Pros and cons of the health transformation program in Iran: evidence from financial outcomes at the household level / 한국역학회지

OBJECTIVES: The health transformation program was a recent reform in the health system of Iran that was implemented in early 2014. Some of the program's important goals were to improve the equity of payments and to reduce out-of-pocket (OOP) payments and catastrophic health expenditures (CHE). In this study, these goals were evaluated using a before-and-after analysis.METHODS: Data on household income and expenditures in Guilan Province were gathered for the years 2013 and 2015. OOP payments for outpatient, inpatient, and drug services were calculated, and the results were compared using the propensity score matching technique after adjusting for confounding variables. Concentration indices and curves were added to quantify changes in inequity before and after the reform. The incidence of catastrophic expenditures was then calculated.RESULTS: Overall and outpatient service OOP payments increased by approximately 10 dollars, while for other types of services, no significant changes were found. Inequity and utilization of services did not change after the reform. However, a significant reduction was observed in CHE incidence (5.75 to 3.82%).CONCLUSIONS: The reform was successful in decreasing the incidence of CHE, but not in reducing the monetary amount of OOP payments or affecting the frequency of health service utilization.

Pros and cons of the health transformation program in Iran: evidence from financial outcomes at the household level / 한국역학회지

OBJECTIVES: The health transformation program was a recent reform in the health system of Iran that was implemented in early 2014. Some of the program's important goals were to improve the equity of payments and to reduce out-of-pocket (OOP) payments and catastrophic health expenditures (CHE). In this study, these goals were evaluated using a before-and-after analysis. METHODS: Data on household income and expenditures in Guilan Province were gathered for the years 2013 and 2015. OOP payments for outpatient, inpatient, and drug services were calculated, and the results were compared using the propensity score matching technique after adjusting for confounding variables. Concentration indices and curves were added to quantify changes in inequity before and after the reform. The incidence of catastrophic expenditures was then calculated. RESULTS: Overall and outpatient service OOP payments increased by approximately 10 dollars, while for other types of services, no significant changes were found. Inequity and utilization of services did not change after the reform. However, a significant reduction was observed in CHE incidence (5.75 to 3.82%). CONCLUSIONS: The reform was successful in decreasing the incidence of CHE, but not in reducing the monetary amount of OOP payments or affecting the frequency of health service utilization.

Evaluation of the efficacy of surgery for treatment of septal perforation

Background: The majority of septal perforations are caused by trauma either with or without infection. In most cases trauma is related to the surgery

Methods: Twenty patients with nasal perforation who underwent surgery from 2008 to 2011 were retrospectively evaluated. Three different surgical approaches were used: bilateral rotational advancement flap of nose floor with fascia through open rhinoplasty, bilateral rotational advancement flap of nose floor with using cartilage through closed method and inferior turbinate rotational flap

Results: After the surgery, all symptoms disappeared and examinations of healing regions in fifteen patients showed that the perforation was completely healed. In five patients, the perforation size reduced

Conclusion: Inferior turbinate flap in small perforations would be a logical method with ideal results. In cases with perforation size of one centimeter or larger and in more posterior types, the external method is recommended for a better exposure

Clinical and molecular genetic analysis of Iranian patients with neonatal diabetes demonstrating mutations in KCNJ11 gene

We screened the KCNJ11 gene from 35 individuals clinically diagnosed with type 1 diabetes mellitus under the age of 6 months in 3 years duration. Six different heterozygous missense mutations were found in 7 of the 35 probands, which accounted for 20% of all individuals. A novel mutation W68R [No Locus, GU170814; 2009] was identified in the kir6.2, the pore-forming subunit of the KATP channels from pancreatic beta -cells. Our results demonstrated that activating mutations in KCNJ11 gene could cause Permanent Neonatal Diabetes Mellitus [PNDM] with onset prior to six months

Hypoglossal schowannoma: a case report and review of literature

Schawannomas [neuromas, neurilemmomas] are benign tumors originating from showann cells or nerve fiber sheet cells. They are solitary, encapsulated tumors usually attached to, or surrounded by a nerve. We present a case of left hypoglossal nerve schwannoma in a 19 year old man who was admitted with progressive left tongue atrophy. Schwannoma of the hypoglossal nerve usually develops in the intracranial and extracranial portion or both in the intracranial and extracranial components forming a dumbbell shape tumor .The peripheral hypoglossal schwannomas are extremely rare

Does post septoplasty nasal packing reduce complications?

The main issues in nasal surgery are to stabilize the nose in the good position after surgery and preserve the cartilages and bones in the favorable situation and reduce the risk of deviation recurrence. Also it is necessary to avoid the synechia formation, nasal valve narrowing, hematoma and bleeding. Due to the above mentioned problems and in order to solve and minimize them nasal packing, nasal splint and nasal mold have been advised. Patients for whom the nasal packing used may faced to some problems like naso-pulmonary reflex, intractable pain, sleep disorder, post operation infection and very dangerous complication like toxic shock syndrome. We have two groups of patients and three surgeons [one of the surgeons used post operative nasal packing in his patients and the two others surgeons did not].Complications and morbidities were compared in these two groups. Comparing the two groups showed that the rate of complication and morbidities between these two groups were same and the differences were not valuable, except the pain and discomfort post operatively and at the time of its removal. Nasal packing has several risks for the patients while its effects are not studied. Septoplasty can be safely performed without postoperative nasal packing. Nasal packing had no main findings that compensated its usage. Septal suture is one of the procedures that can be used as alternative method to nasal packing. Therefore the nasal packing after septoplasty should be reserved for the patients with increased risk of bleeding

Epidemiologic and clinicopathologic characteristics of tongue cancer in Iranian patients

Oral cancer is considered a great threat to public health. Tongue cancer accounts for nearly 30% of all oral cancers and usually seen in 50 to 60 year old men. Oropharyngeal cancers account for 3% of all cancers in Iran; as reported in 2003. The present study was designed to assess the epidemiologic and Clinicopathologic characteristics of tongue cancer patients in two Tehran's referral university hospital between the years 2003 and 2008. In a retrospective study 87 files of patients, diagnosed with tongue cancer who were referred to Imam Khomeini and Loghman Hospitals and Iranian Cancer linstitute in Tehran-Iran from 2003 to 2008 were reviewed. Participants were selected from all the patients who had a record of their specimens in the pathology ward registry and their tongue cancer diagnosis was confirmed by a expert pathologist. Patients characteristics [age, gender and presence of risk factors] and chief complain at the time of diagnosis and their tumor related data [type of cancer, staging, grading, morphology and location of tumor] were recorded. Tongue cancer was most frequently seen in the eighth decade of life among both men and women, but had the lowest frequency among patients with less than 40 years of age. Squamous cell carcinoma had the highest prevalence in our patients. Tongue cancer was the most common cancer of oral cavity among Iranian patients and similar epidemiologic and chnicopathological characteristics of the disease were found in our patients. Assessing variables such as socioeconomic levels and religious believe require further studies with large sample sizes

[ case of subglotitic adenoid cystic carcinoma and medical literature review]

Adenoid cystic carcinoma [ACC] is the second most common salivary glands tumor and the most common malignant tumor of minor salivary glands and also submandibular glands; however ACC of the larynx and trachea is rare. These tumors generally present in subglottic region as smooth submucosal solid mass without ulceration. Their primary symptoms are often as respiratory problems. This study was done on a woman, 54 years, with subglottic ACC that presented with exertional dyspnea, stridor, cough and hoarseness. After confirmation of diagnosis with biopsy, the patient underwent a total laryngectomy and then postoperative radiotherapy. During one year follow up, the patient did not show any evidence of local recurrence or distant metastasis. Surgery with free margins in combination with postoperative radiotherapy was recommended to treat laryngeal ACC in order to obtain better survival

Neuro-otologic manifestations of multiple sclerosis

Multiple sclerosis [MS] has numerous neurologic signs and symptoms, including hearing impairment. The reports concerning the type and severity of hearing loss in MS patients vary and little is known about an association of the disease characteristics with changes in hearing status. To find the otologic and neuro-otologic manifestations of MS with the use of routine hearing assessment tools. The presence of neuro-otologic signs and symptoms were studied in 30 patients diagnosed with MS. Patients underwent pure tone audiometry, speech audiometry and acoustic brain stem response [ABR] tests. The results were compared with 30 healthy age and sex matched controls. The most common finding was sensory-neural hearing loss followed by dizziness and nystagmus. The shape of the audiogram and severity of hearing loss was associated with both chronicity and disease activity. There were abnormal latencies in ABR waves which were more significant with high velocity stimulus. Hearing status deserves careful attention in MS patients. It may be used as a diagnostic means or an indicator for evaluating the characteristics of the underlying disease

Sinonasal hemangiopericytoma: a case report

Hemangiopericytoma is a vascular tumor that is rarely seen in the nose and paranasal sinuses. Biological behavior of these tumors is not completely known, and their natural history is not predictable. This case report presents a patient with a sinonasal hemangiopericytoma. Diagnosis and management of these uncommon tumors is discussed

[Treatment of carotid paraganglioma: review of a 15 - years experience]

Carotid body tumor is a highly vascular mass occurring between the origins of the internal and external carotid arteries, and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of this tumor. 16 patients with carotid paragonglioma were treated in our institution during a period of 15 years. There were 12 women and 4 men with a mean age of 44 years. A slow growing painless lateral neck mass was the main finding in all patients. There was no evidence of a functional or malignant tumor. Carotid angiography and CT scan with contrast was performed in near all patients to define the vascular anatomy of the lesion. None of them underwent embolization. Complete tumor resection was done in all patients vascular reconstruction was necessary in two patients. Hypoglossal nerve was sacrificed in one patient and transient marginal nerve deficit was existed in one. No stroke occurred. High index of suspicion and earlier detection by radiologic finding and early surgical resection by an experienced team offer a safe and effective method for complete excision of tumor with a reduced morbidity rate

[Rigid fixation to prevent iatrogenic septal deviation]

This and similar studies show that surgeons can not rely on the immediate effect of scoring on the cartilage at the operation period. A straight septum on the operating table may deviate toward the opposite side by passing time. During a period of 5 years, 283 cases have undergone rhinoplasty and in 227 patients, septoplasty accompanied the operation. Patients were divided into two groups of 125 and 158 cases. In the first group, septal deviation was corrected mainly by cross hatching of the quadrilateral cartilage accompanied by other modalities. In latter group, who were operated on recently, different methods of rigid fixation of septum in addition to the previous classic manner were used. The outcome was over correction of septum toward the opposite side in 18 cases of the first group. No more iatrogenic over correction of septum was diagnosed in the second group, [P<0.0001]. We recommend rigid fixation for correction of septal deviation instead of simple cross notching

[Etiologic evaluation and treatment progress in necrotizing fasciitis of the head and neck]

Necrotizing fasciitis is an overwhelming infection common to perineum, abdominal wall, and extremities. It is a surgical emergency related to a high mortality rate that is more often seen in elderly and immunocompromised patients. Necrotizing fasciitis occurs uncommonly in the head and neck region. A retrospective study conducted on fasciitis necrotizing patients that were treated at Ghaem hospital since 2002-2005. Over a 4-year period, 4 cases of necrotizing fasciitis of the head and neck region collected at Ghaem hospital. The demographic, predisposing factors, clinical presentation and management were analyzed. The most common associated systemic disease was diabetes. Local swelling and erythematous changes was the most common sign. The cornerstones of proper management include early diagnosis, aggressive surgical debridement, broad-spectrum antibiotics and intensive supportive care. Necrotizing fasciitis mostly occurs in old patients with systemic disease specially diabetes mellitus which the common cause was dental infection

[Thick nasal skin 4 years experience with a proposed technique]

Soft tissue thickness over the tip of the nose varies considerably between patients, subcutaneous fat being thickest in the supratip area. Fat nose is a challenging issue to manage, and surgeons have not found the ultimate solution to handle this problem during the evolution of rhinoplastic surgery. Due to multiplicity of techniques and controversies published in literature, it becomes confusing for the operating surgeon to find the most appropriate and effective way of solving this frustrating dilemma. The focus of this paper is to introduce a new procedure for reducing the overlying soft tissue of nasal tip for better re-draping of skin over the nasal skeleton. The hallmark of this technique is to undermine the nasal skin in two layers. We believe that soft tissue trimming in biplane dissection, described in the paper, can minimize the thickness of the tip skin in a safe and homogenous manner. In this paper we have demonstrated a new dissection method of nasal soft tissue and trimming it in different areas of the nose for different purposes. In the authors' opinion this approach is one of the most effective way of handling unpliable thick nasal skin

[Halitosis and its treatment]

Halitosis is a general term used to describe an unpleasant offensive odor emanating from the oral cavity. Under normal conditions, breathing has a special and not a bothering odor, which is called human odor. Around 90% of all the causes of bad breath originate from the oral cavity, and more specifically, it has been reported that around 40% come from the dorso-posterior region of the tongue. Moreover, nonoral pathologic conditions, including upper and lower respiratory tract and gastro-intestinal infections, as well as some metabolic diseases, have also been identified as halitosis-inducing factors. Oral cavity malodor can be attributed to a variety of products arising from bacterial amino acids' metabolism. These metabolites include many compounds, such as indole, skatole and volatile sulfur compounds, like methyl mercaptan, hydrogen sulfide, dimethyl sulfide, which are the main components of bad breath originating from the oral cavity. The microorganisms that contribute to halitosis include gram negatives, anaerobes, klebsiella, and bacteroids. Local pathologic factors like poor oral hygiene, chronic gingivitis, dental caries, dental plaques, malignancies of the oral cavity and surrounding tissues, tonsillar chronic infections, foreign bodies in tonsils or oral cavity, fissured tongue and sino-nasal diseases can also induce halitosis. In addition, systemic pathologic etiologies like lower respiratory tract infections, gastro-intestinal disorders, blood dyscrasias, diabetes, liver cirrhosis, renal failure, vitamin deficiencies, especially vitamin C deficiency, and some drugs can cause halitosis. Local non-pathologic factors, such as smoking, dental prosthesis, saliva stasis, and systemic non-pathologic ones, like pregnancy, menstruation, menopause, fasting, old age, and some foods can bring about malodorous breath. Old age, salivary gland aplasia, diabetes, menopause, bad oral and dental hygiene, and spices can cause mouth dryness and reduce salivary flow and mouth washing, hence leading to a foul-smelling mouth. Complete and close physical examination and history taking can guide the physician toward the diagnosis and help to find the exact cause of halitosis. Bad odors of short time duration are mainly caused by infections, severe systemic diseases, foreign bodies, or recent drug therapy. In contrast, majority of long-lasting bad odors are due to poor oral hygiene, malignancies of the oral cavity or surrounding tissues, respiratory tract, or bronchiectasis. Intake of some foods and sleeping may result in intermittent halitosis. Eradication of halitosis inducing factors is the first step toward problem solving. Besides, care of the oral hygiene, teeth, gums, tongue brushing, and dental flossing help to overcome bad breath originating from the oral cavity

Auditory acuity throughout the menstrual cycle

A prospecitve study was perfomed to evaluate changes in the auditory acuity by pure tone audiometry [PTA] and speech reception threshold [SRT] that might occure in healthy women throughout the menstrual cycle. Forty women with regular ovulatory menstrual cycles underwent PTA and SRT during the follicular, periovulatory, and luteal phases of the menstrual cycle. No significant auditory perception changes by PTA or SRT was detected during different phases of menstrual cycle. Since hearing acuity seems to be influenced by the variations of ovarian steroids that occur during the menstrual cycle, further studies on more cases is recommended to confirm or rule out these probable changes

[Peripheral blood monocytes responsiveness in aggressive periodontitis patients by comparison of Interleukin-6 production before and after stimulation by E. Coli lipopolysacharide]

Results of other studies suggests that hyper-responsiveness of monocytes to the products of dental plaque especially the endotoxin of Gram negative bacteria and secretion of high levels of pro-inflammatory cytokines may have a role in the pathogenesis of AP. To investigate this possibility, we evaluated the IL-6 production by cultured peripheral blood monocytes before and after stimulation by E.coli lipopolysacharide [LPS] in AP patients and healthy controls. Fifteen patients with AP were compared to 15 periodontal healthy controls in a case control study. Mononuclear layer was obtained from peripheral blood samples and monocytes were isolated and cultured. The reaction of monocytes was studied by IL-6 production before and 6 hours after stimulation by 0.1 micro g/ml E.coli. LPS. The IL-6 concentration in the culture supernatant was measured with ELISA [Enzyme linked Immunosorbent Assay]. Wilcoxon and Mann-Whitney U-tests were used to compare the groups. There was no significant difference in IL-6 production levels before LPS stimulation between patients and controls [P = 0.5]. The IL-6 production after LPS stimulation in the patients was higher than controls, and the difference approached the significance threshold [P = 0.07]. However, the increase in the IL-6 production as a result of LPS stimulation was significantly higher in patients compared to controls [P = 0.029]. Our results suggest that increase in monocyte responsiveness may play a potential role in the pathogenesis of AP. Elevation in cytokines elicited at the site of infection in response to a minimal bacterial challenge can exert significant effects locally and systemically. An over aggressive immune response can provide the basis of explanation for the observed severe tissue damage. and bone loss in periodontium, familial nature of aggressive periodontitis and other immunological findings associated with the pathogenesis of this disease. Future investigations through longitudinal monitoring of monocyte responsiveness over time and following successful treatment are required to elucidate the role of this phenomenon in the pathogenesis of periodontitis

Evaluation of effect of topical phenytoin on wound healing [increasing wound tensile strength and collagen deposition] in rats

Background: Delyed healing and dehiscence of operative wounds represent a significant clinical problem. Sporadic reports indicate that phenytoin may significantly promote wound healing following topical application

Material and Methods: Ten male rats each received 4 dorsal skin incisions and were sutured immediately on proliferative and early maturation phase. The incisions were infiltrated with phenytoin or normal saline for controls randomly. The wounds were harvested 18 days after wounding and were assessed by tensiometric measurement and microscopic examination. Data was expressed as mean [sd] and were analysed using student's paired T test

Results: Application of phenytoin, in both proliferative and maturation phases, resulted in a significant increase in wound tensile strength [34.16[8.15] N and 32.18 [7.43] N in treated wound versus 28.58 N and 26.7[4.93] N controls respectively, n = 20; P<0.01]. Application of phenytoin in these two phases had no difference. The rise in wound tensile strength was associated with increase in wound collagen deposition

[Giant fibrovascular polyp of the hypopharynx and esophagus; a report of one case]

Fibrovascular polyp is a benign a benign and very rare tumor in the hypopharynx and esophagus. It is more common in elderly men. This lesion, in spite of its large size, could be asymptomatic for a long time. We are reporting here a 65 - year - old woman with this tumor from the ENT Department of Ghaem Hospital, Mashhad. IT may be the first reported case in Iranian publications. Her chief complain which brought her to us was feling a mass in the oral cavity upon straining

[ one year clinical study on the frequency of odontogenic sinusitis at ENT department of Ghaem Hospital in Mashhad]

Introduction: although odontogenic sinusitis is a rare entity when compared to the sinus diseases of rhinogenic origin, it is extremely important to identify a dental etiology when it occurs. The offending tooth or teeth would thus require endodontic treatment or extraction, and the sinus disease should carefully be assessed and appropriately managed. In the patients with pain and tenderness on the maxillary sinuses, odontogenic origin is suspicious

Materials and Methods: this is a one-year retrospective study on 38 patients followed in the ENT ward of Ghaem Hospital, Mashhad University of Medical Sciences. Most of patients were 20-30 years old

Results: In all, sinusitis was most common in ethmoid and maxilla, with the symptoms of mostly nasal obstruction and postnasal discharge in the last 3-6 years. 5 patients out of 38 [13.2%] had odontogenic sinusitis. An important point is that patients who had sinusitis with odontogenic origin were older than 35 years [more than the average age of these 38 patients]. Their most complaints were a local pain and tenderness on their cheek and upper jaw

Conclusion: an exact attention to the patient with complaints of pain and tenderness on the maxillary sinus sometimes reveals the odontogenic origin for the sinusitis. In these cases, a close cooperation between the ENT specialist and the dentist is an essential factor