Journal of Education and Health Promotion

Abstract BACKGROUND: The angiotensin‑converting enzyme 2 (ACE2) receptor, a membrane receptor
present in the respiratory system, the gastrointestinal tracts, the heart, and the kidney is the entry
point for SARS‑CoV‑2 to enter human cells. Concerns were raised about the influence of using
antihypertensive drugs like angiotensin‑converting enzyme inhibitors (ACEIs) or angiotensin receptor
blockers (ARBs) in individuals with COVID‑19 due to its tight relationship with the ACE2 receptor. The
aim of this study was to investigate the impact of being on an Angiotensin Receptor Blockers (ARB)
on mortality in patients consecutively diagnosed with COVID‑19.
MATERIAL AND METHODS: This is the retrospective observational study done in all patients
consecutively diagnosed with COVID‑19 from January 2021 to June 2021. All related patient
information and clinical data was retrieved from the hospitals electronic medical record system.
RESULTS: In this study, out of 500 patients, 51 died, having mean age of 66.92 ± 10.85 years.
144 (28.8%) patients were on angiotensin receptor blockers as antihypertensive treatment,
142 (28.4%) having other antihypertensive and 214 (42.8%) were not on any treatment. Out of 51
Death 7 (4.9) patients were on ARBs, 15 ± 10.6 were on other medication [OR 2.31 (0.94–6.22,
P = 0.077) univariable; OR 2.57 (1.00–7.23, P = 0.058) multivariable] and 29 ± 13.6 had no treatment
at all [OR 3.07 (1.38–7.80, P = 0.010) univariable; OR 3.36 (1.41–9.08, P = 0.010) multivariable].
CONCLUSION: Use of ARB medications for the hypertensive patients who acquire COVID‑19
infection has shown protective effects of such medications on COVID‑19 disease severity in the
term of mortality and the mortality rate among hypertensive patients on COVID‑19 with ARBs/ACE
inhibitors showed significant differences as compared to other antihypertensives.

Abstract Osteoporosis is a specific condition which is characterized by low bone mineral density (BMD) and
deterioration of bone structure resulting in an increased susceptibility to fractures. It contributes to a
great deal of morbidity and mortality, and is a large burden to the healthcare system, especially in the
case of the elderly population. In the last four decades, a plethora of studies have reported characteristic
oral radiographic findings in the early stages of osteoporosis, suggesting the possible use of oral
radiographic signs for the early detection of the condition. Digital orthopantomographs (OPGs) are
usually taken for the screening of dental patients during routine dental evaluations. These radiographs
and the characteristic changes seen on them may have a significant role in the screening for initial
osteoporotic changes. A number of precise radiomorphometric indices of the mandible have also
been developed to allow quantification of the mandibular bone mass for identification of the initial
signs of osteoporosis. The present review focuses on the possible role of panoramic radiographs in
the initial screening for osteoporosis in dental clinics in high‑risk groups.

Abstract BACKGROUND: Infection with COVID‑19 has resulted in considerable mortality all around the world.
This study aimed to investigate the effect of convalescent plasma on the treatment of hospitalized
patients with COVID‑19 in Imam Khomeini Hospital at Ardabil, Iran.
MATERIALS AND METHODS: In this quasi‑experimental clinical trial, patients over 18 years of age
with polymerase chain reaction‑positive COVID‑19 were admitted based on the clinical criteria of
respiratory distress with hypoxia (O2
 saturation <90) and tachypnea (R Relative Risk (RR) >24) with
moderate‑to‑severe lung involvement and in the 1st week of respiratory disease who were not intubated
were nonrandomly assigned to two groups: convalescent plasma therapy (CPT) group (197 cases)
and control group (200 cases). We used the Chi‑square, t‑test, Fisher’s exact test, and Pearson’s
correlation coefficient for statistical analysis.
RESULTS: Analyses revealed that length of stay in hospital was significantly lower in the CPT group
as compared to the control group (P = 0.001). Twenty‑four cases (22.0%) in the CPT group and
85 cases (78.0%) in the control group needed intubation. Furthermore, mortality was 17 cases (18.3%)
in the CPT group and 76 cases (81.7%) in the control group, the difference of which was also found
to be statistically significant (P < 0.05).
CONCLUSIONS: It seems that CPT can be used as an alternative treatment at the early stages of
COVID‑19 to prevent the progress of the disease, reduce the need for intubation and consequently
the length of stay in hospital, and finally, decrease mortality.

Abstract BACKGROUND: Severe acute respiratory syndrome coronavirus‑2 (SARS‑CoV‑2) causes COVID‑19. 
On March 11, 2020, the WHO declared it a pandemic. SARS‑CoV‑2 indicates that it poses a 
significant threat to public health and global economy. The aim of the study was to determine (a) 
patient characteristics, (b) demographic characteristics, (c) comorbidities, diagnostic methods used, 
treatment, and outcomes, and (d) mortality rates of patients.
MATERIALS AND METHODS: This retrospective cohort study included 352 hospitalized adult 
patients from Baskent University Hospital in Ankara who were confirmed cases of COVID‑19 between 
March 2020 and March 2021. SPSS v. 14.0 was used for statistical analysis.
RESULTS: Out of 352 patients, 55 died (males: 37, females: 18), while 297 survived (males: 162, females: 
135). The most common comorbidities were hypertension (HT), diabetes mellitus (DM), coronary artery 
disease (CAD), cancer, Vitamin D deficiency, and chronic obstructive pulmonary disease. Comorbidities 
associated with mortality rate were obesity (33%) (P = 0.118), Vitamin D deficiency (28%) (P = 0.009), 
DM (25%) (P = 0.004), CAD (21.2%) (P = 0.142), cancer (20.9%) (P = 0.084), and HT (16.6%) (P = 0.90). 
Normal ward admission resulted in death in 67.3% and survival in 93.9% (P = 0.001), intensive care 
unit (ICU) admission resulted in death in 69.1% and survival in 18.5% (P = 0.001), and oxygen therapy 
was used in 80% death and survival in 39.4% (P = 0.001).
CONCLUSIONS: Our study shows that male gender, advanced age, and presence of comorbidities 
in COVID 19 patients are at higher risk for severe disease, ICU admission, and death. We emphasize 
that morbidity and mortality can be reduced by early and comprehensive identification of risk factors 
and the warning systems that will meet the ICU needs of these patients.

Abstract BACKGROUND: COVID‑19 pandemic has spread all over the world. However, information regarding
clinical characteristics and prognostic factors is scarce. The aim of this study was to explore the
impact of preexistent chronic comorbid conditions and multimorbidity on risk of mortality in patients
with COVID‑19.
MATERIALS AND METHODS: We designed a retrospective, cross‑sectional, observational,
single‑center study. Data were analyzed from all consecutive patients diagnosed with COVID‑19 who
admitted in a pandemic hospital affiliated with Tabriz University of Medical Sciences, Tabriz, Iran,
from February 20, 2020, to September 25, 2020. The independent effects of preexistent conditions
were evaluated using multivariate logistic regression model.
RESULTS: A total of 2597 hospitalized patients with COVID‑19 were included. At least one preexistent
condition was observed in 36.5% of study population. Multivariate logistic regression analysis showed
that older age, male sex, diabetes, cardiovascular disease, hypertension, cancer, chronic kidney
diseases, liver diseases, and chronic obstructive pulmonary disease were associated with increased
risk of mortality. In addition, the number of comorbidities was significantly associated with increased
odds of mortality compared to no‑comorbidity.
CONCLUSION: The results of this study suggest that patients with comorbidities have an increased
risk of in‑hospital mortality following COVID‑19 infection.

Abstract BACKGROUND: The first case of COVID‑19 was reported in Iran on February 19, 2020, in Qom. Since
Mazandaran is one of the high‑risk provinces with many patients and deaths, this study was conducted
to investigate the epidemiological characteristics of COVID‑19‑related deaths in Mazandaran.
MATERIALS AND METHODS: In this descriptive study, demographic information and clinical
findings in patients who died following COVID‑19 in the medical centers of Mazandaran University of
Medical Sciences from February 8, 2020, to October 10, 2020, were extracted. Data were analyzed
by using SPSS 21. Logistic regression was used to compare the data. P < 0.05 was considered as
the significance level.
RESULTS: Out of a total of 34,039 patients admitted during the 8 months, 2907 patients died. Of
these, 1529 (52%) were male, and the rest were female. In terms of age, 10 cases in the age group
of fewer than 15 years, 229 cases in the age group of 15–44 years, 864 patients in the age group of
45–64 years, and 1793 people in the age group of 65 years and over died. 2206 people (more than
75%) by personal visit referred to medical centers. The mortality rate was more than 8 cases per 100
hospitalized patients. Men were 16% more likely to die from COVID‑19 than women.
DISCUSSION AND CONCLUSION: Older adults over 65 have the highest incidence and death rate
due to this disease. The incidence rate was higher in women, and the death rate was higher in men,
which differs from the national pattern.

Abstract BACKGROUND: More than one‑half of people with diabetes need at least one surgery in their
lifespan. Few studies have addressed how to manage the needs of these patients after discharge
from the hospital. The present study is designed to determine the effect of home care on readmission
of Type 2 diabetic patients who underwent surgical procedures.
MATERIALS AND METHODS: The present study was a randomized clinical trial. Sixty‑nine
patients with Type 2 diabetes undergoing surgery were assigned to the intervention and control
groups via blocking order in the selected educational hospitals of Isfahan 2019. Home care
was performed for 3 months with interprofessional team approach. Data collection tools were
re‑admission checklist. Data were entered in SPSS software version 23 and were analyzed by
nonparametric tests.
RESULTS: The background characteristics in the intervention and control groups were not different.
The frequency of readmission in the control and intervention groups from the time of discharge until
3 months later was 25.7% and 18.9%, respectively. Frequency of readmission in the intervention
and control groups was not significant in 3 months from discharge, P > 0.05. The mortality rate was
11.4% and 0% in control and intervention groups, respectively, P < 0.05.
CONCLUSION: It can be argued that continued home care can decrease the rate of readmission
and mortality rate in patients with Type 2 diabetes who will discharge from surgical wards.

Abstract BACKGROUND: Global burden of disease (GBD) provides the estimates of mortality and morbidity,
while case fatality rate (CFR) helps in understanding the severity of the disease. People infected
with severe acute respiratory syndrome coronavirus 2 (SARS CoV‑2) with underlying medical
conditions have shown higher levels of unfavorable outcomes including mortality. We assessed the
association of SARS‑CoV‑2 CFR with disability‑adjusted life years (DALY) of various comorbidities
in the low‑middle income countries (LMIC) and high‑income countries (HIC) to study the relationship
of coronavirus disease‑19 (COVID‑19) mortality with GBDs and to understand the linkage between
COVID‑19 mortality and comorbidities.
MATERIALS AND METHODS: This was an ecological study with secondary data analysis comparing
the DALY of various morbidities from GBD with CFR of COVID‑19. Gross domestic product was the
basis of stratifying 177 countries into low‑middle income (LMIC) and high‑income groups (HIC). The
mortality was analyzed using Pearson correlation and linear regression.
RESULTS: The median global CFR of SARS‑CoV‑2 was 2.15. The median CFR among LMIC (n = 60)
and HIC (n = 117) was 2.01 (0.00–28.20) and 2.29 (0.00–17.26), respectively. The regression analysis
found that, in both LMIC and HIC, maternal disorders were associated with higher SARS‑CoV‑2
CFR, while tuberculosis, mental health disorders, and were associated with lower CFR. Further, in
LMIC, musculoskeletal disorders and nutritional deficiencies were associated with higher CFR, while
respiratory disorders were associated with lower CFR.
CONCLUSIONS: SARS‑CoV‑2 infection appears to be a systemic disease. Individuals with
comorbidities, such as maternal disorders, neurological diseases, musculoskeletal disorders, and
nutritional deficiencies, have poorer outcomes with COVID‑19, leading to higher mortality.

Abstract BACKGROUND: The COVID‑19 pandemic has spread rapidly across the world and has currently
impacted most countries and territories globally. This study aimed to identify health‑care determinants
of mortality and recovery rates of COVID‑19 and compare the efficiency of health systems in response
to this pandemic.
MATERIALS AND METHODS: A cross‑sectional study was conducted using data obtained from the
World Bank database, that provides free and open access to a comprehensive set of health‑ and
socioeconomic‑related data, by September 12, 2020. An adjusted linear regression model was
applied to determine predictors of mortality (per 1 million population [MP]) and recovery rates (per 1
MP) in the included countries. One‑way analysis of variance was applied to assess health systems’
efficiency in response to COVID‑19 pandemic using mortality and recovery rate (output variables)
and current health expenditure (CHE) per capita (input variable).
RESULTS: Globally, San Marino and Qatar had the highest mortality rate (1237/1 MP) and confirmed
case rate (43,280/1 MP) until September 12, 2020, respectively. Iran had a higher mortality rate (273/1
MP vs. 214.5/1 MP) and lower recovery rate (4091.5/1 MP vs. 6477.2/1 MP) compared to countries
with high CHE per capita. CHE per capita (standardized coefficient [SC] = 0.605, P < 0.001) and
population aged 65 years and over as a percentage of total population (SC = −0.79, P < 0.001)
significantly predicted recovered cases from COVID‑19 in the included countries.
CONCLUSION: This study revealed that countries with higher CHE per capita and higher proportion of
older adults were more likely to have a higher recovery rate than those with lower ones. Furthermore,
our study indicated that health systems with higher CHE per capita statistically had a greater efficiency
in response to COVID‑19 compared to those with lower CHE per capita. More attention to preventive
strategies, early detection, and early intervention is suggested to improve the health system efficiency
in controlling COVID‑19 and its related mortalities worldwide.

Abstract BACKGROUND: To have a thorough understanding of epidemic surveillance, it is essential to broaden
our knowledge of death tolls worldwide. This study aimed to determine the age‑standardized mortality
rate (ASMR) and predictors of mortality among coronavirus disease 2019 (COVID‑19) patients.
MATERIALS AND METHODS: In this cross‑sectional design, all COVID‑19 patients with a
positive polymerase chain reaction test in the population covered by Arak University of Medical
Sciences (AUMS) were entered to the study. Data collection was conducted by phone interview.
The study variables comprised age, sex, coronary heart diseases, diabetes, and some symptoms
at admission. The adjusted odds ratio (OR) and 95% confidence intervals (CIs) were obtained by
logistic regression. The direct method was applied to calculate ASMR (per 100,000) of COVID‑19.
The analysis was applied by STATA software 12.0.
RESULTS: A total of 208 cases of COVID‑19 (out of 3050 total infected cases) were dead and
2500 cases were recovered. The mean age of dead patients was 70 years. The COVID‑19 fatality
rate in the population equaled 6.8%; in those patients who were 70 years old or more, however, the
case fatality rate was 16.4%. The ASMR of COVID‑19 was 12.9 (CI 95%: 11.2, 14.8). The odds of
COVID‑19‑related death in the age over 60 were 10.87 (CI 95%: 6.30, 18.75) times than lower 45 years
old. Moreover, it was observed that COVID‑19 significantly increased the odds of COVID‑19‑related
death in diabetes patients (OR = 1.45, CI 95%: 1.02, 2.06, P = 0.036).
CONCLUSION: The ASMR of COVID‑19 was relatively higher in males than females. In general, the
COVID‑19 fatality rate was relatively high. We found that older age and diabetes can have impact
on the death of COVID‑19, but the headache was found to have a negative association with the
COVID‑19‑related death.

Abstract BACKGROUND AND OBJECTIVE: Data on the factors affecting long‑term mortality following a
stroke in Iran are scarce. The current research aimed at investigating the extent of 2‑year mortality
following a stroke and the factors affecting it in the northwest of Iran.
MATERIALS AND METHODS: This prospective cohort study was conducted in Tabriz, Northwest
of Iran. Patients with computed tomography/magnetic resonance imaging confirmed the first‑ever
stroke were included in this study and followed up to 2 years. Clinical examinations, including the
severity of the stroke using the modified National Institutes of Health Stroke Scale (mNIHSS), were
conducted by a neurologist. The general characteristics, lifestyle factors, and laboratory tests were
also completed. To estimate the survival, Kaplan–Meier analysis was used; and for group comparison,
the log‑rank method was applied. To identify the factors predicting 2‑year mortality, semiparametric
Cox regression analysis was used.
RESULTS: A total of 1036 first‑ever stroke patients were included in the present study. The
mortality rates of stroke in 6‑month, 1‑year, and 2‑years follow‑up periods were 31.6%, 34.5%, and
38%, respectively. The two‑year mortality rate was 33.6% in ischemic and 58.7% in hemorrhagic
stroke (P < 0.001). In the multivariate Cox model, variables age, type of stroke, diabetes, and severity
of the stroke, according to the mNIHSS index, were identified as factors predicting 2‑year mortality
following the stroke.
CONCLUSION: The 2‑year mortality following acute stroke was relatively high compared to that of in
developed countries. Implementation of secondary prevention is recommended to better management
of modifiable predictors of mortality.

Abstract AIM: The purpose of this study was to investigate the effects of delay in the operation and counseling
on postoperative complications and mortality rates in elderly patients.
METHODOLOGY: The present study was a descriptive cross‑sectional research. Population of this
study was the entire elderly hospitalized patients who aged over 55 years for emergency orthopedic
surgeries in a teaching hospital in Tehran. Surgery delays were then determined after examining the
checklists, and the relationship between the variables and surgery delays, number of preoperative
counseling, complications, and mortality rate was evaluated. Data were analyzed using the Mann–
Whitney U‑test and Pearson correlation coefficient in SPSS 18 at a 0.05 significance level.
RESULTS: Overall, 89.9% of the patients had counseling. The average hospitalization days were
5 days until surgery, and the standard deviation was 0.50. The mean counseling number was 5.5.
The relationship between number of counseling and surgical delays was significant. Delay in surgery
in this age group, mortality, and the chances of death have become 2.7 times more than who had not
a surgical delay. No significant relationship was observed between surgery delay and the incidence
of Deep Venous Thrombosis (P = 0.102), postoperative sepsis and Myocardial Infarction (P = 0.337),
embolism (P = 0.505), and postoperative Cerebrovascular Accident (P = 0.153).
CONCLUSIONS: The delay in surgery in the elderly causes an increase in mortality. Considering
the findings of this study and the importance of emergency orthopedic surgeries in the elderly, to
reduce the surgical delays and the mortality rate in the elderly, the establishment of a surgical team
for elderly patients in hospitals is recommended.

Abstract Iran as a developing country is at risk of vulnerability to technological disasters. These types of
disasters occur frequently in last years and affected thousands of lives. Technological disasters
in Iran cause thousands of deaths, thousands of injuries, and millions of dollars’ economic loss in
recent years. We searched suitable keywords in national and international disaster databases for
gathering epidemiological data in these disasters in Iran. In addition, we searched suitable keywords
in scientific databases including Google Scholar, Scopus, PubMed, Web of Knowledge, Scientific
Information Database, Magiran, and Irandoc. After screening, only 19 articles discussed challenges
of technological disasters in the country. Road accidents, explosions and fires, mine accidents, and
railway accidents are common events in the country. After 2015, these types of disaster cause 823
deaths and injuries. Experience of response to these disasters showed that technological disaster
management in the country faces too many challenges including comprehensive and prospective
programs, weakness of necessary infrastructure for urban management, weakness in group work
and interorganizational coordination, lack of coherent involvement of people and nongovernmental
organizations, lack of information coverage during the disaster, volunteers in police service presence
at scene, and normalization of these events. Due to interorganizational nature of mitigation in
technological disasters, it must be developed coordination between various organizations to mitigate
these types of disasters.

Abstract CONTEXT: There are numerous factors which affect the health status in different ways, including
financing mechanisms, health‑care expenditures, socioeconomic characteristics, and health‑care
resources. One of the most important factors which contribute to the health status of a population
is health‑care resource which includes number of beds or health‑care professionals for instance.
AIMS: The objectives of this study were as follows: to examine the regression of the life expectancy
and health‑care inputs and also to investigate the regression of death rate and health‑care inputs.
SETTINGS AND DESIGN: This study was a panel dataset analysis of OECD countries.
MATERIALS AND METHODS: A generalized method of moment (GMM) regression models with
country‑level health outcomes (death rate and life expectancy) as dependent variables were estimated.
A panel dataset with n = 26 (the number of countries) and T = 12 (the number of time periods) was
used. The GMM regression model was used to estimate the effect of health‑care resources on
health outcomes.
RESULTS: Findings showed that there are strong reverse correlations between immunization rate and
number of physicians with crude rate of death (−2.64 [P < 001] and −76.50 [P < 001], respectively).
There were also positive correlations between immunization rate and number of physicians with
life expectancy at birth (0.01 [P < 001] and 1.03 [P < 001], respectively). Moreover, there were
negative correlations between inpatient rate and beds with life expectancy (−0.00003 [P < 001]
and −0.12 [P < 001], respectively).
CONCLUSIONS: It is essential for policymakers to consider the optimal level of health resource to
achieve better health outcomes. Oversupply of hospital beds and specialist doctors could lead to
induced demand and put the patients at risk of unnecessary procedures.

Abstract BACKGROUND AND OBJECTIVE: Stroke is the second leading cause of death worldwide and
the number of stroke cases has increased remarkably over the last 20 years. This study aimed at
identifying predictors of with 6‑month mortality of first‑ever stroke patients and the factors contributing
to it in East Azerbaijan province.
MATERIALS AND METHODS: A closed cohort study was carried out from April 2014 to
December 2014. All cases of first‑ever diagnosed stroke were included in the study. Any transient
ischemic attack, silent brain infarctions, and the stroke cases which were neither associated with
trauma, blood disease nor with malignancy were excluded from the study. The variables of this study
include participants’ demographic characteristics, stroke severity National Institutes of Health Stroke
Scale (NIHSS), and stroke risk factors. Patients were followed up within 6 months. To determine the
survival time, the log‑rank method was applied to compare intergroup differences. The tests include
the univariate and multivariate analysis Cox regression. P < 0.05 were considered as statistically
significant.
RESULTS: A total of 576 cases of stroke were included in this study. Average age of ischemic and
hemorrhagic stroke was 70.15 ± 13.0 and 67.79 ± 12.69, respectively. Case‑fatality rate (CFR)
of stroke patients was 49.2 and 21.7% in hemorrhagic and ischemic stroke types, respectively.
Factors contributing to stroke mortality events include the severity of stroke (NIHSS categories
15–19 and ≥20), age over 65, being female, high body mass index and hyperlipidemia. In the
final model, the severity of stroke (with NIHSS 15–19 with hazard ratio (HR) 4.22 (95% confidence
interval [CI] 2.36–7.56) and NIHSS ≥20 with HR 5.34 (95% CI: 2.81–10.12) and age above 65 with
HR 1.61 (95% CI: 1.02–2.51) were the most important predictors of 6‑month mortality.
CONCLUSION: Severity of stroke by NIHSS was the most prominent factor in stroke patients’
mortality. By increasing the follow‑up time, a better evaluation of the predictors of mortality after
stroke can be achieved.

Abstract BACKGROUND: Air pollution is an important environmental issue due to its proven serious impacts
on human health. The aim of this study was to estimate the attribution of particulate matter with an
aerodynamic diameters of ≤ 2.5 and 10 (PM2.5 and PM10) in the prevalence of cardiovascular and
respiratory diseases and premature deaths in Isfahan in 2013–2014.
MATERIALS AND METHODS: This descriptive, ecological study was conducted to assess health
impacts of PM2.5 and PM10 on the population using Air Q2.2.3 software, suggested by the World Health
Organization (WHO).
RESULTS: The results showed that the annual mean, winter mean, summer mean, and the
98 percentile of PM10 concentration in Isfahan were 108, 100, 116, and 264 µg/m3
, respectively. The
number of deaths per year related to PM2.5 was 670 and that for PM10 was 713 cases. The number
of annual deaths due to cardiovascular and respiratory diseases attributed to PM10 was 316 and
68 cases, respectively.
CONCLUSION: The results of this study revealed that about 44.3% of total annual death due to
cardiovascular diseases and 9.55% of that due to respiratory diseases were attributed to PM10
exposure. In the other word, residents were exposed to PM2.5 and PM10 concentrations higher than
the WHO guidelines which caused a notable increase in the rate of mortality.