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Background: During the past three decades, neonate, infant, and child mortality declined in North Africa and Middle East. However, there is substantial heterogeneity in mortality rates across countries. Methods: This study is part of the Global Burden of Diseases study (GBD) 2019. We report the number as well as mortality rates for neonates, infants, and children by cause across 21 countries in the region since 1990. Results: Between 1990 and 2019, the neonate mortality rate in the region declined from 31.9 (29.8, 34.0) to 12.2 (11.1, 13.3) per 1000 live births. Respective figures for under 5 mortality rates (U5MRs) were 79.1 (75.7, 82.7) in 1990 and 24.4 (22.3, 26.7) per 1000 live births in 2019. The majority of deaths among children under 5 years were due to under 1 year deaths: 75.9% in 1990 and 81.8% in 2019. Mortality rates in males were higher than females. The mortality rate among neonates ranged from 2.4 (2.1, 2.6) per 1000 live births in Bahrain to 25.0 (21.6, 28.4) in Afghanistan in 2019. Similarly, in 2019, the U5MR ranged from 5.0 (4.2-6.0) per 1000 live births in United Arab Emirates to 55.3 (47.9-63.5) in Afghanistan. Neonatal disorders, congenital birth defects, and lower respiratory infections were the three main causes of neonate, infant, and child mortality in almost all countries in the region. Conclusion: In 2019, most countries in this region have achieved the SDG targets for neonate and child mortality. However, there is still substantial heterogeneity across countries. [ABSTRACT FROM AUTHOR]

Background: Since 1990, the maternal mortality significantly decreased at global scale as well as the North Africa and Middle East. However, estimates for mortality and morbidity by cause and age at national scale in this region are not available. Methods: This study is part of the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019. Here we report maternal mortality and morbidity by age and cause across 21 countries in the region from 1990 to 2019. Results: Between 1990 and 2019, maternal mortality ratio (MMR) dropped from 148.8 (129.6--171.2) to 94.3 (73.4--121.1) per 100 000 live births in North Africa and Middle East. In 1990, MMR ranged from 6.0 (5.3--6.8) in Kuwait to 502.9 (375.2--655.3) per 100 000 live births in Afghanistan. Respective figures for 2019 were 5.1 (4.0--6.4) in Kuwait to 269.9 (195.8--368.6) in Afghanistan. Percentages of deaths under 25 years was 26.0% in 1990 and 23.8% in 2019. Maternal hemorrhage, indirect maternal deaths, and other maternal disorders rank 1st to 3rd in the entire region. Ultimately, there was an evident decrease in MMR along with increase in socio-demographic index from 1990 to 2019 in all countries in the region and an evident convergence across nations. Conclusion: MMR has significantly declined in the region since 1990 and only five countries (Afghanistan, Sudan, Yemen, Morocco, and Algeria) out of 21 nations didn't achieve the Sustainable Development Goal (SDG) target of 70 deaths per 100 000 live births in 2019. Despite the convergence in trends, there are still disparities across countries. [ABSTRACT FROM AUTHOR]

Background: Since 1990, maternal mortality ratio (MMR) has significantly decreased in Iran. However, estimates for mortality and morbidity by cause at subnational scale are not available. Methods: This study is part of the Global Burden of Diseases study (GBD) 2019. Here we report maternal mortality and morbidity by age and cause across 31 provinces of Iran from 1990 to 2019. Results: Since 1990, MMR declined from 44.5 (95% UI: 38.6-50.1) to 15.9 (14.7--17.3) per 100 000 live births in Iran. In 1990 MMR ranged from 18.5 (11.2--26.4) to 76.9 (38.4--114.7) per 100 000 live births across provinces. Respective figures for 2019 were 7.1 (5.2--9.3) to 34.0 (25.1--44.7) per 100 000 live births. In 2019, MMR was higher in young women (aged 10 to 14) and older women (aged 45 or more). Percentages of deaths under 25 years was 24.8% in 1990 and 16.0% in 2019. There was remarkable decline in years lost due to premature death (YLL) rates from 1990 to 2019. While the decline was modest for years lived with disability (YLD) rates. Indirect maternal deaths and other maternal deaths ranked first or second in almost all provinces. Ultimately, there was an evident decrease in MMR along with increase in socio-demographic Index (SDI) from 1990 to 2019 in all provinces and an evident convergence across provinces. Conclusion: MMR has declined to levels much lower than Sustainable Development Goals in all provinces. Although there was a convergence in trends, there are still disparities across provinces. The decline in disabilities caused by maternal disorders is not as significant as mortality, which needs further actions. [ABSTRACT FROM AUTHOR]

Background: Since 1990, neonatal, infant, and child mortality has substantially decreased in Iran. However, estimates for mortality by cause at subnational scale are not available. Methods: This study is part of the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019. Here we report the number and rates of neonate, infant, and child deaths by cause across provinces of Iran from 1990 to 2019. Results: Between 1990 and 2019, the neonatal mortality rate per 1000 live births decreased from 31.8 (95% UI: 28.1--35.5) to 6.8 (6.1--7.4). The child mortality rates decreased from 71.2 (63.6--79.1) to 11.1 (10.2--12.0) per 1000 live births. Mortality rates among neonates per 1000 live births ranged from 3.1 (2.6--3.7) to 10.0 (9.2--10.8) across provinces in 2019. Child mortality rate per 1000 live births ranged from 5.5 (4.6--6.5) to 17.9 (16.4--19.4) across provinces in 2019. Neonatal disorders, congenital birth defects, and lower respiratory infections were the three main causes of mortality in almost all provinces of Iran. The majority of neonatal disorders were due to neonatal preterm birth and neonatal asphyxia, trauma, and infections. The trends of mortality across provinces from 1990 to 2019 were converging and decreased along with increase in sociodemographic index (SDI). Conclusions: All provinces achieved the Sustainable Development Goal 3.2 of neonatal mortality less than 12 and child mortality less than 25 per 1000 live births. However, disparities still exist across provinces, specifically in low-SDI provinces. [ABSTRACT FROM AUTHOR]

Keywords: Type 2 diabetes; Prediabetes; Ethnicity; Prevalence EN Type 2 diabetes Prediabetes Ethnicity Prevalence 221 224 4 01/24/22 20220101 NES 220101 Dear Editor, We would like to thank the authors of the letter to the editor for their interest in our paper entitled "Nationwide Prevalence of Diabetes and Prediabetes and Associated Risk Factors Among Iranian Adults: Analysis of Data from PERSIAN Cohort Study". In the study by Lord et al. [[7]], although ethnicity was associated with prediabetes among residents of high-prediabetes clusters, they found no association between ethnicity and diabetes status. We did not adjust the model for cardiovascular diseases (CVDs) because CVDs are generally considered to be a consequence of prediabetes and diabetes that occur later in the causal graph and hence are not determinants for prediabetes and diabetes [[13]]. To the best of our knowledge, this is the first study that included major ethnic groups in Iran and provides a direct comparison of diabetes/prediabetes prevalence among different ethnicities. [Extracted from the article]

Introduction: Over the past decades prevalence of diabetes has increased in Iran and other countries. This study aimed to update the prevalence of diabetes and prediabetes in Iran and to determine associated sociodemographic risk factors, as well as diabetes awareness and control. Methods: This is a nationally representative cross-sectional survey that included 163,770 Iranian adults aged 35–70 years, from different ethnic backgrounds, between 2014 and 2020. Diabetes was diagnosed at fasting blood sugar of ≥ 6.99 mmol/L (126 mg/dL), or receiving blood glucose-lowering treatment. Multivariable logistic regression was applied to detect determinants associated with prevalence of diabetes and prediabetes, as well as predictors of diabetes awareness and glycemic control. Results: Sex- and age-standardized prevalence of diabetes and prediabetes was 15.0% (95% CI 12.6–17.3) and 25.4% (18.6–32.1), respectively. Among patients with diabetes, 79.6% (76.2–82.9) were aware of their diabetes. Glycemic control was achieved in 41.2% (37.5–44.8) of patients who received treatment. Older age, obesity, high waist to hip ratio (WHR), and specific ethnic background were associated with a significant risk of diabetes and prediabetes. Higher awareness of diabetes was observed in older patients, married individuals, those with high WHR, and individuals with high wealth score. Moreover, glycemic control was significantly better in women, obese individuals, those with high physical activity, educational attainment, and specific ethnic background. Conclusions: The prevalence of diabetes and prediabetes is increasing at an alarming rate in Iranian adults. High proportion of uncontrolled patients require particular initiatives to be integrated in the health care system. [ABSTRACT FROM AUTHOR]

Background: Raised blood pressure is a serious risk factor for several non-communicable diseases (NCDs) in Iran. In this study, we aimed to estimate the mean of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and subsequently, the prevalence of hypertension by sex, age, province, and year in Iran. Methods: We conducted a systematic review using PubMed, Web of Science, and Scopus databases through December 2017. We also used individual level data from eight national surveys, aggregated data from seven subnational population-based studies, and extracted data reported in 52 published studies. We used a two-stage model including Age-Spatio-Temporal and Gaussian process regression (GPR) to estimate mean systolic and diastolic blood pressure and used a crosswalk model to estimate the prevalence of hypertension by sex, age, province, and year. Results: The number of hypertensive adults increased in Iran from 1.8 million (882 thousand in women) in 1990 to 13.6 million (7.2 million in women) in 2016. The national age-standardized prevalence of hypertension increased from 8.7% (7.8--9.7) to 28.8% (27.7--30.0) in women and from 8.0% (7.2--8.9) to 24.2% (23.1--25.3) in men from 1990 to 2016. Mean systolic and diastolic blood pressures show a similar increasing trend. Conclusion: During the past 27 years, we observed an increase in the age-standardized prevalence and mean levels of blood pressure. If the current trend in levels of blood pressure and prevalence of hypertension continue in the coming years, Iran will not achieve the sixth target of the Global Action Plan by 2020 and the Sustainable Development Goals (SDGs) by 2030. Keywords: Epidemiology, Hypertension, Iran, Public Health [ABSTRACT FROM AUTHOR]

Background: It is increasingly common to collect and store specimens for future unspecified research. However, the effects of prolonged storage on the stability and quality of analytes in serum have not been well investigated. We aimed to determine whether the stability of liver enzymes extracted from frozen bio-samples stored at the baseline is affected by storage conditions. Methods: A total of four liver enzymes in the sera of 400 patients were examined following storage. After deter-mining the baseline measurements, the serum of each patient was aliquoted and stored at -70°C for three and six months, as well as one, two, and five years after collecting the original sample. The percent change from baseline measurements was calculated both statistically and clinically. Linear models were also used to correct the results of the samples based on the time they were frozen. Results: In almost all samples, liver enzymes were detectable until two years after the baseline, while in a signifi-cant proportion of samples, enzymes were not ultimately detectable five years after the baseline. Linear regression analysis on log-transformed levels of enzymes shows that the performance is acceptable until one year after the baseline. The performance of the prediction model declines substantially two and five years after the baseline, except for GGT. Conclusion: Long-term storage of serum samples significantly decreases the concentration of the liver enzymes from the baseline, except for GGT. It is not recommended to store samples for more than two years, as liver en-zymes are not detectable afterwards. [ABSTRACT FROM AUTHOR]

Background: Little is known about secondary prevention of cardiovascular diseases, using cardio-protective drugs, in the community-level, especially in low- and middle-income countries. We aimed to assess main drug use and its predictors in Northeast of Iran. Methods: This is a cross-sectional analysis on the Golestan Cohort Study data (2004-2008) with 50 045 participants. We assessed drug use in those with a history of ischemic heart disease (IHD) or stroke, recorded by face-to-face interviews. We explored drug use predictors (i.e., age, gender, wealth, education, residency, smoking, body mass index, physical activity, hypertension, and diabetes) through multivariable logistic regression. Results: A total of 3371 (6.7%) participants (56.7 ± 9.0 years, 58.1% female) reported a history of IHD, stroke or both. Median duration since diagnosis was 3.14 years (IQR: 1.25-6.30). Rates of using anti-platelets, statins, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and beta-blockers were 28.8% (95% CI: 27.3-30.3), 5.4 (4.7-6.2), 15.7 (14.5-17.0), and 40.6 (38.9-42.3), respectively. About 43% (41 - 45) of patients did not use any protective drugs. Use of ≥ three drugs was only 7.3% (6.6--8.2). Indicators of ≥1 drug use were: older age (OR for ≥60 vs. <50: 1.37), high wealth score (fifth vs first quintile: 1.60), literacy (1.56), city dwelling (1.32), body mass index (<18.5 and ≥30 vs. 25-29: 0.55 and 1.25, respectively), physical activity (third vs. first tertile: 0.64), hypertension (3.47), and diabetes (1.29); (all P < 0.05). Conclusion: Drug use after IHD or stroke is low in Northeast of Iran. Comprehensive efforts to promote secondary prevention are urgently needed. [ABSTRACT FROM AUTHOR]

Background: Summary measures of health are essential in making estimates of health status that are comparable across time and place. They can be used for assessing the performance of health systems, informing effective policy making, and monitoring the progress of nations toward achievement of sustainable development goals. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) as main summary measures of health. We assessed the trends of health status in Iran and 15 neighboring countries using these summary measures. Methods: \Ne used the results of GBD 2015 to present the levels and trends of DALYs, life expectancy (LE), and HALE in Iran and its 15 neighboring countries from 1990 to 2015. For each country, we assessed the ratio of observed levels of DALYs and HALE to those expected based on socio-demographic index (SDI), an indicator composed of measures of total fertility rate, income per capita, and average years of schooling. Results: All-age numbers of DALYs reached over 19 million years in Iran in 2015. The all-age number of DALYs has remained stable during the past two decades in Iran, despite the decreasing trends in all-age and age-standardized rates. The all-cause DALY rates decreased from 47,200 in 1990 to 28,400 per 100,000 in 2015. The share of non-communicable diseases in DALYs increased in Iran (from 42% to 74%) and all of its neighbors between 1990 and 2015; the pattern of change is similar in almost all 16 countries. The DALY rates for NCDs and injuries in Iran were higher than global rates and the average rate in High Middle SDI countries, while those for communicable, maternal, neonatal, and nutritional disorders were much lower in Iran. Among men, cardiovascular diseases ranked first in all countries of the region except for Bahrain. Among women, they ranked first in 13 countries. Life expectancy and HALE show a consistent increase in all countries. Still, there are dissimilarities indicating a generally low LE and HALE in Afghanistan and Pakistan and high expectancy in Qatar, Kuwait, and Saudi Arabia. Iran ranked 11th in terms of LE at birth and 12th in terms of HALE at birth in 1990 which improved to 9th for both metrics in 2015. Turkey and Iran had the highest increase in LE and HALE from 1990 to 2015 while the lowest increase was observed in Armenia, Pakistan, Kuwait, Kazakhstan, Russia, and Iraq. Conclusions: The levels and trends in causes of DALYs, life expectancy, and HALE generally show similarities between the 16 countries, although differences exist. The differences observed between countries can be attributed to a myriad of determinants, including social, cultural, ethnic, religious, political, economic, and environmental factors as well as the performance of the health system. Investigating the differences between countries can inform more effective health policy and resource allocation. Concerted efforts at national and regional levels are required to tackle the emerging burden of non-communicable diseases and injuries in Iran and its neighbors. [ABSTRACT FROM AUTHOR]

Background: The burden of chronic kidney disease (CKD) is increasing globally in particular in fast emerging economies such as Iran. Population-based studies on prevalence of CKD in Iran are scarce. The objective of the current study was to explore the prevalence and determinants of CKD in the setting of Golestan Cohort Study (GCS), the largest prospective cohort in the Middle East. Methods: In this observational study, 11,409 participants enrolled in the second phase of GCS were included. Sex, age, literacy, residence, anthropometric measurements, smoking, opium use, self-reported history of cardiovascular diseases (heart disease and/or stroke), hypertension, diabetes, and lipid profile were the predictors of interest. The outcomes of interest were eGFR and CKD defined as eGFR< 60 ml/min/1.73m2. Results: Mean (SD) of GFR was 70.0 ± 14.7 ml/min/1.73m2 among all participants, 68.2 ± 14.2 among women, and 72.0 ± 15.0 among men. Prevalence of CKD was 23.7% (26.6% in women, 20.6% in men). The prevalence of CKD stages 3a, 3b, 4, and 5 were 20.0%, 3.3%, 0.4% and 0.1%, respectively. Female sex, older age, urban residence, history of CVD, hypertension or diabetes, larger body mass and surrogates of body fat and opium use were all associated with CKD. Opium had a significant positive association with CKD in adjusted model. All anthropometric measurements had positive linear association with CKD. Being literate had inverse association. Sex had significant interaction with anthropometric indices, with higher odds ratios among men compared with women. A significantly high association was observed between the rate of change in waist circumference and systolic blood pressure with risk of CKD. Conclusion: One in four people in this cohort had low eGFR. Obesity and overweight, diabetes, hypertension, and dyslipidemia are major risk factors for CKD. Halting the increase in waist circumference and blood pressure may be as important as reducing the current levels. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular diseases (CVD) are becoming major causes of death in developing countries. Risk scoring systems for CVD are needed to prioritize allocation of limited resources. Most of these risk score algorithms have been based on a long array of risk factors including blood markers of lipids. However, risk scoring systems that solely use office-based data, not including laboratory markers, may be advantageous. In the current analysis, we validated the office-based Framingham risk scoring system in Iran. Methods: The study used data from the Golestan Cohort in North-East of Iran. The following risk factors were used in the development of the risk scoring method: sex, age, body mass index, systolic blood pressure, hypertension treatment, current smoking, and diabetes. Cardiovascular risk functions for prediction of 10-year risk of fatal CVDs were developed. Results: A total of 46,674 participants free of CVD at baseline were included. Predictive value of estimated risks was examined. The resulting Area Under the ROC Curve (AUC) was 0.774 (95% CI: 0.762-0.787) in all participants, 0.772 (95% CI: 0.753-0.791) in women, and 0.763 (95% CI: 0.747-0.779) in men. AUC was higher in urban areas (0.790, 95% CI: 0.766-0.815). The predicted and observed risks of fatal CVD were similar in women. However, in men, predicted probabilities were higher than observed. Conclusion: The AUC in the current study is comparable to results of previous studies while lipid profile was replaced by body mass index to develop an office-based scoring system. This scoring algorithm is capable of discriminating individuals at high risk versus low risk of fatal CVD. [ABSTRACT FROM AUTHOR]

Background: High blood pressure is the second most important risk factor of cardiovascular diseases (CVDs) in Iran. It is imperative to estimate the burden of CVDs that can be averted if high blood pressure is controlled at the population level. The aim of the current study was to estimate the avertable CVD mortality in the setting of Golestan Cohort Study (GCS). Methods: Over 50,000 participants were recruited and followed for a median of 7 years. The exposures of interest in this study were non-optimal systolic blood pressure (SBP) and hypertension measured at baseline. Deaths by cause have been precisely recorded. The Population Attributable Fraction (PAF) of deaths and Years of Life Lost (YLLs) due to CVDs attributable to exposures of interest were calculated. Results: Overall, 223 deaths due to ischemic heart disease (IHD), 207 deaths due to cerebrovascular accidents (CVA), and 460 deaths due to all CVDs could be averted if the SBP of all subjects in the study were optimal. Similarly, 5,560 YLLs due to IHD, 4,771 YLLs due to CVA, and 11,135 YLLs due to CVDs could be prevented if SBP were optimal. In all age groups, the avertable deaths and YLLs were higher due to IHD compared with CVA. Deaths and YLLs attributable to non-optimal SBP in women were less than men Conclusions: A very large proportion of CVD deaths can be averted if blood pressure is controlled in Iran. Effective interventions in primary and secondary health care setting are mandatory to be implemented as early as possible. [ABSTRACT FROM AUTHOR]

Correction to: Diabetes Ther https://doi.org/10.1007/s13300-021-01187-8 The original version was published with an incorrect article title. The correct article title is "A Response to the Letter to the Editor Regarding "Nationwide Prevalence of Diabetes and Prediabetes and Associated Risk Factors Among Iranian Adults: Analysis of Data from PERSIAN Cohort Study". [Extracted from the article]

Background: we aimed to recap and highlight the major results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 by mortality and morbidity to clarify the current health priorities and challenges in Iran. Methods: We estimated Iran's mortality and burden of 289 diseases with 67 risk factors and 1160 sequelae, which were used to clinically present each disease and its disability or cause of death. We produced several measures to report health loss and status: all-cause mortality, cause-specific mortality, years of life lost due to death (YLL), healthy years of life lost due to disability (YLD), disability-adjusted life years (DALYs), life expectancy, and healthy life expectancy, for three time periods: 1990, 2005, and 2010. Results: We found out that life expectancy at birth was 71.6 years in men and 77.8 years in women. Almost 350 thousand deaths occurred in both sexes and all age groups in 2010. In both males and females and all age groups, ischemic heart disease was the main cause of death, claiming about 90 thousand lives. The main contributors to DALYs were: ischemic heart disease (9.1%), low back pain (9.0%), road injuries (7.3%), and unipolar depressive disorders (6.3%). The main causes of death under 5 years of age included: congenital anomalies (22.4%), preterm birth complications (18.3%), and other neonatal disorders (13.5%). The main causes of death among 15 - 49 year olds in both sexes included: injuries (23.6%) and ischemic heart disease (12.7%) The highest rates of YLDs were observed among 70+ year olds for both sexes (27,365 per 100,000), mainly due to low back pain, osteoarthritis, diabetes, falls, and major depressive disorder. The main risk factors to which deaths were attributable among children under 5 years included: suboptimal breast feeding, ambient PM pollution, tobacco smoking, and underweight. The most important risk factors among 15 to 49 year olds were: dietary risks, high blood pressure, high body mass index, physical inactivity, smoking, and ambient PM pollution. The pattern was similar among 50+ year olds. Conclusion: Although non-communicable diseases had the greatest burden in 2010, the challenge of communicable and maternal diseases for health system is not over yet. Diet and physiological risk factors appear to be the most important targets for public health policy in Iran. Moreover, Iranians would greatly benefit from effective strategies to prevent injury and musculoskeletal disorders and expand mental care. Persistent improvement is possible by strengthening the health information system to monitor the population health and evaluate current programs. [ABSTRACT FROM AUTHOR]

Background: we aimed to recap and highlight the major results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 by mortality and morbidity to clarify the current health priorities and challenges in Iran. Methods: We estimated Iran's mortality and burden of 289 diseases with 67 risk factors and 1160 sequelae, which were used to clinically present each disease and its disability or cause of death. We produced several measures to report health loss and status: all-cause mortality, cause-specific mortality, years of life lost due to death (YLL), healthy years of life lost due to disability (YLD), disability-adjusted life years (DALYs), life expectancy, and healthy life expectancy, for three time periods: 1990, 2005, and 2010. Results: We found out that life expectancy at birth was 71.6 years in men and 77.8 years in women. Almost 350 thousand deaths occurred in both sexes and all age groups in 2010. In both males and females and all age groups, ischemic heart disease was the main cause of death, claiming about 90 thousand lives. The main contributors to DALYs were: ischemic heart disease (9.1%), low back pain (9.0%), road injuries (7.3%), and unipolar depressive disorders (6.3%). The main causes of death under 5 years of age included: congenital anomalies (22.4%), preterm birth complications (18.3%), and other neonatal disorders (13.5%). The main causes of death among 15 - 49 year olds in both sexes included: injuries (23.6%) and ischemic heart disease (12.7%) The highest rates of YLDs were observed among 70+ year olds for both sexes (27,365 per 100,000), mainly due to low back pain, osteoarthritis, diabetes, falls, and major depressive disorder. The main risk factors to which deaths were attributable among children under 5 years included: suboptimal breast feeding, ambient PM pollution, tobacco smoking, and underweight. The most important risk factors among 15 to 49 year olds were: dietary risks, high blood pressure, high body mass index, physical inactivity, smoking, and ambient PM pollution. The pattern was similar among 50+ year olds. Conclusion: Although non-communicable diseases had the greatest burden in 2010, the challenge of communicable and maternal diseases for health system is not over yet. Diet and physiological risk factors appear to be the most important targets for public health policy in Iran. Moreover, Iranians would greatly benefit from effective strategies to prevent injury and musculoskeletal disorders and expand mental care. Persistent improvement is possible by strengthening the health information system to monitor the population health and evaluate current programs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Non-communicable diseases (NCDs) and their risk factors are the major public health problems. There are some documented trend and point estimations of metabolic risk factors for Iranian population but there are little information about their exposure distribution at sub-national level and no information about their trends and their effects on the population health. METHODS: The present study protocol is aimed to provide the standard structure definitions, organization, data sources, methods of data gathering or generating, and data on trend analysis of the metabolic risk factors in NASBOD study. We will estimate 1990 to 2013 trends of prevalence, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) and disability-adjusted life years DALYs for MRFs by gender, age group, and province. We will also quantify the uncertainty interval for the estimates of interest.CONCLUSION: The findings of study could provide practical information regarding metabolic risk factors and their burden for better health policy to reduce the burden of diseases, and to plan cost-effective preventive strategies. The results also could be used for future complementary global, regional, national, and sub national studies. [ABSTRACT FROM AUTHOR]

Background: The Gastro-Esophageal Malignancies in Northern Iran (GEMINI) research project is an example of recent progress in health research in Iran. The original aim of this project was to identify etiologic factors and prevention measures for upper gastrointestinal cancers in Northern provinces of Iran, but its achievements have gone much beyond this initial goal. Methods: GEMINI consists of several projects including cancer registries, pilot studies, case-control studies, and the Golestan Cohort Study. GEMINI has been conducted through extensive collaborations between the Digestive Disease Research Center of Tehran University of Medical Sciences with other domestic and international health organizations. The achievements of GEMINI include producing new knowledge, introducing new research methods, developing and expanding health research and health care infrastructures, investing in , human resources, and increasing the awareness and knowledge of policy makers and officials at all levels about the importance of chronic diseases in Iran's health priorities. Conclusions: The success of GEMINI reveals the feasibility of large-scale health research studies in developing countries and serves as , a successful model not only for health research in Iran, but also for similar research studies in other developing nations. [ABSTRACT FROM AUTHOR]

Background: The Gastro-Esophageal Malignancies in Northern Iran (GEMINI) research project is an example of recent progress in health research in Iran. The original aim of this project was to identify etiologic factors and prevention measures for upper gastrointestinal cancers in Northern provinces of Iran, but its achievements have gone much beyond this initial goal. Methods: GEMINI consists of several projects including cancer registries, pilot studies, case-control studies, and the Golestan Cohort Study. GEMINI has been conducted through extensive collaborations between the Digestive Disease Research Center of Tehran University of Medical Sciences with other domestic and international health organizations. The achievements of GEMINI include producing new knowledge, introducing new research methods, developing and expanding health research and health care infrastructures, investing in , human resources, and increasing the awareness and knowledge of policy makers and officials at all levels about the importance of chronic diseases in Iran's health priorities. Conclusions: The success of GEMINI reveals the feasibility of large-scale health research studies in developing countries and serves as , a successful model not only for health research in Iran, but also for similar research studies in other developing nations. [ABSTRACT FROM AUTHOR]

Background: Short term randomized trials have shown the effectiveness of a fixed dose combination therapy (known as Polypill) on reducing blood pressure and serum cholesterol but the impact of Polypill on cardiovascular disease risk or mortality has not yet been directly investigated. Previous studies combined the effects of each component assuming a multiplicative joint risk assumption that may have led to overestimating the combined effects. We conducted an updated meta-analysis of randomized trials of anti-hypertensives, statins and aspirin. We used the estimated effect sizes applying a more conservative assumption to estimate the number of ischémie heart disease (IHD) and stroke deaths that could have been averted by Polypill in Iranians aged 55 years or older in 2006. Methods: We searched Medline and reviewed previous meta-analyses to select randomized trials on Angiotensin Converting Enzyme- inhibitors, thiazides, aspirin, and statins. We used a random-effects model to pool relative risks for each component and estimated the joint relative risks using multiplicative and additive assumptions for 4 combinations of Polypill components. We used age- and cause-specific mortality, separately by gender, and estimated the number of preventable deaths from IHD and stroke. Results: Under the additive joint RR assumption, the standard Polypill formulation was estimated to prevent 28500 (95% CI: 21700,34100) IHD deaths and 12700 (95% CI: 8800,15900) stroke deaths. Removing aspirin from the combination decreased preventable IHD deaths by 15% under the additive assumption (5600 deaths) and by 21% under the multiplicative assumption (6800 deaths) and reduced preventable stroke deaths under both additive and multiplicative assumptions by 3% (300 deaths). There was no significant difference between Polypill combinations with anti-hypertensive agents in full-dose or half-dose. Conclusion: Polypill can prevent a large number of IHD and stroke deaths in Iran. The cost-effectiveness, feasibility, and acceptability of this prevention strategy remain to be investigated. [ABSTRACT FROM AUTHOR]

Background: Short term randomized trials have shown the effectiveness of a fixed dose combination therapy (known as Polypill) on reducing blood pressure and serum cholesterol but the impact of Polypill on cardiovascular disease risk or mortality has not yet been directly investigated. Previous studies combined the effects of each component assuming a multiplicative joint risk assumption that may have led to overestimating the combined effects. We conducted an updated meta-analysis of randomized trials of anti-hypertensives, statins and aspirin. We used the estimated effect sizes applying a more conservative assumption to estimate the number of ischémie heart disease (IHD) and stroke deaths that could have been averted by Polypill in Iranians aged 55 years or older in 2006. Methods: We searched Medline and reviewed previous meta-analyses to select randomized trials on Angiotensin Converting Enzyme- inhibitors, thiazides, aspirin, and statins. We used a random-effects model to pool relative risks for each component and estimated the joint relative risks using multiplicative and additive assumptions for 4 combinations of Polypill components. We used age- and cause-specific mortality, separately by gender, and estimated the number of preventable deaths from IHD and stroke. Results: Under the additive joint RR assumption, the standard Polypill formulation was estimated to prevent 28500 (95% CI: 21700,34100) IHD deaths and 12700 (95% CI: 8800,15900) stroke deaths. Removing aspirin from the combination decreased preventable IHD deaths by 15% under the additive assumption (5600 deaths) and by 21% under the multiplicative assumption (6800 deaths) and reduced preventable stroke deaths under both additive and multiplicative assumptions by 3% (300 deaths). There was no significant difference between Polypill combinations with anti-hypertensive agents in full-dose or half-dose. Conclusion: Polypill can prevent a large number of IHD and stroke deaths in Iran. The cost-effectiveness, feasibility, and acceptability of this prevention strategy remain to be investigated. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to estimate the level and trend of plasma cholesterol and raised total cholesterol (TC > 200 mg/dl) prevalence at national and subnational level of Iran. Methods: Nine national surveys and 27 studies, encompassing 3,505 unique points on over 500,000 adults, aged > 25 years with a report of laboratory measurement of TC were found. Age-spatio-temporal model and Gaussian Process Regression were used to estimate mean TC for each sex, 5-year age groups, and 31 provinces from 1990 to 2016. Results: At national level, age-standardized prevalence of TC > 200 mg/dL has decreased from 57·2%(53·3–61·1) to 22·4%(20·5–24·3) in women and 53·2%(49·1–57·3) to 18·0%(16·4–19·6) in men. TC distribution presented a condensation between 170-200 mg/dL. At subnational level, decreasing and converging patterns of raised TC prevalence were detected. Conclusion: The decrease in raised TC is likely the result of statin widespread use, food industry improvements, and the expanded primary health care. [ABSTRACT FROM AUTHOR]

Background: Environmental risk factors are significant contributors to cancer mortality, which are neglected. Purpose: This study aimed to estimate the population attributable fraction of cancer mortality due to the environmental risk factors. Methods: Golestan cohort study is a population-base cohort on 50045 participants between 40–75 with about 18 years of follow up. We detected 2,196 cancer mortality and applied a multiple Cox model to compute the hazard ratio of environmental risk factor on all cancer and cancer-specific mortality. The population attributable fraction was calculated, accordingly. Results: Biomass fuels for cooking, as an indoor air pollution, increased the risk of colorectal, esophageal, gastric cancer, and all-cancer mortality by 84%, 66%, 37%, and 17% respectively. Using gas for cooking, particularly in rural areas, could save 6% [Population Attributable Fraction: 6.36(95%CI: 1.82, 10.70)] of esophageal cancer, 3% [Population Attributable Fraction: 3.43 (0, 7.33)] of gastric cancer, and 6% [Population Attributable Fraction: 6.25 (1.76, 13.63)] of colorectal cancer mortality. Using a healthy tap water source could save 5% [Population Attributable Fraction:5.50(0, 10.93)] of esophageal cancer mortality, particularly in rural areas. There was no significant association between indoor air pollution for heating purposes and animal contact with cancer mortality. Conclusion: Considering the results of this study, eliminating solid fuel for most daily usage, among the population with specific cancer types, is required to successfully reduce cancer related mortality. Adopting appropriate strategies and interventions by policymakers such as educating the population, allocating resources for improving the healthy environment of the community, and cancer screening policies among susceptible populations could reduce cancer related mortalities. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Rise in cesarean section rate over a 30-year period in a public hospital in tehran, iran," by M. H. Badakhsh and colleagues in the 2012 issue.

BACKGROUND Measuring serum alanine aminotransferase (ALT) enzyme is a routine clinical test commonly used to evaluate abnormalities in the body in general, and in the liver function in particular. Higher ALT levels are associated with some metabolic disorders. The upper limit normal (ULN) is considered as a reliable threshold for the definition of high ALT. OBJECTIVES: To assess the existing evidence on the ULN for ALT in the general population. DATA SOURCE: PubMed (Medline), EMBASE, Scopus, and Web of Science (ISI) were searched using a specified search strategy. ELIGIBILITY CRITERIA: We collected documents published from 1980 to 2018 in the English language, focusing on human samples at the population level and extracted the data after qualitative evaluation. METHODS We conducted this study in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We used specific search terms and their combinations to find documents from relevant databases. We used a snowballing approach to find documents not captured in the main phase of the search. Two authors separately conducted the search, screened the articles, and selected documents that were qualified for data extraction based on the defined inclusion criteria. Finally, data extraction was conducted by two authors using PRISMA checklist. Reported ULNs for ALT and 95% confidence intervals (CIs) were documented in previously developed datasheets. RESULTS Out of 15242 studies, 47 articles were included for data extraction and analysis. Data were sparse and lacked the consistency to precisely estimate ULN for serum ALT. The ULN of ALT was significantly diverse across various geographical locations and sexes. The lowest value of ULN for ALT was 19 IU/L in Chinese children (age range: 7 to < 10 years), and the highest value of ULN for ALT was 55 IU/L in children from Ghana aged < 5 years. LIMITATIONS: The main limitation of the current systematic review was the scarcity of the reported measures for ULN of ALT. CONCLUSION Based on the results of the current systematic review, it is suggested that the normal range of ALT be redefined, but this redefinition should be done according to the localized data. In order to redefine the ULN for ALT, regional differences, methods used in ALT measurements, and ULN determination should be considered. [ABSTRACT FROM AUTHOR]

Background: Recent evidence suggests overall diet quality, as assessed by dietary scores, may play a role in the development of upper gastrointestinal (UGI) cancers. However, the existing dietary scores are derived from high-income countries with different dietary habits than regions with the highest burden of UGI cancers, where limited data is available. This study aimed to investigate the association between overall diet quality and risk of esophageal and stomach cancers in a high-risk region for UGI cancers. Methods: We recruited 50 045 individuals aged 40-75 between 2004-2008 from northeastern Iran and followed them annually through July 2020. Data on demographics, diet, and various exposures were collected using validated questionnaires. Diet quality was assessed by calculating the Healthy Eating Index (HEI), Alternative Healthy Eating Index (AHEI), Alternative Mediterranean Diet (AMED), Dietary Approaches to Stop Hypertension (DASH), and World Cancer Research Fund--American Institute for Cancer Research (WCRF-AICR) scores. Results: During an average 12 years of follow-up, 359 participants developed esophageal cancer and 358 developed stomach cancer. After adjustments, each standard deviation increase in baseline dietary scores was associated with up to 12% reduction in esophageal cancer risk and up to 17% reduction in stomach cancer risk. Esophageal cancer showed stronger inverse associations with adherence to AMED (HRQ4-vs-Q1 = 0.69 (0.49-0.98), P-trend = 0.038). Stomach cancer showed stronger inverse correlation with WCRF-AICR (HRQ4-vs-Q1 = 0.58 (0.41-0.83), P-trend = 0.004), and DASH (HRC4-vs-C1 = 0.72 (0.54-0.96), P-trend = 0.041). These associations were comparable across different population subgroups. We did not observe significant associations between HEI and AHEI scores and UGI cancers in this population. Conclusion: Despite the differences in consuming individual food groups, adherence to the available dietary recommendations (derived from high-income countries) was associated with lower risk for subsequent esophageal and gastric cancers in this high-risk population. Educating the public to have a healthy eating pattern might be an effective strategy towards prevention of UGI cancers in high-risk regions. [ABSTRACT FROM AUTHOR]

A letter to the editor and a reply are presented in response to the article "The Gastro-Esophageal Malignancies in Northern Iran Research Project: Impact on the Health Research and Healthcare Systems in Iran," by A. Etemadi and colleagues in the 2013 issue.

An introduction is provided to an article within the journal that discusses the evaluation of the Health Research System (HRS) in Iran.

The authors reflect on a study conducted by Badakhsh and colleagues which featured the rise in the rate of cesarean section (CS) in Tehran, Iran, which is higher than the recommendation of the World Health Organization (WHO). They mention the factors for inappropriate CS such as the diversity of demographic profiles and women's preferences. Moreover, the use of the RAND Appropriateness Method (RAM) in the study is discussed.

Introduction: Chronic kidney disease (CKD) is a growing global health problem. Recently, an epidemic of CKD of unknown origin (CKDu), a form of CKD seen mostly in agricultural communities, has been emerged. One of the proposed causes of CKDu is pesticide use in farmers. On the other hand, the research on relation between indoor use of pesticides and CKDu is little. In this study, we aimed to investigate the association between indoor use of pesticide as well as the exposure time with CKDu. This study was done as part of the population-based cohort of Prospective Epidemiological Research Studies in Iran. We used the baseline data of the Zahedan Adult Cohort Study. All subjects with diabetes mellitus and/or hypertension, estimated glomerular filtration rate (eGFR) between 60–89 ml/min/1.73 m2, and unavailable creatinine measurement were excluded. Subjects with an eGFR of less than 60 ml/min/1.73 m2 were defined as having CKDu, and their data were compared with those with an eGFR of more than 90 ml/min/1.73 m2. Data regarding indoor pesticide use and duration of exposure were obtained through a questionnaire. After applying the exclusion criteria, 1079 subjects remained in the study. Female sex, single marital status, low physical activity, triglyceride (TG) levels of more than 150 mg/dl, body mass index (BMI) of more than 25 kg/m2, non-smokers, indoor pesticide use, and high pesticide exposure time were associated with CKDu. The effects of age, female sex, TG levels more than 150 mg/dl, pesticide use (OR 1.36; 95% CI 1.01–1.84), and high exposure time (third tertile of exposure time) compared to non-users (OR 1.64; 95% CI 1.07–2.51) remained significant in multivariable analysis. Conclusion: We found a positive association between pesticide use, as well as longer exposure time to pesticides, and impaired kidney function in cases without diabetes mellitus and hypertension. Further longitudinal studies should be carried out to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: The increasing trends in Diabetes prevalence and its attributed burden emphasized as an important issue that needs serious and urgent attention, all over the word. We estimated the mean Fasting Plasma Glucose (FPG) and the prevalence of Diabetes in aged 25 years or older Iranian adults, by sex, age, province, and year through the time period of 1990 to 2016. Methods: In order to access the most comprehensive relevant data at the same time the systematic data searched added to the data of 5 national surveys and 7 sub-national population based investigations. Two round of modeling, including the Age-Spatio-Temporal and Gaussian Process Regression were used for estimation of mean FPG trend and uncertainties. To estimate Diabetes estimations in target groups, a crosswalk model was applies to the FPG estimates. The model reiterated separately for women and men. All of estimations standardized based on the Iran national census population of 2016 by year, age groups and sexes at national and sub-national levels. Results: In 2016, the number of the diabetic population was 4.43 (3.93–4.99) million (2.38 million women). Between 1990 and 2016, the age-standardized mean of FPG increased from 84.69 mg/dl (79.8–89.8) to 100.5 mg/dl (97.9–103.3) in women and from 82.7 mg/dl (78.3–87.5) to 98.8 mg/dl (96.2–101.4) in men. Simultaneously, with considerable difference, the Diabetes prevalence, has increased from 6.1% (4.7–7.8) to 9.8% (8.7–11.1) in women and from 5.0% 18 (3.8–6.3) to 8.1% (7.2–9.2) in men (75% attributed to population growth). Considering the geographical patterns, the greatest increment in the prevalence of Diabetes detected in the northwestern and the central provinces. Conclusion: Significant increasing trends of Diabetes led to alarming threat, which can make the strategies and goals of our prevention programs out of control. We should plan for more effective communicative interventions for prevention and management of Diabetes, to be designed, implemented and monitored based on the updated scientific evidence. [ABSTRACT FROM AUTHOR]

A response from the author of the article "Cardiovascular disease prevention using fixed dose pharmacotherapy in Iran: updated meta-analyses and mortality estimation," in the September 2012 issue is presented.

Background: Elevated blood pressure is associated with cardiovascular disease, stroke and chronic kidney disease. In this study, we examined the socioeconomic inequality and its related factors in prevalence, Awareness, Treatment and Control (ATC) of hypertension (HTN) in Iran.Method: The study used data from the recruitment phase of The Prospective Epidemiological Research Studies in IrAN (PERSIAN). A sample of 162,842 adults aged >  = 35 years was analyzed. HTN was defined according to the Joint National Committee)JNC-7(. socioeconomic inequality was measured using concentration index (Cn) and curve.Results: The mean age of participants was 49.38(SD =  ± 9.14) years and 44.74% of the them were men. The prevalence of HTN in the total population was 22.3%(95% CI: 20.6%; 24.1%), and 18.8%(95% CI: 16.8%; 20.9%) and 25.2%(95% CI: 24.2%; 27.7%) in men and women, respectively. The percentage of awareness treatment and control among individuals with HTN were 77.5%(95% CI: 73.3%; 81.8%), 82.2%(95% CI: 70.2%; 81.6%) and 75.9%(95% CI: 70.2%; 81.6%), respectively. The Cn for prevalence of HTN was -0.084. Two factors, age (58.46%) and wealth (32.40%), contributed most to the socioeconomic inequality in the prevalence of HTN.Conclusion: The prevalence of HTN was higher among low-SES individuals, who also showed higher levels of awareness. However, treatment and control of HTN were more concentrated among those who had higher levels of SES, indicating that people at a higher risk of adverse event related to HTN (the low SES individuals) are not benefiting from the advantage of treatment and control of HTN. Such a gap between diagnosis (prevalence) and control (treatment and control) of HTN needs to be addressed by public health policymakers. [ABSTRACT FROM AUTHOR]

Background: Environmental exposures account for a growing proportion of global mortality. Large cohort studies are needed to characterize the independent impact of environmental exposures on mortality in low-income settings. Methods: We collected data on individual and environmental risk factors for a multiethnic cohort of 50,045 individuals in a low-income region in Iran. Environmental risk factors included: ambient fine particular matter air pollution; household fuel use and ventilation; proximity to traffic; distance to percutaneous coronary intervention (PCI) center; socioeconomic environment; population density; local land use; and nighttime light exposure. We developed a spatial survival model to estimate the independent associations between these environmental exposures and all-cause and cardiovascular mortality. Findings: Several environmental factors demonstrated associations with mortality after adjusting for individual risk factors. Ambient fine particulate matter air pollution predicted all-cause mortality (per μg/m3, HR 1.20, 95% CI 1.07, 1.36) and cardiovascular mortality (HR 1.17, 95% CI 0.98, 1.39). Biomass fuel use without chimney predicted all-cause mortality (reference = gas, HR 1.23, 95% CI 0.99, 1.53) and cardiovascular mortality (HR 1.36, 95% CI 0.99, 1.87). Kerosene fuel use without chimney predicted all-cause mortality (reference = gas, HR 1.09, 95% CI 0.97, 1.23) and cardiovascular mortality (HR 1.19, 95% CI 1.01, 1.41). Distance to PCI center predicted all-cause mortality (per 10km, HR 1.01, 95% CI 1.004, 1.022) and cardiovascular mortality (HR 1.02, 95% CI 1.004, 1.031). Additionally, proximity to traffic predicted all-cause mortality (HR 1.13, 95% CI 1.01, 1.27). In a separate validation cohort, the multivariable model effectively predicted both all-cause mortality (AUC 0.76) and cardiovascular mortality (AUC 0.81). Population attributable fractions demonstrated a high mortality burden attributable to environmental exposures. Interpretation: Several environmental factors predicted cardiovascular and all-cause mortality, independent of each other and of individual risk factors. Mortality attributable to environmental factors represents a critical opportunity for targeted policies and programs. [ABSTRACT FROM AUTHOR]

Background: Determining the risk of Cardiovascular Disease (CVD) is a necessity for timely preventive interventions in high-risk groups. However, laboratory testing may be impractical in countries with limited resources. This study aimed at comparison and assessment of the agreement between laboratory-based and non-laboratory-based WHO risk charts models.Methods: This study was performed using the baseline data of 8138 participants in the pars cohort study who had no history of CVD and stroke. The updated 2019 WHO model was used to determine the 10-year fatal and non-fatal CVD risks. In general, there are two types of new WHO risk prediction models for CVD. The scores were determined based on age, sex, smoking status, diabetes, Systolic Blood Pressure (SBP), and total cholesterol for the laboratory-based model and age, sex, smoking status, SBP, and Body Mass Index (BMI) for the non-laboratory-based model. The agreement of these two models was determined via kappa statistics for the classified risk (low: < 10%, moderate: 10-< 20%, high: ≥ 20%). Correlation coefficients (r) and scatter plots was used for correlation between scores.Results: The results revealed very strong correlation coefficients for all sex and age groups (r = 0.84 for males < 60 years old, 0.93 for males ≥ 60 years old, 0.85 for females < 60 years old, and 0.88 for females ≥ 60 years old). In the laboratory-based model, low, moderate, and high risks were 76.10%, 18.17%, and 5.73%, respectively. These measures were respectively obtained as 77.00%, 18.08%, and 4.92% in the non-laboratory-based model. Based on risk classification, the agreement was substantial for males < 60 years old and for both males and females aged ≥ 60 years (kappa values: 0.79 for males < 60 years old, 0.65 for males ≥ 60 years old, and 0.66 for females ≥ 60 years old) and moderate for females < 60 years old (kappa = 0.46).Conclusions: The non-laboratory-based risk prediction model, which is simple, inexpensive, and non-invasive, classifies individuals almost identically to the laboratory-based model. Therefore, in countries with limited resources, these two models can be used interchangeably. [ABSTRACT FROM AUTHOR]

Background: Drawing on the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study, we attempted to investigate the drivers of change in the healthcare system in terms of mortality and morbidity due to diseases, injuries, and risk factors for the two decades from 1990 to 2010. Methods: We decomposed trends in mortality, cause of death, years of life lost due to disability, disability-adjusted life years (DALYs), life expectancy, health-adjusted life expectancy, and risk factors into the contribution of total increase in population size, aging of the population, and changes in age-specific and sex-specific rates. Results: We observed a decrease in age-specific mortality rate for both sexes, with a higher rate for women. The ranking of causes of death and their corresponding number of years of life lost remained unchanged between 1990 and 2010. However, the percentages of change indicate patterns of reduction for most causes, such as ischemic and hemorrhagic stroke, hypertensive heart disease, stomach cancer, lower respiratory infections, and congenital anomalies. The number of years lost due to disability caused by diabetes and drug use disorders has significantly increased in the last two decades. Major causes of DALYs, such as injuries, interpersonal violence, and suicide, showed increasing trends, while rates of communicable diseases, neonatal disorders, and nutritional deficiencies have declined significantly. Life expectancy and health-adjusted life expectancy increased for both sexes by approximately 7 years, with the highest rate of increase pertaining to females over the age 30. Conclusions: Time trend information presented in this paper can be used to evaluate problems and policies specific to medical conditions or risk factors. Despite recent improvements, implementing policies to reduce the number of deaths and years of life lost due to road traffic injury remains the highest priority for Iranian policymakers. Immediate action by Iranian researchers is required to match Iran's decreasing mortality rate due to liver and stomach cancers to a rate comparable to the global level. Prevention and treatment plans for mental disorders, such as major depressive disorder, anxiety disorder, and particularly drug use disorders, should be considered in reforms of the health, education, and judiciary systems in Iran. [ABSTRACT FROM AUTHOR]

Background: Population health and disease profiles are diverse across Iran's neighboring countries. Borrowing the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010), we aim to compare Iran with 19 countries in terms of an important set of population health and disease metrics. These countries include those neighboring Iran and a few other countries from the Middle East and North Africa (MENA) region. Methods: We show the pattern of health transition across the comparator countries from 1990 through 2010. We use classic GBD metrics measured for the year 2010 to indicate the rank of Iran among these nations. The metrics include disability-adjusted life years (DALYs), years of life lost as a result of premature death (YLLs), years of life lost due to disability (YLDs), health-adjusted life expectancy (HALE), and age-standardized death rate (ASD). Results: Considerable and uniform transition from communicable, maternal, neonatal, and nutritional (CMMN) conditions to non-communicable diseases (NCDs) was seen between 1990 and 2010. On average, ischemic heart disease, lower respiratory infections, and road injuries were the three principal causes of YLLs, while low back pain and major depressive disorders were the top causes of YLDs in these countries. Iran ranked 13th in HALE and 12th in ASD. The function of Iran's health care, measured by DALYs, was somewhat in the middle of the HALE spectrum for the comparator countries. This intermediate position becomes rather highlighted when Afghanistan, as outlier, is taken out of the comparison. Conclusion: Effective policies to reduce NCDs need to be formulated and implemented through an integrated health care system. Our comparison shows that Iran can learn from the experience of a number of these countries to devise and execute the required strategies. [ABSTRACT FROM AUTHOR]

Background: Population health and disease profiles are diverse across Iran's neighboring countries. Borrowing the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010), we aim to compare Iran with 19 countries in terms of an important set of population health and disease metrics. These countries include those neighboring Iran and a few other countries from the Middle East and North Africa (MENA) region. Methods: We show the pattern of health transition across the comparator countries from 1990 through 2010. We use classic GBD metrics measured for the year 2010 to indicate the rank of Iran among these nations. The metrics include disability-adjusted life years (DALYs), years of life lost as a result of premature death (YLLs), years of life lost due to disability (YLDs), health-adjusted life expectancy (HALE), and age-standardized death rate (ASD). Results: Considerable and uniform transition from communicable, maternal, neonatal, and nutritional (CMMN) conditions to non-communicable diseases (NCDs) was seen between 1990 and 2010. On average, ischemic heart disease, lower respiratory infections, and road injuries were the three principal causes of YLLs, while low back pain and major depressive disorders were the top causes of YLDs in these countries. Iran ranked 13th in HALE and 12th in ASD. The function of Iran's health care, measured by DALYs, was somewhat in the middle of the HALE spectrum for the comparator countries. This intermediate position becomes rather highlighted when Afghanistan, as outlier, is taken out of the comparison. Conclusion: Effective policies to reduce NCDs need to be formulated and implemented through an integrated health care system. Our comparison shows that Iran can learn from the experience of a number of these countries to devise and execute the required strategies. [ABSTRACT FROM AUTHOR]

Background: Drawing on the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study, we attempted to investigate the drivers of change in the healthcare system in terms of mortality and morbidity due to diseases, injuries, and risk factors for the two decades from 1990 to 2010. Methods: We decomposed trends in mortality, cause of death, years of life lost due to disability, disability-adjusted life years (DALYs), life expectancy, health-adjusted life expectancy, and risk factors into the contribution of total increase in population size, aging of the population, and changes in age-specific and sex-specific rates. Results: We observed a decrease in age-specific mortality rate for both sexes, with a higher rate for women. The ranking of causes of death and their corresponding number of years of life lost remained unchanged between 1990 and 2010. However, the percentages of change indicate patterns of reduction for most causes, such as ischemic and hemorrhagic stroke, hypertensive heart disease, stomach cancer, lower respiratory infections, and congenital anomalies. The number of years lost due to disability caused by diabetes and drug use disorders has significantly increased in the last two decades. Major causes of DALYs, such as injuries, interpersonal violence, and suicide, showed increasing trends, while rates of communicable diseases, neonatal disorders, and nutritional deficiencies have declined significantly. Life expectancy and health-adjusted life expectancy increased for both sexes by approximately 7 years, with the highest rate of increase pertaining to females over the age 30. Conclusions: Time trend information presented in this paper can be used to evaluate problems and policies specific to medical conditions or risk factors. Despite recent improvements, implementing policies to reduce the number of deaths and years of life lost due to road traffic injury remains the highest priority for Iranian policymakers. Immediate action by Iranian researchers is required to match Iran's decreasing mortality rate due to liver and stomach cancers to a rate comparable to the global level. Prevention and treatment plans for mental disorders, such as major depressive disorder, anxiety disorder, and particularly drug use disorders, should be considered in reforms of the health, education, and judiciary systems in Iran. [ABSTRACT FROM AUTHOR]

Background: There is limited data on the natural history of autoimmune hepatitis (AIH) and on the long-term follow-up of AIH patients who have been referred for regular medical attention. Objectives: We evaluated the clinical presentation and natural history of AIH in a large cohort of type I AIH patients from Iran. Patients and Methods: Between 1997 and 2008, 102 patients were enrolled in the study. Patients were diagnosed using the International Autoimmune Hepatitis Group criteria and were followed up for an average of 60 months. Clinical and biochemical data were gathered from all the patients at both the beginning and the end of the follow-up period. Liver biopsy was performed in all patients before treatment, and the biopsies were performed in 28 patients after treatment. Results: Biochemical remission was achieved by 80 (79.4%) patients. Of these, 53 (66.5%) showed near-normal liver histology or liver function test results and sonogram. The remaining 27 (33.5%) patients also achieved clinical and biochemical remission, but developed compensated cirrhosis. After a period of remission, 24 patients (32.5%) relapsed. Among the 22 (21.6%) patients who showed ultimate treatment failure, 6 underwent orthotopic liver transplantation and 3 died of liver failure while awaiting a transplant. Sixteen (72.7%) of the 22 patients who did not respond to therapy were non-compliant with medications and had irregular follow-up. The overall 10-year survival rate in the cohort was 96%. Conclusions: Long-term survival in AIH patients is very good. Prompt diagnosis and appropriate first-line and salvage therapy that includes close follow-up will make liver transplantation a rare necessity in the treatment of this disease. [ABSTRACT FROM AUTHOR]

Introduction: In 2017, the American College of Cardiology/ American Heart Association (ACC/AHA) provided a new guideline for hypertension prevention and management. We aimed to update the prevalence, awareness, control, and determinants of hypertension based on this guideline in Khuzestan province, southwest of Iran, and to estimate the number of people who are eligible for non-pharmacologic and pharmacologic intervention. Methods: This population-based cross-sectional study was conducted in Khuzestan, a large province in the southwest of Iran. Comprehensive information about the potential relating factors of hypertension was collected, blood pressure was measured, and anthropometric measurements were obtained. Moreover, the dietary pattern was evaluated in 2830 individuals, using a qualitative food frequency questionnaire. Results: Among 30, 506 participants, 30, 424 individuals aged 20-65 years were eligible for the study. In comparison with the previous guideline released by the Joint National Committee (JNC8), the prevalence of hypertension in Khuzestan dramatically increased from 15.81 to 42.85% after implementation of the ACC/AHA guideline, which was more dominant in the male population and the 45-54 age group. The sex and age adjustment of the hypertension prevalence was estimated to be 39.40%. The percentage of hypertension awareness, treatment, and control were 45.85%, 35.42%, and 59.63%, which dropped to 22.72%, 26.37%, and 28.94% after implementation of new guideline, respectively. Conclusion: In the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition were shifted into the hypertension category and the level of awareness, treatment, and control were dramatically decreased, which highlight a great need to expand the public health infrastructure for further managing the substantial increased burden on healthcare system. However, further studies with population over 65 years are required to estimate the eligibility for antihypertensive treatment in this province after implementation of new guideline. [ABSTRACT FROM AUTHOR]

Background: In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) provided a new guideline for hypertension prevention and management. We aimed to update the prevalence, awareness, control, and determinants of hypertension based on this guideline in Khuzestan province, southwest of Iran, and to estimate the number of people who are eligible for non-pharmacologic and pharmacologic intervention. Methods: This population-based cross-sectional study was conducted in Khuzestan, a large province in the southwest of Iran. Comprehensive information about the potential relating factors of hypertension was collected, blood pressure was measured, and anthropometric measurements were obtained. Moreover, the dietary pattern was evaluated in 2830 individuals, using a qualitative food frequency questionnaire. Results: Among 30,506 participants, 30,424 individuals aged 20–65 years were eligible for the study. In comparison with the previous guideline released by the Joint National Committee (JNC8), the prevalence of hypertension in Khuzestan dramatically increased from 15.81 to 42.85% after implementation of the ACC/AHA guideline, which was more dominant in the male population and the 45–54 age group. The sex and age adjustment of the hypertension prevalence was estimated to be 39.40%. The percentage of hypertension awareness, treatment, and control were 45.85%, 35.42%, and 59.63%, which dropped to 22.72%, 26.37%, and 28.94% after implementation of new guideline, respectively. Conclusions: In the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition were shifted into the hypertension category and the level of awareness, treatment, and control were dramatically decreased, which highlight a great need to expand the public health infrastructure for further managing the substantial increased burden on healthcare system. However, further studies with population over 65 years are required to estimate the eligibility for antihypertensive treatment in this province after implementation of new guideline. [ABSTRACT FROM AUTHOR]

Background: As pancreatic cancer (PC) is a malignancy with poor prognosis, finding strategies for its prevention became a notable priority. Among all the factors influencing the risk of PC, dietary items especially fats are considered as the most modifiable risk factors.This study is designed to assess the associations of dietary intake of fatty acids with the risk of PC incidence.Methods: A total of 50,045 adults between 40 and 75 years old participated in this cohort study in 2004-2008 and were followed up to the present. Intakes of fatty acids was evaluated by validated food-frequency questionnaire (FFQ). Cox proportional hazards regression model was used to estimate hazard ratio (HR) with 95 % confidence interval of differing levels of dietary intakes of fatty acids for incidence of PC.Results: At the end of follow-up period, 76 cases of PC were identified and 46,904 participants without history of cancer, acute kidney disorders, fibrosis and cirrhosis were included in the study. Dietary total saturated fatty acids (SFAS) was associated with PC risk (HR = 1.05 (1.01-1.09), Ptrend=0.01), whereas dietary total monounsaturated fatty acids (MUFAS) was inversely associated with the risk of PC (HR = 0.92 (0.86-0.99), Ptrend=0.04). Dietary total polyunsaturated fatty acids (PUFAS) did show a protective but not significant association with the risk of PC (HR = 0.91(0.84-1.00), Ptrend=0.05).Conclusions: The amount of total fat intake is not a risk factor for PC in our study and focusing on the intake of specific fatty acids becomes more striking. Unsaturated fatty acids including PUFAS and especially MUFAS are considered as protective dietary factors in PC prevention. In contrast, total SFAS is positively associated with the increased risk of PC. However, very long chain and odd-chain saturated fatty acids intake may be protective against PC. [ABSTRACT FROM AUTHOR]

Background: Transport-related injuries (TIs) are a substantial public health concern for all regions of the world. The present study quantified the burden of TIs and deaths in the Eastern Mediterranean region (EMR) in 2017 by sex and age. Methods: TIs and deaths were estimated by age, sex, country, and year using Cause of Death Ensemble modelling (CODEm) and DisMod-MR 2.1. Disability-adjusted life years (DALYs), which quantify the total burden of years lost due to premature death or disability, were also estimated per 100 000 population. All estimates were reported along with their corresponding 95% uncertainty intervals (UIs). Results: In 2017, there were 5.5 million (UI 4.9-6.2) transport-related incident cases in the EMR -- a substantial increase from 1990 (2.8 million; UI 2.5-3.1). The age-standardized incidence rate for the EMR in 2017 was 787 (UI 705.5-876.2) per 100 000, which has not changed significantly since 1990 (-0.9%; UI -4.7 to 3). These rates differed remarkably between countries, such that Oman (1303.9; UI 1167.3-1441.5) and Palestine (486.5; UI 434.5-545.9) had the highest and lowest age-standardized incidence rates per 100 000, respectively. In 2017, there were 185.3 thousand (UI 170.8-200.6) transport-related fatalities in the EMR -- a substantial increase since 1990 (140.4 thousand; UI 118.7-156.9). The age-standardized death rate for the EMR in 2017 was 29.5 (UI 27.1-31.9) per 100 000, which was 30.5% lower than that found in 1990 (42.5; UI 36.8-47.3). In 2017, Somalia (54; UI 30-77.4) and Lebanon (7.1; UI 4.8-8.6) had the highest and lowest age-standardized death rates per 100,000, respectively. The age-standardised DALY rate for the EMR in 2017 was 1,528.8 (UI 1412.5-1651.3) per 100 000, which was 34.4% lower than that found in 1990 (2,331.3; UI 1,993.1-2,589.9). In 2017, the highest DALY rate was found in Pakistan (3 454 121; UI 2 297 890-4 342 908) and the lowest was found in Bahrain (8616; UI 7670-9751). Conclusion: The present study shows that while road traffic has become relatively safer (measured by deaths and DALYs per 100 000 population), the number of transport-related fatalities in the EMR is growing and needs to be addressed urgently. [ABSTRACT FROM AUTHOR]

Background: In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) provided a new guideline for hypertension prevention and management. We aimed to update the prevalence, awareness, control, and determinants of hypertension based on this guideline in Khuzestan province, southwest of Iran, and to estimate the number of people who are eligible for non-pharmacologic and pharmacologic intervention. Methods: This population-based cross-sectional study was conducted in Khuzestan, a large province in the southwest of Iran. Comprehensive information about the potential relating factors of hypertension was collected, blood pressure was measured, and anthropometric measurements were obtained. Moreover, the dietary pattern was evaluated in 2830 individuals, using a qualitative food frequency questionnaire. Results: Among 30,506 participants, 30,424 individuals aged 20–65 years were eligible for the study. In comparison with the previous guideline released by the Joint National Committee (JNC8), the prevalence of hypertension in Khuzestan dramatically increased from 15.81 to 42.85% after implementation of the ACC/AHA guideline, which was more dominant in the male population and the 45–54 age group. The sex and age adjustment of the hypertension prevalence was estimated to be 39.40%. The percentage of hypertension awareness, treatment, and control were 45.85%, 35.42%, and 59.63%, which dropped to 22.72%, 26.37%, and 28.94% after implementation of new guideline, respectively. Conclusions: In the ACC/AHA guideline, a higher number of individuals with the pre-hypertension condition were shifted into the hypertension category and the level of awareness, treatment, and control were dramatically decreased, which highlight a great need to expand the public health infrastructure for further managing the substantial increased burden on healthcare system. However, further studies with population over 65 years are required to estimate the eligibility for antihypertensive treatment in this province after implementation of new guideline. [ABSTRACT FROM AUTHOR]

Background: In developing countries like Iran, the burden of obesity increases through comorbid diseases. We estimated the mean body mass index (BMI) and prevalence of overweight/obesity by components of sex, age, province, and year in Iran from 1990 to 2016. Methods: Through a comprehensive systematic review, all relevant data sources pooled results with individual level national and sub-national population-based studies. Two stages of age-spatio-temporal modeling and Gaussian process regression were used to estimate mean BMI, followed by estimation of obesity and overweight prevalence through the crosswalk modeling. Results: In 2016, the age-standardized mean BMI was 27.9 (27.2-28.7) kg/m² in women and 25.9 (25.2-26.5) kg/m² in men. At the same time, the prevalence rates of overweight and obesity were 71.7% (67.9-75.8), and 36.8% (34.1-39.7) in females, and 57.1% (53.7-60.6), and 18.4% (16.9-20) in men. This shows a considerable increase from 1990 when the figures were respectively 24.4 (23.3-25.5), 36.6% (32.2-41.5), and 8.2% (95% UI: 6.9-9.7) in women, and 23.5 (22.5-24.5), 30% (26.4-34), and 4.7% (4.0-5.5) in men, with 66% attributed to population growth. Conclusion: Considering the increasing trends of BMI, Sustainable Development Goals (SDGs) seem far out of reach. We need to call for action, aiming for both weight loss strategies and controlling the comorbidities that mediate high BMI risk. [ABSTRACT FROM AUTHOR]

Sofosbuvir seems to be a revolutionary treatment for Hepatitis C-infected patients with advanced chronic kidney disease (CKD) but existing evidence is not quite adequate. The aim of this study was to evaluate the efficacy and safety of Sofosbuvir-based therapy without Ribavirin for all hepatitis C virus genotypes among patients with advanced CKD. We conducted an updated systematic literature search from the beginning of 2013 up to June 2020. Sustained virologic response (SVR) rate at 12 and/or 24 weeks after the end of treatment, and adverse events in HCV-infected patients with advanced CKD were pooled using random effects models. We included 27 published articles in our meta-analyses, totaling 1,464 HCV-infected patients with advanced CKD. We found a substantial heterogeneity based on the I2 index (P = 0.00, I2 = 56.1%). The pooled SVR rates at 12 and 24 weeks after the end of Sofosbuvir-based treatment were 97% (95% Confidence Interval: 95–99) and 95% (89–99) respectively. The pooled SVR12 rates were 98% (96–100) and 94% (90–97) in patients under 60 and over 60 years old respectively. The pooled incidence of severe adverse events was 0.11 (0.04–0.19). The pooled SVR12 rate after completion of the half dose regimen was as high as the full dose treatment but it was associated with less adverse events (0.06 versus 0.14). The pooled SVR12 rate was 98% (91–100) in cirrhotic patients and 100% (98–100) in non-cirrhotic patients. The endorsement of Sofosbuvir-based regimen can improve the treatment of hepatitis C virus infection in patients with advanced CKD. [ABSTRACT FROM AUTHOR]