationship between physical activities in the elderly with age, sex, educational level, body mass index, comorbidities, and fall experience over the previous year was evaluated. Physical activity in the elderly was evaluated using the physical activity scale for the elderly. Results: In the multiple regression model, the age (β: -1.6, 95% CI: -2.0- -1.1), sex, female (β: 11.0, 95% CI: 4.3-17.6), and comorbidities (β: -6.8, 95% CI: -13.5 - -0.1) had a significant relationship with the physical activity score. On the contrary, there was no significant difference between the score of physical activity and both groups with and without the experience of fall over the previous year (β: 0.09, 95% CI: -8.0 - 8.2). Conclusion: Increasing age with comorbidity resulted in a decrease in the average physical activity score in the studied elderly population. However, the experience of fall had no relationship with it. Providing the conditions alongside the training required to carry out physical activities, especially in the elderly people with the disease, was suggested.

We aimed to investigate the potential associations between exposure to fuel types for cooking and birth outcomes in Northern Region of Ghana. Third trimester pregnant women were recruited during antenatal visit to the hospital and followed-up till delivery. Three questionnaires were administered covering baseline information, exposure to fuel types, and birth outcomes. Adjusting for potential confounding factors, log binomial regression model was applied to investigate the association between low birth weights (LBW), preterm birth and perinatal deaths in mothers and fuel types.Of the 1626 participants recruited at baseline, about 1323 women in the delivery period completed the study. At delivery period, maternal mean (SD) age was 27.3 (5.2) years. Mothers who used charcoal and firewood for cooking had 1.47 times (95% CI 1.04–2.05) and 1.18 times (95% CI 0.83–1.69) increased in risk of preterm birth respectively after controlling for potential confounding variables. Although, non-significant, mothers who used charcoal had 1.34 times (95% CI 0.45–3.97) increased risk in LBW, while those who used firewood had 1.23 times (95% CI 0.41–3.71) risk in LBW. Similarly, babies of mothers who used charcoal and those who used firewood respectively had 1.72 times (95% CI 0.52–5.65) and 1.70 times (95% CI 0.49–5.92) risk in small for gestational age after controlling for maternal BMI at first visit and anemia. Lastly, mothers who used charcoal and those who used firewood respectively had 1.87 times (95% CI 0.29–11.64) and 2.02 times (95% CI 0.31–13.04) increased risk in perinatal mortality after controlling for potential confounding variables. We observed a significant association between charcoal and preterm birth. Also, we observed a non-significant association between charcoal and firewood users and LBW, SGA and perinatal mortality respectively, compared to those using gas or electricity. This suggests cooking with charcoal and firewood could have health consequences on the outcome of pregnancy.

Background: To assess socio-economic inequality in the prevalence of tobacco smoking among Iranian adults in 2010. Methods: Data from the fifth national STEPS survey were analyzed. A blinder- Oaxaca decomposition model was applied to assess socio-economic inequality in the prevalence of daily cigarette and water-pipe smoking in men and women. Results: Overall, 4,203 participants appeared to be in the first and fifth quintiles of SES For men, the prevalence of daily cigarette smoking was higher among those with low SES (23.1%) than those with high SES (11.1%) (P

Purpose: To determine the changes in the depth of the demarcation line in the central to peripheral cornea following accelerated compared to standard corneal cross-linking (CXL). Methods: In this prospective, non-randomized study, 60 eyes with progressive keratoconus underwent accelerated or standard CXL (30 in each group). Anterior segment optical coherence tomography (AS-OCT) was done one month later by two independent masked examiners to measure the depth of the demarcation line in the central cornea and on peripheral rings. Results: The inter-examiner agreement (intra-class correlation coefficient) was >0.75 for all measured points, and average measurements were used in the analysis. The depth of the visualized demarcation line in the center was 223.4 ± 67.4 μm and 354.9 ± 79.0 μm in the accelerated and standard groups, respectively (P

Background: With aging, muscles strength decrease. Balance disorder is one of the common aging problems which can cause falls and serious injuries. The purpose of this study was to present a model along with the determinants of balance status in the elderly. Methods: This cross-sectional study is part of a cohort study, "investigation of the health status of elderly in Amirkola City", which was performed on 1616 old people aged≥ 60 years, (response rate 72 %). The baseline data of this study were collected in the Center for Social Determinants of Health (SDH) Research Centre of the Babol University of Medical Sciences during March 2011 to July 2012. We considered the age, sex, physical activity, quadriceps muscle strength, daily activity, serum level of vitamin D, BMI, number of comorbidities and orthostatic hypotension as independent variables. Using the results of Berg balance test, the balance status of participants (as dependent variable) was categorized into two groups: score between 41-56 as normal (low risk of fall) and score < 41 as balance disorder (medium or high risk of fall). Then, the association of independent variables with balance status were evaluated in the logistic regression model. Results: The mean and standard deviation of participants' age was 69.37±7.6 years, 54.7% of them were men and 7.5% of them had balance disorder. The odds ratio of medium or high falls in women to men, the number of comorbidities, having strong quadriceps to weak muscles, seniors aged 80 years and over, to 60-69, seniors with high physical activity to low physical activity, daily activities were (OR=2.1, 95%CI: 1.0-4.1), (OR=1.7, 95%CI: 1.0-2.9), (OR=0.05, 95%CI: 0.0-0.4), (OR=5.0, 95%CI: 2.3-10.6), (OR=0.3, 95%CI: 0.1-0.6), (OR=14.4, 95%CI: 3.4-60.4), respectively and statistically significant. The odds ratio of fall for vitamin D, orthostatic blood pressure and BMI variables did not show any statistically significant differences. The results of the analysis showed that the balance in all age groups in men was better than women. Conclusion: Weak quadriceps, aging, being a woman and having comorbidities are the most important risk factors of balance disorder in the elderly.

Abstract Objectives Considering the increase in the non-communicable diseases associated with tobacco use in recent decades in Iran, it is necessary to have a general view of the current condition. This study aimed to identify factors associated with tobacco use and to estimate the probability of a 5-year transition in the stages of tobacco use in an adult population. Methods In this study, 5190 people in the 40–64-year-old population of Shahroud (North East of Iran) were interviewed in 2009 and 2014 on tobacco smoking. The association of independent variables with tobacco smoking was evaluated using the population-averaged logit model. We calculated smoking transition probabilities from non-smoking to current smoking and past-smoking stages during a 5-year span. Results The prevalence of current tobacco smoking in 40–69-years age group was 11.1% (95% CI 10.3–12.0), 1% among women (95% CI 0.8–1.3) and 25.6% among men (95% CI 23.7–27.6). During this 5-year period, the probability of transition of a non-smoker to an overall current tobacco smoker was 2.3%. Meanwhile, 18.5% of the overall current tobacco smokers had changed into past smokers. Unemployed (OR = 2), male gender (OR = 53.9), widow/widowers (OR = 5.4), divorces (OR = 3.3), and high economic status (OR = 1.2) are associated to tobacco smoking. Conclusions Compared with the other studies, the prevalence of tobacco use in this population is low but transition rate of non-smokers into current smokers or past smokers is high. Conducting interventions on determinants of starting and quitting smoking and education and awareness raising on the risk and harms of smoking seems necessary.

Objective: To determine the incidence and predictive factors of the falls in elderly women in Northern Iran.Methods: A total of 717 elderly women aged 60 years and above in Amirkola, Northern of Iran participated in this study. Age, history of falls during the 12 months leading to the study, accompanying diseases, status of balance, cognitive status, orthostatic hypotension, state of depressive symptoms, strength of quadriceps muscles and serum vitamin D level were assessed as independent variables during baseline measurement. Incidence of fall (dependent variable) was recorded during a six-month follow-up period.Results: Of the participants, 7.8% had experience of fall, out of which 50.0% experienced it once, 25.0% twice, and the rest three times or more. With aging, the incidence of orthostatic hypotension also increased and symptomatic depression became aggravated. In the final model, the variables of the number of accompanying diseases (RR=1.78, 95% CI: 1.00-3.18), severe cognitive impairment (RR=12.70, 95% CI: 3.05-52.86), and depressive symptoms (RR=3.19, 95% CI: 1.48-6.86) remained as strong associated variables for incidence of fall.Conclusion: With increasing severity of depressive symptoms and cognitive impairment along with the comorbidities, incidence of fall also increases in the elderly. Thus, psychological aspects of the elderly and comorbidities in this group should be taken care of seriously.

Background: Orthostatic hypotension (OH) in the elderly is an important health challenge that poses a significant burden. We sought to determine the prevalence and correlates of OH in an elderly population-based study. Methods: This study was conducted within the framework of the Amirkola Health and Ageing Project (AHAP) on 1,588 elderly individuals aged ≥60 years. The baseline measurement was performed from April 2011 to July 2012. The relationships between OH (dependent variable) and age, sex, diabetes, hypertension, and cognitive status (independent variables) were investigated by logistic regression. Results: The mean age of the participants was 69.37±7.42 years (men: 69.96±7.68 y, women: 68.66±7.02 y). The prevalence of OH was 10.7%: 8.4% in the male and 13.7% in the female patients. In the final model, hypertension (OR=2.4, 95% CI: 1.6–3.7), diabetes (OR=1.3, 95% CI: 1.0–1.9), age (OR=2.9, 95% CI: 1.7–4.8), and female sex (female [OR=1.6, 95% CI: 1.1–2.3]) were significantly correlated with OH. Conclusion: The prevalence of OH in our elderly subjects increased with age. Additionally, the older participants with diabetes and hypertension had a higher likelihood of having this OH.

Background The problem of access to medical information, particularly in low-income countries, has been under discussion for many years. Although a number of developments have occurred in the last decade (e.g., the open access (OA) movement and the website Sci-Hub), everyone agrees that these difficulties still persist very widely, mainly due to the fact that paywalls still limit access to approximately 75% of scholarly documents. In this study, we compare the accessibility of recent full text articles in the field of ophthalmology in 27 established institutions located worldwide. Methods A total of 200 references from articles were retrieved using the PubMed database. Each article was individually checked for OA. Full texts of non-OA (i.e., “paywalled articles”) were examined to determine whether they were available using institutional and Hinari access in each institution studied, using “alternative ways” (i.e., PubMed Central, ResearchGate, Google Scholar, and Online Reprint Request), and using the website Sci-Hub. Results The number of full texts of “paywalled articles” available using institutional and Hinari access showed strong heterogeneity, scattered between 0% full texts to 94.8% (mean = 46.8%; SD = 31.5; median = 51.3%). We found that complementary use of “alternative ways” and Sci-Hub leads to 95.5% of full text “paywalled articles,” and also divides by 14 the average extra costs needed to obtain all full texts on publishers’ websites using pay-per-view. Conclusions The scant number of available full text “paywalled articles” in most institutions studied encourages researchers in the field of ophthalmology to use Sci-Hub to search for scientific information. The scientific community and decision-makers must unite and strengthen their efforts to find solutions to improve access to scientific literature worldwide and avoid an implosion of the scientific publishing model. This study is not an endorsement for using Sci-Hub. The authors, their institutions, and publishers accept no responsibility on behalf of readers.

Background: The present study evaluated the lifestyle behavior patterns and its associations with demographic factors in the Iranian population. Methods: A total of 8244 people aged 25-70 years who participated in a national survey in 2011 were included in the study. Factors related to lifestyle (such as diet, physical activity, and tobacco use) have been collected using a questionnaire. A self-organizing map was used for cluster analysis and a multinomial logistic model was used for assessment of associations. Results: Seven clusters were identified as the following: cluster 1 (15.84%): healthiest lifestyle; cluster 2 (12.45%): excessive consumption of sweet tasting soft drinks, salt, and fast food; cluster 3 (33.73%): no recreational physical activity; cluster 4 (6.86%) alcohol consumption, smoking, and consumption of sweet tasting soft drinks; cluster 5 (14.18%): less salt and oil intake and lack of physical activity; cluster 6 (7.85%): no use of dairy products; cluster 7 (9.08%): the most unhealthy lifestyles; excessive work-related physical activity and smoking and unhealthy diet. Male gender was associated with higher odds of being in clusters 4 and 7. Individuals who were in unhealthy lifestyle clusters were mostly less educated and more self-employed or laborers. Conclusions: A very small percentage of individuals was in the healthy lifestyle cluster yet they had poor nutrition. Health policy-makers should pay more attention to low recreational physical activity among elder people and in middle-aged and housekeepers, and also to high work-related physical activities that have a strong tendency to be in a cluster with smoking among workers and less educated men.

Objective (s): The relationship between social capital and health is well establishes. The present study aimed to investigate the relationship between social capital and its related factors in patients with type 2 diabetes. Methods: This was a cross-sectional study and conducted on 326 type 2 diabetes patients who referred to the Iranian Diabetes Society in 2016-2017. Data was collected by the Onyx and Bullen social capital questionnaire. This questionnaire has 36 items and 8 domains. The score range from 0 to 100. Data were analyzed by using statistical tests such as independent t-test, Pearson correlation coefficient, one-way ANOVA, and multiple regression. Results: The mean age of the patients was 55.33 (SD=11.32) years. The mean and (95% confidence interval) of the social capital score of participants was 45.72 (44.16-47.30). Among the eight domains of social capital, the highest mean score was related to the work connections domain 68.06 (63.90-72.22) and the lowest mean score was for the participation in the local communities domain 30.45 (27.97-32.93). The results of multiple regression model showed that gender had a significant association with trust and security where women had lower trust and security score than men (β=-7.88, P

Purpose: The aim of the study was a systematic review of refractive errors across the world according to the WHO regions. Methods: To extract articles on the prevalence of refractive errors for this meta-analysis, international databases were searched from 1990 to 2016. The results of the retrieved studies were merged using a random effect model and reported as estimated pool prevalence (EPP) with 95% confidence interval (CI). Results: In children, the EPP of myopia, hyperopia, and astigmatism was 11.7% (95% CI: 10.5–13.0), 4.6% (95% CI: 3.9–5.2), and 14.9% (95% CI: 12.7–17.1), respectively. The EPP of myopia ranged from 4.9% (95% CI: 1.6–8.1) in South–East Asia to 18.2% (95% CI: 10.9–25.5) in the Western Pacific region, the EPP of hyperopia ranged from 2.2% (95% CI: 1.2–3.3) in South-East Asia to 14.3% (95% CI: 13.4–15.2) in the Americas, and the EPP of astigmatism ranged from 9.8% in South-East Asia to 27.2% in the Americas. In adults, the EPP of myopia, hyperopia, and astigmatism was 26.5% (95% CI: 23.4–29.6), 30.9% (95% CI: 26.2–35.6), and 40.4% (95% CI: 34.3–46.6), respectively. The EPP of myopia ranged from 16.2% (95% CI: 15.6–16.8) in the Americas to 32.9% (95% CI: 25.1–40.7) in South-East Asia, the EPP of hyperopia ranged from 23.1% (95% CI: 6.1%–40.2%) in Europe to 38.6% (95% CI: 22.4–54.8) in Africa and 37.2% (95% CI: 25.3–49) in the Americas, and the EPP of astigmatism ranged from 11.4% (95% CI: 2.1–20.7) in Africa to 45.6% (95% CI: 44.1–47.1) in the Americas and 44.8% (95% CI: 36.6–53.1) in South-East Asia. The results of meta-regression showed that the prevalence of myopia increased from 1993 (10.4%) to 2016 (34.2%) (P = 0.097). Conclusion: This report showed that astigmatism was the most common refractive errors in children and adults followed by hyperopia and myopia. The highest prevalence of myopia and astigmatism was seen in South-East Asian adults. The highest prevalence of hyperopia in children and adults was seen in the Americas.

Background Visual acuity, like many other health-related problems, does not have an equal distribution in terms of socio-economic factors. We conducted this study to estimate and decompose economic inequality in presenting visual acuity using two methods and to compare their results in a population aged 40-64 years in Shahroud, Iran. Methods: The data of 5188 participants in the first phase of the Shahroud Cohort Eye Study, performed in 2009, were used for this study. Our outcome variable was presenting vision acuity (PVA) that was measured using LogMAR (logarithm of the minimum angle of resolution). The living standard variable used for estimation of inequality was the economic status and was constructed by principal component analysis on home assets. Inequality indices were concentration index and the gap between low and high economic groups. We decomposed these indices by the concentration index and BlinderOaxaca decomposition approaches respectively and compared the results. Results The concentration index of PVA was -0.245 (95% CI: -0.278, -0.212). The PVA gap between groups with a high and low economic status was 0.0705 and was in favor of the high economic group. Education, economic status, and age were the most important contributors of inequality in both concentration index and Blinder-Oaxaca decomposition. Percent contribution of these three factors in the concentration index and Blinder-Oaxaca decomposition was 41.1% vs. 43.4%, 25.4% vs. 19.1% and 15.2% vs. 16.2%, respectively. Other factors including gender, marital status, employment status and diabetes had minor contributions. Conclusion This study showed that individuals with poorer visual acuity were more concentrated among people with a lower economic status. The main contributors of this inequality were similar in concentration index and Blinder-Oaxaca decomposition. So, it can be concluded that setting appropriate interventions to promote the literacy and income level in people with low economic status, formulating policies to address economic problems in the elderly, and paying more attention to their vision problems can help to alleviate economic inequality in visual acuity.

Purpose: The present study was designed to determine the extent that horizontal inequity was realized regarding eye care utilization in a middle-aged population as well as factors affecting this equity. Methods: Data were obtained from a population-based study (Shahroud Eye Cohort Study) in 2009 that included 5190 participants from 40 to 64 years of age. Horizontal inequity was determined based on the following variables: (i) economic status, (ii) eye care service needs, (iii) non-need variables, and (iv) eye care utilization (visiting an ophthalmologist or optometrist). Decomposition analysis of the concentration index based on a nonlinear model and indirect standardization was used to ascertain the contribution of each factor in inequity of eye care utilization. Results: After adjusting for need variables, the results of our study demonstrated that horizontal inequity in eye care utilization in a middle-aged Iranian population remained positive and significant (horizontal inequity: 0.19; 95% confidence interval: 0.17–0.23) indicating that use of services was focused among participants with a better financial situation. Furthermore, decomposition analysis demonstrated that educational level and economic status had the greatest contribution (54.1% and 41.1%, respectively) in comparison to other variables. Conclusion: This study demonstrated that horizontal inequity exists in eye care utilization among the middle-aged Iranian population.

Purpose: To determine upper eyelid ptosis prevalence and some related factors in 44- to 69-year-olds of Shahroud in the north of Iran. Methods: In 2009, using multi-stage cluster sampling, 300 clusters of 40–64-year-olds were selected in Shahroud city, and all 5190 participants were invited to be re-examined in 5 years (2014). The current report is the second phase of the study in which 4737 (91.3%) people participated and underwent vision tests, slit lamp examination, biometry, and ophthalmoscopy in 2014. Upper eyelid ptosis was determined by an ophthalmologist. Results: The prevalence of upper eyelid ptosis was 4.7% [95% confidence interval (CI): 4.1–5.4]; 5.2% in women and in 4.0% in men. The prevalence of bilateral and unilateral ptosis was 1.3% (95% CI: 1.0–1.7) and 3.4% (95% CI: 2.8–4.0), respectively. The observed prevalence of ptosis was 3.1% in the 45- to 49-year age group and 5.8% in 65- to 69-year-olds. The prevalence of ptosis increased with age. In the multiple logistic regression model, ptosis prevalence correlated with older age, diabetes (odds ratio = 1.53, 95% CI: 1.16–2.02) and hypertension (odds ratio = 1.41, 95% CI: 1.03–2.92). Mean corneal astigmatism was 1.02 (95%C]: 0.87–1.18) diopter in ptotic eyes and 0.87 (95% CI: 0.84–0.89) diopter in non-ptotic eyes (p = 0.013). Conclusions: The present report provides valuable information on the prevalence of ptosis in a population of 45-to 69-year-olds. The prevalence of ptosis in this study was considerably high and significantly increased with age.

INTRODUCTION: Selection of the managers and leaders is a major concern of leading organizations. Recruitment of the qualified individuals in an educational organization depends on effective selection techniques. The present study reports the experience of Tehran University of Medical Sciences (TUMS) in designing a framework for selection of school dean. MATERIALS AND METHODS: First, a literature review was conducted to identify the common frameworks for the selection of deans in academic environment. Then, the perceptions of key stakeholders were collected via focus group discussions. Thematic analysis was used to categorize participants' comments. Following, an institutional guideline for selection of school dean was developed based on the derived themes and subthemes by a task force and approved by the board of directors. RESULTS: Three themes and nine subthemes were extracted, resulting in the selection framework for the school dean at TUMS with three phases of preparation, selection, and appointment. The preparation phase includes organizational needs analysis, designing the selection strategy and determining the eligibility of nominee. In the selection phases, various methods such as personal resume, interview, and consultation with beneficiaries were recommended, and the appointment phase includes formal appointment of the selected nominee by the university chancellor. CONCLUSIONS: We developed a framework for selection of school dean at TUMS. It recognizes the process that top managers would look out when selecting school deans. The framework may result to choose the proper individuals who have suitable plans and stronger Curriculum Vitae, while involving key stakeholders and collecting wisdom.

Introduction Tobacco use is one of the main risk factors for a number of chronic diseases, including cancer, lung diseases, and cardiovascular diseases. Nass is a form of smokeless tobacco. It is used most commonly in Central Asia, Afghanistan, Pakistan, and Iran, and is significantly associated with oral and oesophageal cancers. The aim of this study was to determine the prevalence of nass use and its associated factors among patients attending an outpatient clinic in Afghanistan. Methods This cross-sectional study was performed in an outpatient clinic in Andkhoy, Afghanistan, from April to July 2017. The study included 387 consecutive patients. The data collection tool was a questionnaire, which includes three main items: demographic, physical, and biomedical measurements. We performed binary logistic regression to identify independent risk factors of nass use. Results The study included 387 participants, of whom 225 were males (58.1%) and 162 were females (41.9%). The overall prevalence of nass use was 48.8% (95% CI: 43.8–53.9%), with the Turkmen ethnic group having significantly higher prevalence than other ethnic groups (58.2%, 95% CI: 50.8–65.3% vs 41.8%, 95% CI: 34.7–49.2%). The mean and standard deviation of the age was 63.9 (17.2) years for nass users and 42.3 (17.4) years for non-users. Based on a multivariate analysis, family history of nass use (OR=31.4, 95% CI: 12.5–78.5), illiteracy (OR=8.9, 95% CI: 2.5–31.2), rural residence (OR=2.0, 95% CI: 1.0–3.9), and unemployment (OR=5.4, 95% CI: 1.4–21.4) were associated with nass use. Conclusions Our results indicate that about half of the participants were nass users, and nass use associated factors were family history of nass use, illiteracy, unemployment, and rural residency in outpatient clinics in Afghanistan. More surveillance data are needed on a national level to inform the development of strategies for the prevention and control of nass consumption in Afghanistan.

OBJECTIVES The aim of this study was to evaluate the effect of pre-hypertension and its sub-classification on the development of diabetes. METHODS In this cohort study, 2,941 people 40 to 64 years old without hypertension or diabetes were followed from 2009 through 2014. According to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)-7 criteria, we classified participants into normal and pre-hypertension groups. The effect of pre-hypertension on the 5-year incidence rate of diabetes was studied using inverse probability of treatment weighting. We modeled the exposure and censored cases given confounding factors such as age, sex, body mass index, smoking, economic status, and education. RESULTS The 5-year incidence rate of diabetes among people with pre-hypertension and those with normal blood pressure (BP) was 12.7 and 9.7%, respectively. The risk ratio (RR) for people with pre-hypertension was estimated to be 1.13 (95% confidence interval [CI], 0.90 to 1.41). The RRs among people with normal BP and high-normal BP, according to the JNC-6 criteria, compared to those with optimal BP were 0.96 (95% CI, 0.73 to 1.25) and 1.31 (95% CI, 1.01 to 1.72), respectively. CONCLUSIONS Our results showed that participants who had higher levels of BP (high-normal compared to optimal BP) had a higher risk of diabetes development. With regard to the quantitative nature of BP, using the specifically distinguishing of stage 1 hypertension or high-normal BP may be a more meaningful categorization for diabetes risk assessment than the JNC-7 classification.

Privacy and confidentiality are among the inalienable rights of every human being that contribute to preservation of a sense of reverence and dignity. The present study was conducted to examine patients’ awareness of their entitlement to these important rights.This cross-sectional study was conducted on 200 patients in Tehran, Iran during the year 2010. Collected data included patients’ demographics (age, gender, marital status, place of residence, and educational level), type of hospital ward, frequency of hospitalization, duration of hospital stay, and patients’ awareness of privacy and confidentiality. Two trained interviewers gathered the data using a self-made questionnaire, which was specifically designed to assess patients’ awareness of privacy and confidentiality. Validity and reliability of the questionnaire were determined using content validity and Cronbach's Coefficient Alpha (a = 0.7), respectively. To analyze data, patients were assigned to three categories of poor (0 ≤ scores ≤ 3), moderate (4 ≤ scores ≤ 7) and good (8 ≤ scores ≤ 10) levels of awareness. Statistical analysis was performed by SPSS software version 21. The results showed that 21% of the patients had poor, 72% moderate, and 7% good awareness of privacy and confidentiality, with a mean of 4.61 ± 1.63. In this study, 153 patients (76.5%) provided a correct definition of privacy, and 161 patients (80.5%) were aware of instances of privacy violation. In addition, a good level of awareness was found in 77 patients (38.5%) in terms of physician confidentiality, and in 158 patients (81.4%) regarding confidentiality of examination results and medical consultations. Our study results highlight the necessity to inform patients about the ethical and legal issues related to privacy and confidentiality, before or during admission.

There is a relationship between mental and physical health. Depression and anxiety are linked with the development of several chronic diseases. The purpose of the present study was to determine the prevalence and factors associated with anxiety and depression among adult hypertensive outpatients in Afghanistan. Methods. Two hundred thirty-four consecutive hypertensive patients from December 2015 to August 2016 were recruited to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire, which has scores for classifying the participants having anxiety and depression symptoms. Results. Of the total 234 patients, 81 (34.6%) were males and 153 (65.4%) were females. The mean age was 54.6±12.7 for the hypertensive patients with anxiety and 63.8±15.0 for the hypertensive patients with depression while this figure was 49.5±10.2 for the adult participants in general population in Kabul city (Saeed, 2013). The prevalence of anxiety and depression (42.3% vs. 58.1%) among hypertensive persons is compared with the same mental disorders among Afghan refugees (39.3% vs. 22.1%) in Dalakee Refugee Camp (in Iran) (Hosseini Divkolaye and Burkle, 2017). Of the total participants, 99 had anxiety (42.3%), 136 had depression (58.1%), and 66 had (28.2%) comorbid anxiety-depression. Multivariate analysis was used. For anxiety age, female gender, smoking, diabetes mellitus, and 2 or more chronic diseases had a significant association. For depression, age and diabetes mellitus had a significant association, and for comorbid anxiety, depression, age, diabetes mellitus, and 2 or more chronic diseases had a significant association. Conclusion. This study shows that anxiety and depression are highly prevalent among hypertensive patients in an outpatient clinic in Afghanistan. There was an association between some sociodemographic and clinical characteristics and anxiety and depression. More studies are needed on a national level to inform the development of strategies for the prevention and control of psychological distress among patients with chronic diseases in Afghanistan.