The establishment of a methadone treatment clinic for women in Tehran, Iran

In Iran women are less likely than men to use drugs, but suffer greater morbidity, are stigmatised, and are less likely to seek treatment. In 2007, we established a clinic in Tehran for drug using women. We report here on our study of the 97 women who registered in the first year of operation. We profiled these women: demographics, drug use, risk behaviour, and use of services. The clinic's services were heavily used. We interviewed clients and staff about the clinic and learned that intensive help is needed for women trying to recover from years of drug use. We conclude that female drug users will make use of harm reduction services if they are provided in a setting designed and operated for women.     

How Iranian lay people in three ethnic groups conceptualize a case of a depressed woman: an explanatory model

Objective(s). Although depression is a major public health problem, little is known about lay people's views of this subject in Iran. The aim of this study was to explore how depression in women is viewed among lay people in three major ethnic groups – Kurd, Turk, and Fars.

Design. Participants were selected from public urban healthcare centers. Four focus group discussions were conducted for each of the three ethnic groups and classified by level of education from three locations, in the capital city (Tehran), west (Ilam), and the northwest (Tabriz) of Iran. Twelve focus groups; 38 men and 38 women have been conducted by using a case vignette describing a woman with major depression.

Results. Depression symptoms were perceived as a temporary phenomenon. It was regarded as a colloquial term for feeling blue, mostly related to external stressors (social model). The common terms used in all ethnic groups were depression, and nerve/soul distress. Environmental cause and war were considered as external causes of the symptoms, and emotional factors, cognition distortion, and biological reasons, as internal factors. The participants believed it was necessary to seek help from religion, family and friends, positive thinking, and distraction from social problems, besides consultations with psychologists as counselors. Medication was often seen as the last resort. Stigma was mentioned as an important factor that makes people avoid visiting psychiatrists.

Conclusion. These data may have implications for mental healthcare practice, especially for the approach to diagnosis of depression. Moreover, there is a need for developing and integrating gender-relevant and cultural indicators in the existing national mental health systems in Iran.     

Impact of rosuvastatin use on costs and outcomes in patients at high risk for cardiovascular disease in US managed care and medicare populations: A data analysis

BACKGROUND: High blood cholesterol is a major modifiable risk factor for coronary heart disease (CHD) and stroke. OBJECTIVE: The aim of this study was to estimate the economic impact of rosuvastatin calcium use in patients at high risk for CHD and stroke, according to the National Cholesterol Education Program Adult Treatment Panel (ATP) III guidelines. METHODS: An economic simulation model was developed that used a Markov process to project the number of cardiovascular events and associated costs in a high-risk population in various treatment scenarios. According to the ATP III, high-risk patients are those with CHD, atherosclerosis of peripheral and/or cerebral arteries, diabetes, and/or multiple other risk factors conferring a risk of at least 20% within 10 years. Data on population characteristics and costs of cardiovascular disease (CVD) were obtained from claims data sets from employer-funded commercial and Medicare health plans in the United States. Treatment of lipid disorders was translated into CVD risk reduction based on results from the Heart Protection Study. The estimated efficacies of individual lipid-lowering drugs were based on data published in package inserts. The model generated costs at the health plan level of lipid-lowering therapy in high-risk patients and the number and total costs of cardiovascular events. Estimates were compared for scenarios representing the mix of treatments used before and after the introduction of rosuvastatin. Estimates were generated separately for commercial and Medicare health plans. RESULTS: For every 1 million members of a commercial health plan, an estimated 44,457 met ATP III criteria for high-risk status. Use of rosuvastatin in place of other 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors ("statins") by 11 % of these patients over a period of 5 years was estimated to result in 36 fewer cardiovascular events and a net savings of US 4.03 million dollars. A Medicare plan of 1 million members with an estimated 433,268 high-risk patients and 7% rosuvastatin use was estimated to avoid 727 events and save US 34.32 million dollars. CONCLUSIONS: The results of this data analysis suggest that increasing the use of rosuvastatin can result in cardiovascular event reduction and cost savings. Because the impact of lipid-modifying therapy on cardiovascular risk has not been thoroughly documented in controlled clinical studies, our model assumed that incremental lipid changes had effects in proportion to the magnitude of change.     

Clinical Impact of Thrombophilia Screening in Young Adults with Ischemic Stroke

Objective: We evaluated the ability of genetic and serological testing to diagnose clinically relevant thrombophilias in young adults with ischemic stroke. Methods: We performed a retrospective cohort study of patients aged 18-65 years diagnosed with acute ischemic stroke at a comprehensive stroke center between 2011 and 2015 with laboratory testing for thrombophilia. The primary outcome was any positive thrombophilia screening test. The secondary outcome was a change in clinical management based on thrombophilia testing results. Logistic regression was used to assess whether the prespecified risk factors of age, sex, prior venous thromboembolism, family history of stroke, stroke subtype, and presence of patent foramen ovale were associated with outcomes. Results: Among 196 young ischemic stroke patients, at least 1 positive thrombophilia test was identified in 85 patients (43%; 95% CI, 36%-51%) and 16 (8%; 95% CI, 5%-13%) had a resultant change in management. Among 111 patients with cryptogenic strokes, 49 (44%) had an abnormal thrombophilia test and 9 (8%) had a change in management. After excluding cases of isolated hyperhomocysteinemia or methylenetetrahydrofolate reductase or Factor V Leiden gene mutation heterozygosity, the proportion of patients with an abnormal thrombophilia screen decreased to 24%. Prespecified risk factors were not significantly associated with positive thrombophilia testing or a change in management. Conclusions: Two-of-five young patients with ischemic stroke who underwent thrombophilia screening at our institution had at least 1 positive test but only one-in-twelve had a resultant change in clinical management. Neither cryptogenic stroke subtype nor other studied clinical factors were associated with a prothrombotic state.     

Patterns and frequencies of acquired and constitutional uniparental isodisomies in pediatric and adult B‐cell precursor acute lymphoblastic leukemia

Single nucleotide polymorphism (SNP) arrays are increasingly being used in clinical routine for genetic analysis of pediatric B‐cell precursor acute lymphoblastic leukemias (BCP ALL). Because constitutional DNA is not readily available as a control at the time of diagnosis, it is important to be able to distinguish between acquired and constitutional aberrations in a diagnostic setting. In the present study we focused on uniparental isodisomies (UPIDs). SNP array analyses of 143 pediatric and 38 adult B‐cell precursor acute lymphoblastic leukemias and matched remission samples revealed acquired whole chromosome or segmental UPIDs (wUPIDs, sUPIDs) in 32 cases (18%), without any age‐ or gender‐related frequency differences. Acquired sUPIDs were larger than the constitutional ones (mean 35.3 Mb vs. 10.7 Mb; P < 0.0001) and were more often terminally located in the chromosomes (69% vs. 4.5%; P < 0.0001). Chromosomes 3, 5, and 9 were most often involved in acquired wUPIDs, whilst recurrent acquired sUPIDs targeted 6p, 9p, 9q, and 14q. The majority (56%) of sUPID9p was associated with homozygous CDKN2A deletions. In pediatric ALL, all wUPIDs were found in high hyperdiploid (51–67 chromosomes) cases and an extended analysis, also including unmatched diagnostic samples, revealed a higher frequency of wUPID‐positivity in higher modal number (56–67 chromosomes) than in lower modal number (51–55 chromosomes) high hyperdiploid cases (34% vs. 11%; P = 0.04), suggesting different underlying mechanisms of formation of these subtypes of high hyperdiploidy. © 2016 Wiley Periodicals, Inc.     

New Agents in Treatment of Hyperkalemia: an Opportunity to Optimize Use of RAAS Inhibitors for Blood Pressure Control and Organ Protection in Patients with Chronic Kidney Disease

Purpose of Review

The overactive renin-angiotensin-aldosterone system (RAAS) plays an important part in many pathologic conditions including hypertension, heart failure, and renal disease. Hyperkalemia, a potentially life-threatening side effect of RAAS inhibitors, limits their use. The recent introduction of new hyperkalemia treatments provides opportunities to take full benefit of RAAS inhibitors.

Recent Findings

Optimizing RAAS inhibition is an important therapeutic goal, particularly in chronic kidney disease. Different strategies have been investigated to achieve this goal, including inhibiting the pathway at multiple steps and using maximum or even supramaximal doses. Hyperkalemia is one of the most significant barriers to all of the strategies mentioned above. Up until the recent past, there have been limited therapeutic options available for the prevention and treatment of hyperkalemia in the long term. New promising agents to treat hyperkalemia in outpatient settings, namely, patiromer and sodium zirconium, may provide a solution.

Summary

This article will review the benefits and risks of RAAS inhibitors, strategies to optimize their use, and the new hyperkalemia treatments that can lower the risk associated with RAAS inhibiting therapies.