Non-COVID-19 hospitalization and mortality during the COVID-19 pandemic in Iran: a longitudinal assessment of 41 million people in 2019-2022.

BACKGROUND: During a COVID-19 pandemic, it is imperative to investigate the outcomes of all non-COVID-19 diseases. This study determines hospital admissions and mortality rates related to non-COVID-19 diseases during the COVID-19 pandemic among 41 million Iranians. METHOD: This nationwide retrospective study used data from the Iran Health Insurance Organization. From September 23, 2019, to Feb 19, 2022, there were four study periods: pre-pandemic (Sept 23-Feb 19, 2020), first peak (Mar 20-Apr 19, 2020), first year (Feb 20, 2020-Feb 18, 2021), and the second year (Feb 19, 2021-Feb 19, 2022) following the pandemic. Cause-specific hospital admission and in-hospital mortality are the main outcomes analyzed based on age and sex. Negative binomial regression was used to estimate the monthly adjusted Incidence Rate Ratio (IRR) to compare hospital admission rates in aggregated data. A logistic regression was used to estimate the monthly adjusted in-hospital mortality Odds Ratio (OR) for different pandemic periods. RESULTS: During the study there were 6,522,114 non-COVID-19 hospital admissions and 139,679 deaths. Prior to the COVID-19 outbreak, the standardized hospital admission rate per million person-month was 7115.19, which decreased to 2856.35 during the first peak (IRR 0.40, [0.25-0.64]). In-hospital mortality also increased from 20.20 to 31.99 (OR 2.05, [1.97-2.13]). All age and sex groups had decreased admission rates, except for females at productive ages. Two years after the COVID-19 outbreak, the non-COVID-19 hospital admission rate (IRR 1.25, [1.13-1.40]) and mortality rate (OR 1.05, [1.04-1.07]) increased compared to the rates before the pandemic. The respiratory disease admission rate decreased in the first (IRR 0.23, [0.17-0.31]) and second years (IRR 0.35, [0.26-0.47] compared to the rate before the pandemic. There was a significant reduction in hospitalizations for pneumonia (IRR 0.30, [0.21-0.42]), influenza (IRR 0.04, [0.03-0.06]) and COPD (IRR 0.39, [0.23-0.65]) during the second year. There was a significant and continuous rise in the hematological admission rate during the study, reaching 186.99 per million person-month in the second year, reflecting an IRR of 2.84 [2.42-3.33] compared to the pre-pandemic period. The mortality rates of mental disorders (OR 2.15, [1.65-2.78]) and musculoskeletal (OR 1.48, [1.20-1.82), nervous system (OR 1.42, [1.26-1.60]), metabolic (OR 1.99, [1.80-2.19]) and circulatory diseases (OR 1.35, [1.31-1.39]) increased in the second year compare to pre-pandemic. Myocardial infarction (OR 1.33, [1.19-1.49]), heart failure (OR 1.59, [1.35-1.87]) and stroke (OR 1.35, [1.24-1.47]) showed an increase in mortality rates without changes in hospitalization. CONCLUSIONS: In the era of COVID-19, the changes seem to have had a long-term effect on non-COVID-19 diseases. Countries should prepare for similar crises in the future to ensure medical services are not suspended.

Vitamin D and potential effects on cancers: a review.

Cancer is characterized by the abnormal and uncontrollable division and growth of cells that can infiltrate tissues and alter normal physiological function, which will become crucial and life-threatening if left untreated. Cancer can be a result of genetics, such as mutations or environmental causes, including smoking, lack of physical activity, as well as nutritional imbalance in the body. Vitamin D is one of the foremost nutrients that play a crucial role in a variety of biochemical pathways, and it is an important key factor in several diseases. Vitamin D is an essential nutrient for preventing malignancies and a complementary treatment for cancer through direct and indirect biochemical pathways. In this article, we summarized the correlation between vitamin D and various cancers using an extensive search on PubMed, Google Scholar, and Scopus. This paper reviews the role of vitamin D in different types of cancer.

Prevalence and Determinants of Catastrophic Healthcare Expenditures in Iran From 2013 to 2019.

OBJECTIVES: Protecting people against financial hardship caused by illness stands as a fundamental obligation within healthcare systems and constitutes a pivotal component in achieving universal health coverage. The objective of this study was to analyze the prevalence and determinants of catastrophic health expenditures (CHE) in Iran, over the period of 2013 to 2019. METHODS: Data were obtained from 7 annual national surveys conducted between 2013 and 2019 on the income and expenditures of Iranian households. The prevalence of CHE was determined using a threshold of 40% of household capacity to pay for healthcare. A binary logistic regression model was used to identify the determinants influencing CHE. RESULTS: The prevalence of CHE increased from 3.60% in 2013 to 3.95% in 2019. In all the years analyzed, the extent of CHE occurrence among rural populations exceeded that of urban populations. Living in an urban area, having a higher wealth index, possessing health insurance coverage, and having employed family members, an employed household head, and a literate household head are all associated with a reduced likelihood of CHE (p<0.05). Conversely, the use of dental, outpatient, and inpatient care, and the presence of elderly members in the household, are associated with an increased probability of facing CHE (p<0.05). CONCLUSIONS: Throughout the study period, CHE consistently exceeded the 1% threshold designated in the national development plan. Continuous monitoring of CHE and its determinants at both household and health system levels is essential for the implementation of effective strategies aimed at enhancing financial protection.

Is Palbociclib a cost-effective strategy in the second-line treatment of metastatic breast cancer in Iran?

BACKGROUND & AIMS: This study evaluates the cost-effectiveness of Palbociclib in the second-line treatment of hormone receptor-positive (HR+) human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) in Iran. METHODS: The present economic evaluation used a partitioned survival model (PSM). This model compares lifetime costs and disease outcomes among groups receiving different medication combinations containing Palbociclib, Fulvestrant, Everolimus, Ribociclib, and Abemaciclib as the second-line therapy for HR+/HER2- MBC. The model was conducted from Iran's healthcare perspective, structured with 1-month cycles, and the evaluation time horizon in the base analysis was set to 180 cycles (15 years). Transition probabilities were extracted using the survival curves. The cost information was extracted based on the year 2020. The Quality Adjusted Life Years (QALY) was considered the final outcome unit, and the cost-effectiveness of different combinations is calculated as cost per QALY. The annual discount rate of 5% was considered for costs and QALYs. Two times Iran's GDP per capita (800,000,000 IRR = US$5934) was used as the threshold. Finally, due to the uncertainty of some parameters, deterministic and probabilistic sensitivity analyses were carried out. RESULTS: The base case results showed that the highest cost was for the 'Ribociclib+ Fulvestrant' combination (US$89,629.56), and the lowest price was for the 'Iranian Everolimus + Fulvestrant' combination (US$10,740.09). 'Palbociclib + Fulvestrant' brings about the highest value of 1.456 incremental QALYs compared to other strategies. Finally, the 'Iranian Palbociclib + Fulvestrant' was the cost-effective combination, with an incremental cost-effectiveness ratio (ICER) of US$4,201 compared to other strategies. The base case results were supported by the probabilistic sensitivity analysis. Deterministic sensitivity analysis showed that the cost of Iranian Palbociclib has a threshold of US$582.99. CONCLUSIONS: The 'Iranian Palbociclib + Fulvestrant' combination was cost-effective in second-line therapy for HR+ HER2- MBC in Iran.

Directed evolution of cholesterol oxidase with improved thermostability using error-prone PCR.

Cholesterol oxidase is industrially important as it is frequently used as a biosensor in food and agriculture industries and measurement of cholesterol. Although, most natural enzymes show low thermostability, which limits their application. Here, we obtained an improved variant of Chromobacterium sp. DS1 cholesterol oxidase (ChOS) with enhanced thermostability by random mutant library applying two forms of error-prone PCR (serial dilution and single step). Wild-type ChOS indicated an optimal temperature and pH of 70 ºC and pH 7.5, respectively. The best mutant ChOS-M acquired three amino acid substitutions (S112T, I240V and A500S) and enhanced thermostability (at 50 °C for 5 h) by 30%. The optimum temperature and pH in the mutant were not changed. In comparison to wild type, circular dichroism disclosed no significant secondary structural alterations in mutants. These findings show that error-prone PCR is an effective method for enhancing enzyme characteristics and offers a platform for the practical use of ChOS as a thermal-resistance enzyme in industrial fields and clinical diagnosis.

Improvement of thermostability of cholesterol oxidase from streptomyces Sp. SA-COO by random mutagenesis.

To enhance the thermal stability of Streptomyces Sp. SA-COO cholesterol oxidase, random mutagenesis was used. A random mutant library was generated using two types of error-prone PCR (single step and serial dilution) and two mutants (ChOA-M1 and ChOA-M2) with improved thermostability were obtained. The best mutant ChOA-M1 acquired three amino acid substitutions (G49T, W52K, and F62V) and improved thermostability (at 50 °C for 5 h) by 40% and increased the kcat/Km value by 23%. The optimum pH was desirably changed to encompass a broad range from alkali to acid and circular dichroism revealed no significant secondary structure changes in mutants against wild type. These findings indicated that random mutagenesis was an effective technique for optimizing cholesterol oxidase properties and make a foundation for practical applications of Cholesterol oxidase in clinical diagnosis and industrial fields.

Expression optimization, purification, and functional characterization of cholesterol oxidase from Chromobacterium sp. DS1.

Cholesterol oxidase is a bifunctional bacterial flavoenzyme which catalyzes oxidation and isomerization of cholesterol. This valuable enzyme has attracted a great deal of attention because of its wide application in the clinical laboratory, synthesis of steroid derived drugs, food industries, and its potentially insecticidal activity. Therefore, development of an efficient protocol for overproduction of cholesterol oxidase could be valuable and beneficial in this regard. The present study examined the role of various parameters (host strain, culture media, induction time, isopropyl ß-D-1-thiogalactopyranoside concentration, as well as post-induction incubation time and temperature) on over-expression of cholesterol oxidase from Chromobacterium sp. DS1. Applying the optimized protocol, the yield of recombinant cholesterol oxidase significantly increased from 92 U/L to 2115 U/L. Under the optimized conditions, the enzyme was produced on a large-scale, and overexpressed cholesterol oxidase was purified from cell lysate by column nickel affinity chromatography. Km and Vmax values of the purified enzyme for cholesterol were estimated using Lineweaver-Burk plot. Further, the optimum pH and optimum temperature for the enzyme activity were determined. This study reports a straightforward protocol for cholesterol oxidase production which can be performed in any laboratory.

Expression optimization of recombinant cholesterol oxidase in Escherichia coli and its purification and characterization.

Cholesterol oxidase is a bacterial flavoenzyme which catalyzes oxidation and isomerization of cholesterol. This enzyme has a great commercial value because of its wide applications in cholesterol analysis of clinical samples, synthesis of steroid-derived drugs, food industries, and potentially insecticidal activity. Accordingly, development of an efficient protocol for overexpression of cholesterol oxidase can be very valuable and beneficial. In this study, expression optimization of cholesterol oxidase from Streptomyces sp. SA-COO was investigated in Escherichia coli host strains. Various parameters that may influence the yield of a recombinant enzyme were evaluated individually. The optimal host strain, culture media, induction time, Isopropyl ß-D-1-thiogalactopyranoside concentration, as well as post-induction incubation time and temperature were determined in a shaking flask mode. Applying the optimized protocol, the production of recombinant cholesterol oxidase was significantly enhanced from 3.2 to 158 U/L. Under the optimized condition, the enzyme was produced on a large-scale, and highly expressed cholesterol oxidase was purified from cell lysate by column nickel affinity chromatography. Km and Vmax values of the purified enzyme for cholesterol were estimated using Lineweaver-Burk plot. Further, the optimum pH and optimum temperature for the enzyme activity were also determined. We report a straightforward and easy protocol for cholesterol oxidase production which can be performed in any laboratory.

Functional polymorphisms of FAS and FASL gene and risk of breast cancer - pilot study of 134 cases.

Fas/Fas ligand (FasL) system is one of the key apoptotic signaling entities in the extrinsic apoptotic pathway. De-regulation of this pathway, i.e. by mutations may prevent the immune system from the removal of newly-formed tumor cells, and thus lead to tumor formation. The present study investigated the association between -1377 G/A (rs2234767) and -670 A/G (rs1800682) polymorphisms in Fas as well as single nucleotide polymorphisms INV2nt -124 A/G (rs5030772) and -844 C/T (rs763110) in FasL in a sample of Iranian patients with breast cancer. This case-control study was done on 134 breast cancer patients and 152 normal women. Genomic DNA was extracted from whole blood samples. The polymorphisms were determined by using tetra-ARMS-PCR method. There was no significant difference in the genotype distribution of FAS rs2234767 polymorphism between cases and controls. FAS rs1800682, FASL rs5030772, and FASL rs763110 genotypes showed significant associations with an increasing risk of breast cancer (odds ratio OR = 3.18, P = 0.019; OR = 5.08, P = 0.012; OR = 2.40, P = 0.024, respectively). In conclusion, FAS rs2234767 was not associated with breast cancer risk. Though, FAS rs1800682, FASL rs5030772, and FASL rs763110 polymorphisms were associated with the risk of breast cancer in the examined population.

Association between polymorphisms of glutathione S-transferase genes (GSTM1, GSTP1 and GSTT1) and breast cancer risk in a sample Iranian population.

AIM: Genetic and environmental factors are risk factors for breast cancer. Our aim was to investigate the associations between genetic polymorphism of GST genes (GSTM1, GSTT1 and GSTP1) and susceptibility to breast cancer in an Iranian population. MATERIALS & METHODS: This case-control study was carried out on 134 patients with breast cancer and 152 healthy, cancer-free women. GSTP1 polymorphism was determined using tetra-primer amplification refractory mutation system PCR assay and GSTM1 and GSTT1 were genotyped by a multiplex PCR. RESULTS: We found that the GSTM1 null genotype is a risk factor for predisposition to breast cancer (odds ratio [OR] = 2.01; 95% CI = 1.78-3.45; p = 0.010). No significant difference was found between the groups regarding GSTT1 null genotype (p > 0.05). The GSTP1 Ile/Val and Val/Val genotypes were associated with breast cancer risk (OR = 3.29; 95% CI = 1.84-5.91; p < 0.0001 and OR = 20.68; 95% CI = 5.66-75.60; p < 0.0001, respectively). CONCLUSION: In summary, GSTM1 and GSTP1, but not GSTT1 genetic polymorphisms are associated with increased risk of breast cancer in our population.

Evaluation of UDP-glucuronosyltransferase 2B17 (UGT2B17) and dihydrofolate reductase (DHFR) genes deletion and the expression level of NGX6 mRNA in breast cancer.

The present study was aimed to investigate the possible association between 19-base pair (bp) deletion polymorphism of the DHFR gene (rs70991108), null genotype of UDP-glucuronosyltransferase 2B17 (UGT2B17) as well as the expression level of nasopharyngeal carcinoma-associated gene 6 (NGX6) with the risk of breast cancer. This case-control study was done on 236 patients with breast cancer and 203 cancer free women. Detection of 19-bp del of DHFR was done using bi-directional PCR allele-specific amplification and UGT2B17 genotyping was performed using multiplex PCR assay. NGX6 mRNA expression level was determined by quantitative reverse transcriptase PCR in 62 breast cancerous and 62 adjacent non-cancerous tissues. Our finding showed an association between null genotype of UGT2B17 and risk of breast cancer and the null genotype increased susceptibility to breast cancer (OR: 2.99; 95 % CI: 1.94-4.60; p < 0.0001). However, no statistically significant difference was found between breast cancer patients and cancer free normal women regarding 19-bp ins/del of DHFR (χ(2) = 0.91, p = 0.63). Real-time PCR data showed that the relative expression level of NGX6 mRNA was significantly lower in cancerous than that in non-cancerous breast tissue specimens (0.936 ± 0.042 and 1.042 ± 0.039, respectively). However, NGX6 mRNA expression was not correlated with tumors grade (p > 0.05). In conclusion, the null genotype of UGT2B17 revealed to be a risk factor for breast cancer in a sample of Iranian population. Furthermore, down-regulation of NGX6 mRNA expression in breast carcinoma confirms the growing proof regarding the tumor suppressor role of NGX6.

Bi-directional PCR allele-specific amplification (bi-PASA) for detection of caspase-8 -652 6N ins/del promoter polymorphism (rs3834129) in breast cancer.

Caspase-8 (CASP8) plays a critical role in regulating apoptosis, and its functional polymorphisms may modify cancer risk. We investigated the possible association between CASP8 -652 6N ins/del (rs3834129) and the risk of breast cancer in a sample of Iranian population. This case-control study was done on 236 breast cancer patients and 203 cancer free healthy female. We designed a rapid and simple bi-directional PCR allele-specific amplification (bi-PASA) for detection of CASP8 -652 6N ins/del polymorphism. The results showed that the CASP8 -652 6N del/dl genotype was inversely associated with breast cancer risk (OR=0.33, 95% CI=0.17-0.65, p=0.001). The frequencies of the del allele in cases and controls were 29.1% and 38.6%, respectively. An inverse association between CASP8 6N del variant and the risk of breast cancer (OR=0.66, 95% CI=0.66-0.87, p=0.002) was found. In conclusion, the result suggests that the CASP8 -652 6N del polymorphism plays a protective role in susceptibility to breast cancer in our population. Further studies in other populations with larger samples are needed to confirm these findings.

Genotyping of -374A/T, -429A/G, and 63 bp Ins/del polymorphisms of RAGE by rapid one-step hexaprimer amplification refractory mutation system polymerase chain reaction in breast cancer patients.

Several studies have focused on the RAGE genetic background and have demonstrated that its polymorphisms affect the receptor's activity, expression, and downstream signaling. However, there is only little information regarding RAGE polymorphism in breast cancer. In the present study, the authors studied RAGE polymorphisms in 71 patients with breast cancer and 93 healthy women. RAGE -374T/A, -429T/C, and 63 bp Ins/del polymorphisms were analyzed using a hexaprimer amplification refractory mutation system PCR (H-ARMS-PCR). The results showed that RAGE polymorphisms are not associated with breast cancer in the current study population. Larger studies are required to confirm these data in other populations.

Association of genetic polymorphisms of glutathione-S-transferase genes (GSTT1, GSTM1, and GSTP1) and susceptibility to nonalcoholic fatty liver disease in Zahedan, Southeast Iran.

Oxidative damage is thought to play a pivotal role in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). Glutathione-S-transferases (GSTs) are involved in cell protection against oxidative stress. We examined whether GSTM1, GSTT1, and GSTP1 polymorphisms are associated with NAFLD in a sample of the Iranian population. The current case-control study included 83 patients with NAFLD and 93 healthy subjects. The GSTM1 and GSTT1 polymorphisms were analyzed by multiplex polymerase chain reaction (PCR). The GSTP1 polymorphism was detected by tetra amplification refractory mutation system-PCR assay. The GSTM1-null genotype was significantly associated with the development of NAFLD (odds ratios [OR]=2.171, 95% confidence intervals [CI]=1.188-3.970, p=0.015). The GSTP1 Val allele was shown to be a risk factor for NAFLD (OR=1.739, 95% CI=1.089-2.777, p=0.024). The GSTT1 polymorphism was not significantly different between control and patient groups (p=0.221). This study showed that GSTM1 and GSTP1, but not GSTT1, genetic polymorphisms are associated with NAFLD in a sample of the Iranian population, and may be used to determine the risk of development of NAFLD.