A partnership model to improve population health screening for noncommunicable conditions and their common risk factors, Qazvin, Islamic Republic of Iran.

Early findings and management of health conditions are among the key functions of health care systems. We developed a partnership framework to establish an extended primary health care-based selective screening service for the entire population of a small town as a key project of Qazvin Health Plan, Qazvin, Islamic Republic of Iran. Eight scientific associations and a diverse technical taskforce extensively reviewed evidence to adapt the grade A and B preventive recommendations of the American Preventive Service Taskforce. A list of 15 priority health conditions was identified and screening protocols were developed accordingly. Then strategies for working with private sector providers for better health care were applied to form our partnership model through which we ensured provision of screening services in 3 areas: service provision, quality and costs. Six private medical offices and a laboratory cooperated with the public health centre of the town to screen eligible residents. Preliminary analysis of the results suggests that the framework has successfully engaged private care providers.

A partnership model to improve population health screening for noncommunicable conditions and their common risk factors, Qazvin, Islamic Republic of Iran

Early findings and management of health conditions are among the key functions of health care systems. We developed a partnership framework to establish an extended primary health care-based selective screening service for the entire population of a small town as a key project of Qazvin Health Plan, Qazvin, Islamic Republic of Iran. Eight scientific associations and a diverse technical taskforce extensively reviewed evidence to adapt the grade A and B preventive recommendations of the American Preventive Service Taskforce. A list of 15 priority health conditions was identified and screening protocols were developed accordingly. Then strategies for working with private sector providers for better health care were applied to form our partnership model through which we ensured provision of screening services in 3 areas: service provision, quality and costs. Six private medical offices and a laboratory cooperated with the public health centre of the town to screen eligible residents. Preliminary analysis of the results suggests that the framework has successfully engaged private care providers

Le dépistage précoce des maladies est l'une des fonctions centrales des systèmes de soins de santé. La présente étude a mis au point un cadre afin d'établir un service de dépistage sélectif pour l'ensemble de la population d'une petite ville comme projet clé du Plan sanitaire de Qasvin. Les données locales et nationales ont été examinées en détail afin d'adapter les recommandations de prévention prioritaires des niveaux A et B du US Preventive Services Taskforce [Groupe de travail sur les services de prévention des Etats-Unis].Une liste de 15 affections chroniques, les tests de dépistage associés et leurs intervalles ont été établis en fonction. Par la suite, un ensemble de stratégies éprouvées visant à mieux collaborer avec les prestataires de soins privés a été utilisé pour concevoir un modèle de partenariat grâce auquel des services couverts par une assurance pour le dépistage, le suivi et de prise en charge des maladies seraient créés et financés. Six cabinets médicaux privés et un laboratoire ont coopéré avec le seul centre de santé publique de la ville pour sélectionner les résidents éligibles. L'analyse préliminaire des résultats laisse penser que le cadre a permis d'impliquer les prestataires de soins privés

Ways to improve the current performance of the boards of trustees of medical universities in iran.

BACKGROUND: Establishment of boards of trustees for all universities was legalized in 1988. It is crucial to assess the performance of the boards and to adjust them to the mandates raised by new visions of the country. METHODS: Subjects were members of boards of trustees and officers in charge of board's affairs at medical universities. Furthermore, a sample of 860 resolutions adopted by the boards was selected to assess the state of their enforcement. RESULTS: About 70% of the resolutions addressed have been enforced. There is a consensus on focusing on policy-making and high supervision on the objectives of the institutes rather than other areas. Furthermore, ways suggested improving the performance of the boards. CONCLUSION: Despite the rather high enforcement rate of the resolution in the past ten years, several interventions are suggested to improve the current performance of the boards of trustees and to meet new directions.

Health in the 5th 5-years Development Plan of Iran: Main Challenges, General Policies and Strategies.

Access to the right to the highest attainable level of health is a constitutional right that obliges governments and other players to take step to increase all individuals' chances of obtaining good health. At the least, health and education are two crucial requirements for this as well. Iran's vision 2025 is going to lead the country to a developed state with the highest rank of economic, scientific and technological status in the region. Enjoying health, welfare, food security, social security, equal opportunities, etc, are also considered as part of characteristics of Iranian society in 2025. Although health system of Iran has many achievements in providing health services specially for the poor following the Islamic Revolution of 1979, but the evidences gathered to develop the 5(th) 5-years economical, social and cultural plan (5(th)5YDP:2011-2015), listed a variety of main challenges in stewardship, financing, resources generation and service provision functions of the existing health system. Thus, to overcome the main challenges, about 11% of general policies of 5(th)5YDP are directly address health related issues with emphasizing on healthy human and comprehensive health approach with considering: Integration of policy making, planning, evaluation, supervision and public financing; Developing both quantity and quality of health insurance system and reducing out-of-pocket expenditures for health services to 30% by the end of the 5th plan. The strategies of 5(th)5YDP adopted by the parliament as an Act will change the health system fundamentally through tuning the main drivers; so, its implementation needs brave leaders, capable managers, motivated technical staff and social mobilization.

Health observatories in iran.

BACKGROUND: The Islamic Republic of Iran, in her 20 year vision by the year 2025, is a developed country with the first economic, scientific and technological status in the region, with revolutionary and Islamic identity, inspiring Islamic world, as well as effective and constructive interaction in international relations. Enjoying health, welfare, food security, social security, equal opportunities, fair income distribution, strong family structure; to be away from poverty, corruption, and discrimination; and benefiting desirable living environment are also considered out of characteristics of Iranian society in that year. Strategic leadership towards perceived vision in each setting requires restrictive, complete and timely information. According to constitution of National Institute for Health Researches, law of the Fifth Development Plan of the country and characteristics of health policy making, necessity of designing a Health Observatory System (HOS) was felt. Some Principles for designing such system were formulated by taking following steps: reviewing experience in other countries, having local history of the HOS in mind, superior documents, analysis of current production and management of health information, taking the possibilities to run a HOS into account. Based on these principles, the protocol of HOS was outlined in 3 different stages of opinion poll of informed experts responsible for production on management of information, by using questionnaires and Focus Group Discussions. The protocol includes executive regulations, the list of health indicators, vocabulary and a calendar for periodic studies of the community health situation.

A province-based surveillance system for the risk factors of non-communicable diseases: A prototype for integration of risk factor surveillance into primary healthcare systems of developing countries.

OBJECTIVES: To establish a surveillance system for risk factors of non-communicable diseases, develop a valid tool and methodology for surveillance surveys, and build capacity in 41 provincial surveillance sites to design and conduct the surveys and provide provincially interpretable baseline data. STUDY DESIGN: Population-based national study. METHODS: The World Health Organization's STEPwise approach to non-communicable disease surveillance was adapted to design a national risk factor surveillance model. The first national population-based and cross-sectional study was conducted in 2005 in 41 universities of medical sciences in all 30 provinces of Iran. This involved multi-stage cluster sampling from 25-64 year-old Iranians and non-institutionalized populations. A national technical unit at the Ministry of Health and Medical Education supervised all study processes including data management and analysis. RESULTS: From the national results, the survey estimated that the prevalence of daily current smoking was 17.9%. Of the target population, 5% consumed at least five combined servings of fruit and vegetables per day. The median daily time spent undertaking transport-related physical activity (43.8 min) was significantly higher than the median time spent on work-related physical activity (27.5 min) or recreational physical activity (28.6 min). Overall, 54.7% of the target population were overweight or obese, and waist circumference was greater among women than men. The prevalence of hypertension was 23.8%, with a higher prevalence among women than men. In addition, 6% of the target population had a high fasting blood glucose (> or =126 mg/dl), and 45.1% had a total cholesterol level of at least 200 mg/dl. CONCLUSION: Integration of province-based surveillance activities into the Iranian primary healthcare system is feasible. Provincial reports could provide a baseline picture of the most important risk factors for non-communicable diseases. There are several important risks with a prominent burden that may cause a progressive epidemic of major non-communicable diseases in the future in the absence of quality interventions.

Targeted ultrasound contrast agent for molecular imaging of inflammation in high-shear flow.

Targeted ultrasound contrast materials (gas-filled microbubbles carrying ligands to endothelial selectins or integrins) have been investigated as potential molecular imaging agents. Such microbubbles normally exhibit good targeting capability at the slower flow conditions. However, in the conditions of vigorous flow, binding may be limited. Here, we describe a microbubble capable of efficient binding to targets both in slow and fast flow (exceeding 4 dyne/cm(2) wall shear stress) using a clustered polymeric form of the fast-binding selectin ligand sialyl Lewis(X). Microbubbles were prepared from decafluorobutane gas and stabilized with a monolayer of phosphatidylcholine, PEG stearate and biotin-PEG-lipid. Biotinylated PSLe(x) (sialyl Lewis(X) polyacrylamide) or biotinylated anti-P-selectin antibody (RB40.34) was attached to microbubbles via a streptavidin bridge. In a parallel plate flow chamber targeted adhesion model, PSLe(x) bubbles demonstrated specific adhesion, retention and slow rolling on P-selectin-coated plates. Efficiency of firm targeted adhesion to a P-selectin surface (140 molecules/microm(2)) was comparable for antibody-carrying bubbles and PSLe(x)-targeted bubbles at 0.68 dyne/cm(2) shear stress. At fast flow (4.45 dyne/cm(2)), PSLe(x)-targeted bubbles maintained their ability to bind, while antibody-mediated targeting dropped more than 20-fold. At lower surface density of P-selectin (7 molecules/microm(2)), targeting via PSLe(x) was more efficient than via antibody under all the flow conditions tested. Negative control casein-coated plates did not retain bubbles in the range of flow conditions studied. To confirm echogenicity, targeted PSLe(x)-bubbles were visualized on P-selectin-coated polystyrene plates by ultrasound imaging with a clinical scanner operated in pulse inversion mode; control plates lacking targeted bubbles did not show significant acoustic backscatter. In vivo, in a murine model of inflammation in the femoral vein setting, targeting efficacy of intravenously administered PSLe(x)-microbubbles was comparable with targeting mediated by anti-P-selectin antibody, and significantly exceeded the accumulation of non-targeted control bubbles. In the inflamed femoral artery setting, PSLe(x)-mediated microbubble targeting was superior to antibody-mediated targeting.

Coagulation cascade, fibrinolytic system, antithrombin III, protein C and protein S in patients maintained on continuous ambulatory peritoneal dialysis.

We studied the coagulation cascade, fibrinolytic system and naturally occurring anticoagulants in a group of 14 patients with end-stage renal disease maintained on continuous ambulatory peritoneal dialysis (CAPD). The results were compared with those obtained in a group of ten normal volunteers. Plasma procoagulant activities of factors XII, XI, IX, VIII, VII, X and II were significantly greater in the CAPD group as compared to the normal control group. Likewise plasma concentrations of total and free protein S were increased in the CAPD group. Although the mean value for plasma factor V activity in the CAPD group was higher than that found in the control group the difference did not attain statistical significance. In addition plasma fibrinogen concentration and factor VIII-related antigen level were significantly increased in CAPD patients. No significant difference was found between the CAPD patients and the control group with respect to plasma levels of protein C, antithrombin III, plasminogen or alpha 2-antiplasmin. In summary, the results demonstrate a tendency for increased levels of various coagulation factors and protein S in CAPD patients with no significant alterations in the levels of various fibrinolytic and endogenous anticoagulant agents, i.e. antithrombin III and protein C. The clinical significance and the mechanism responsible for the observed changes require further investigation.

Increased levels of protein C activity, protein C concentration, total and free protein S in nephrotic syndrome.

Plasma protein C (PC) antigen concentration has been shown to be normal or increased in patients with proteinuria. However, the available data concerning PC anticoagulant activity in nephrotic syndrome (NS) are limited. We measured plasma PC antigen concentration. PC anticoagulant activity, total and free protein (PS) concentrations, and antithrombin III (AT-III) antigen concentration in 21 adult patients with NS. The results were compared with those obtained in a control group of normal volunteers. PC antigen concentration and its anticoagulant activity were significantly increased in the NS group when compared with the normal control group. Likewise, plasma total and free PS values were significantly higher in the NS patients than the corresponding values found in the control group. In contrast, plasma AT-III antigen concentration was significantly reduced in patients with NS. A negative correlation was found between plasma PC and AT-III levels. These observations suggest that increased plasma PC concentration and anticoagulant activity in NS may afford some protection against the thrombotic diathesis associated with antithrombin deficiency and other coagulation abnormalities in this otherwise hypercoagulable state.

Hypomagnesemia and renal magnesium wasting in renal transplant recipients receiving cyclosporine.

Following the adoption and use of cyclosporine as the drug of choice in the management of renal allograft recipients, several cases of symptomatic hypomagnesemia were noted. These observations prompted the current prospective study of serum concentration and urinary excretion of magnesium in 27 renal transplant recipients treated with cyclosporine and prednisone. Relevant laboratory measurements were obtained shortly before and regularly after transplantation. The results were compared with those obtained in a group of 17 allograft recipients treated with azathioprine and prednisone. The cyclosporine-treated patients showed a significant reduction in the serum magnesium concentration and an inappropriately increased urinary excretion and fractional excretion of magnesium, suggesting renal magnesium wasting. The observed hypomagnesemia required magnesium supplementation in nearly all cyclosporine-treated patients. In contrast, azathioprine-treated patients showed normal serum magnesium concentrations and required no magnesium supplementation. In conclusion, administration of cyclosporine in renal allograft recipients appears to be commonly associated with renal magnesium wasting and hypomagnesemia. Therefore, it is recommended that serum levels of magnesium be monitored regularly in renal allograft recipients receiving cyclosporine and that magnesium supplementation be employed as needed to avoid magnesium depletion.

Extrinsic and common coagulation pathways in end-stage renal disease associated with spinal cord injury.

Data on the effects of combined long-standing spinal cord injury (SCI) and end-stage renal disease (ESRD) on blood coagulation system are limited. We studied the extrinsic and common pathways of blood coagulation system in 9 men with SCI-ESRD treated with maintenance hemodialysis. Plasma procoagulant activities of factors (F)VII, X and II were measured in a clotting assay using appropriate deficient plasmas as substrate. In addition, the antigen concentration of FII was measured using monospecific antibodies against human FII raised in goat in a gradient plate immunodiffusion system. Also measured were plasma fibrinogen concentration and platelet count. The results were compared with those obtained in a group of 10 ambulatory ESRD patients and 8 normal control volunteers. Plasma coagulant activity of FVII was markedly elevated and plasma fibrinogen concentration was moderately increased in SCI-ESRD patients. In contrast, plasma FII was mildly depressed while platelet count was within normal limits in SCI-ESRD patients. The data indicate that the combination of SCI and ESRD can lead to the alteration of the extrinsic and common coagulation pathways. Further studies are needed to elucidate the precise mechanism and the clinical significance of the observed abnormalities.

Activation of intrinsic coagulation pathway in pre-eclampsia.

Disseminated intravascular coagulation, thrombocytopenia, consumption of factors VIII and II, and antithrombin deficiency have been previously demonstrated in pre-eclampsia. However, the precise mechanism responsible for initiation of disseminated intravascular coagulation has not been elucidated. The present study documents activation of the intrinsic coagulation pathway in a patient with severe pre-eclampsia. The studies revealed marked reductions of plasma coagulant activities of all intrinsic pathway factors, i.e., XII, XI, IX, and VIII. In addition, the ratio of plasma factor XII activity to antigen concentration was markedly abnormal, and plasma high-molecular-weight kininogen concentration was diminished. It is suggested that activation of the intrinsic coagulation pathway may be operative in the genesis of disseminated intravascular coagulation in pre-eclampsia.

Antithrombin deficiency in end-stage renal disease associated with paraplegia: effect of hemodialysis.

Plasma antithrombin III activity and concentration were determined in nine men with end-stage renal disease (ESRD) associated with spinal cord injury (SCI). To determine the possible effects of hemodialysis measurements were repeated following dialysis. Values obtained in the SCI-ESRD group were compared with those obtained in a group of healthy volunteers and a group of 10 ambulatory men with ESRD. A normal pooled plasma was used as the internal standard for all assays. While antithrombin deficiency was observed in both uremic groups it was most severe in the group with SCI. Results demonstrated the association of antithrombin deficiency with ESRD and its potentiation in the presence of SCI. The mechanisms by which SCI compounds the uremia-induced antithrombin deficiency were not known. A mild increase in antithrombin level was noted following dialysis and was thought to be in part due to fluid removal by dialysis.

Intrinsic coagulation pathway in end-stage renal disease associated with spinal cord injury treated with hemodialysis.

Plasma procoagulant activities of factors XII, XI, IX, and VIII and plasma concentrations of factor XII antigen and high molecular weight kininogen (HMK) were determined in nine men with chronic renal failure (CRF) associated with long-standing spinal cord injury (SCI) treated with hemodialysis. The results were compared with those obtained in a group of 10 ambulatory CRF patients and 8 normal volunteers (control group). Congenitally deficient plasmas were used as the substrate for the measurement of procoagulant activities in a one-stage clotting assay. Monospecific antibodies were employed in the measurement of factor XII antigen and HMK using gradient plate immunodiffusion and rocket immunoelectrophoresis. Factor XII coagulant activity and antigen concentration were significantly increased in the SCI group. The mean values for plasma factor XI and IX activities in the SCI group were comparable with those observed in the ambulatory patients and normal control group. However, marked variations in factor XI and IX levels were noted among the SCI patients with a few instances of mild to moderate factor deficiencies and several cases of markedly elevated levels. Factor VIII activity was markedly increased, with only two of the nine patients exhibiting normal values. HMK concentration in the SCI group was comparable with values obtained for the other groups. Following dialysis, factor XII antigen concentration rose and factor XI activity fell slightly but significantly. The results indicate that the combination of CRF and long-standing SCI is associated with marked aberrations of intrinsic coagulation pathway. The underlying mechanisms and the clinical consequences of these abnormalities are not known and require further investigation.

Coagulation abnormalities in patients with end-stage renal disease treated with hemodialysis.

Plasma levels of various blood coagulation factors, antithrombin III and plasminogen were measured in 18 patients with end-stage renal disease treated by longterm hemodialysis. The results were compared with those obtained in a group of normal volunteers. Factors XII, IX and II activities were significantly reduced; factors VIII, VII and X levels were increased; and factors XI and V activities and high molecular weight kininogen concentration were comparable to the control group. Antithrombin III activity and concentration were significantly reduced. The mean plasma fibrinogen concentration was normal although levels above and below normal limits were noted in a few patients. Similarly the mean platelet count was normal, although mild thrombocytopenia occurred in several patients and thrombocytosis in one. In conclusion, the present study confirms published results about factor VIII and AT-III, and provides new information on changes of other coagulation factors in uremia treated by long-term hemodialysis.

Acquired deficiency and urinary excretion of antithrombin III in nephrotic syndrome.

The published data concerning changes of antithrombin III (ATIII) in nephrotic syndrome (NS) are contradictory. While increased ATIII activity has been reported by some investigators, decreased concentration has been shown by others and normal values by yet another group of authors. We determined plasma and urine concentrations of ATIII in a group of 20 patients with NS using an immunologic assay. In addition, plasma ATIII activity was determined. The results were compared with those obtained in a group of normal volunteers. Plasma concentration and activity of ATIII were both greatly reduced in the patients with NS. In addition, substantial quantities of ATIII were recovered in the urine of all tested patients. The present study, therefore, substantiates the low plasma concentrations of ATIII and its urinary losses in NS. In addition, a parallel reduction in plasma ATIII activity is demonstrated providing functional evidence of acquired ATIII deficiency in this condition.

Urinary excretion and deficiency of prothrombin in nephrotic syndrome.

Plasma and urinary prothrombin concentration and plasma prothrombin activity were measured in a group of 17 patients with the nephrotic syndrome. An immunologic assay using a monospecific antibody against human prothrombin was employed in the measurement of prothrombin concentration in the plasma and urine. Prothrombin-deficient plasma was used as the substrate in the measurement of plasma prothrombin activity. A control group consisting of five normal volunteers was included for comparison. Both the activity and concentration of prothrombin were significantly lower in the nephrotic group as compared with the control group. Significant quantities of immunoreactive prothrombin were detected in the urine of the majority of nephrotic patients. This study has provided unequivocal evidence of urinary excretion and acquired deficiency of prothrombin in the nephrotic syndrome.

Effect of hemodialysis on contact group of coagulation factors, platelets, and leukocytes.

Earlier reports have suggested possible activation and consumption of factor XII during hemodialysis. To investigate this possibility, a series of in vivo and in vitro experiments were conducted using different dialysis membranes and two different dialysates (acetate and bicarbonate). Factors XII and XI activities, factor XII concentration, and high-molecular-weight kininogen were measured. In addition, platelet count, white blood cell count, and hematocrit were monitored. Contrary to the previous reports, no discernible consumption of factor XII, factor XI, or high-molecular-weight kininogen was found irrespective of the type of membrane or the composition of the dialysate used. Transient leukopenia was noted with cellulosic membranes, whereas none occurred with polyacrylonitrile dialyzers. The composition of dialysate did not affect the white blood cell count during dialysis.