Maryam Keshtkar-Jahromi

Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis.

IMPORTANCE Among nontraditional cardiovascular risk factors, recent influenzalike infection is associated with fatal and nonfatal atherothrombotic events. OBJECTIVES To determine if influenza vaccination is associated with prevention of cardiovascular events. DATA SOURCES AND STUDY SELECTION A systematic review and meta-analysis of MEDLINE (1946-August 2013), EMBASE (1947-August 2013), and the Cochrane Library Central Register of Controlled Trials (inception-August 2013) for randomized clinical trials (RCTs) comparing influenza vaccine vs placebo or control in patients at high risk of cardiovascular disease, reporting cardiovascular outcomes either as efficacy or safety events. DATA EXTRACTION AND SYNTHESIS Two investigators extracted data independently on trial design, baseline characteristics, outcomes, and safety events from published manuscripts and unpublished supplemental data. High-quality studies were considered those that described an appropriate method of randomization, allocation concealment, blinding, and completeness of follow-up. MAIN OUTCOMES AND MEASURES Random-effects Mantel-Haenszel risk ratios (RRs) and 95% CIs were derived for composite cardiovascular events, cardiovascular mortality, all-cause mortality, and individual cardiovascular events. Analyses were stratified by subgroups of patients with and without a history of acute coronary syndrome (ACS) within 1 year of randomization. RESULTS Five published and 1 unpublished randomized clinical trials of 6735 patients (mean age, 67 years; 51.3% women; 36.2% with a cardiac history; mean follow-up time, 7.9 months) were included. Influenza vaccine was associated with a lower risk of composite cardiovascular events (2.9% vs 4.7%; RR, 0.64 [95% CI, 0.48-0.86], P = .003) in published trials. A treatment interaction was detected between patients with (RR, 0.45 [95% CI, 0.32-0.63]) and without (RR, 0.94 [95% CI, 0.55-1.61]) recent ACS (P for interaction = .02). Results were similar with the addition of unpublished data. CONCLUSIONS AND RELEVANCE In a meta-analysis of RCTs, the use of influenza vaccine was associated with a lower risk of major adverse cardiovascular events. The greatest treatment effect was seen among the highest-risk patients with more active coronary disease. A large, adequately powered, multicenter trial is warranted to address these findings and assess individual cardiovascular end points.

Crimean-Congo Hemorrhagic Fever Virus as a Nosocomial Pathogen in Iran

Crimean-Congo hemorrhagic fever (CCHF) is a viral disease with several different modes of transmission. We describe the manifestations, outcome, and likely modes of transmission for three nosocomial cases. All three cases were healthcare workers (two men and one woman). They had fever, myalgia, and petechia. Disseminated intravascular coagulation resulted in the death occurred in the woman. Because this disease is manifested with non-specific influenza-like symptoms, diagnosis can be difficult. Data for these patients can be used to investigate airborne or sexual transmission of this virus, although neither route was substantiated for these patients. Use of universal precautions and early case detection are the most helpful strategy for preventing nosocomial transmission of CCHF.

Antibody Response to Influenza Immunization in Kidney Transplant Recipients Receiving either Azathioprine or Mycophenolate: A Controlled Trial

Aims: We aimed to assess humoral immune response to the influenza vaccine in adult kidney transplant recipients (KTRs) subjected to two immunosuppressive regimens containing either mycophenolate mofetil (MMF) or azathioprine (Aza). Methods: 40 eligible KTRs (24 treated with Aza [KTRs-Aza] and 16 treated with MMF [KTRs-MMF]) and 40 matched healthy controls (HCs) were administered the trivalent 2006–2007 anti-influenza vaccine. Antibody (Ab) titers were measured before (pre-vacc) and 1 month after (post-vacc) vaccination. The proportion of protective Ab titers (i.e. ≧1:40), the serological response (i.e. ≧4-fold rise in titers) rates, and the magnitudes of change in titers were evaluated. Results: KTRs and HCs were similar in serologic responses, magnitudes of change in Ab titers, and proportions of acquired protective titers against all antigens. Whereas KTRs-MMF and KTRs-Aza were identical in magnitude of rise in titers as well as in serologic responses, KTRs-MMF did poorer in developing post-vacc-protective titers against A/H1N1 (p < 0.05). The function of the transplanted kidney has not deteriorated after vaccination. Conclusions: Anti-influenza vaccination was safe in KTRs and evoked Ab responses comparable to those of HCs. KTRs-MMF and KTRs-Aza responded almost equally to the vaccine. Annual anti-influenza vaccination can be recommended to all stable KTRs.

Clinical and epidemiologic features of Crimean-Congo hemorrhagic fever among children and adolescents from southeastern Iran.

This study aimed to investigate the clinical and epidemiologic features of Crimean-Congo hemorrhagic fever among 34 children and adolescents (mean age, 13.3 ± 4.6 years) from a highly endemic region. Clinical manifestations were similar to those in adults. The case-fatality ratio was 26.5% (9 of 34). Compared with adult patients, children and adolescents may be more vulnerable to severe and fatal Crimean-Congo hemorrhagic fever.

Effect of eradication of Helicobacter pylori on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura: A controlled trial

Several recent studies have suggested that an association exists between Helicobacter pylori (HP) eradication and improvement in platelet count in a significant proportion of patients with idiopathic thrombocytopenic purpura (ITP). In this controlled study, we prospectively examined adult patients with chronic ITP for HP infection, and assessed the effect of HP eradication on platelet count. One hundred forty‐two consecutive Iranian patients with chronic ITP were assessed. Those who met the criteria and had platelet counts >30 × 109/L within the medication‐free screening month were enrolled (n = 129; 66 females; mean age, 29.2 ± 7.0 years). HP‐positive patients received a 2‐week course of triple HP eradication therapy (i.e., amoxicillin, clarithromycin, and omeprazole) and were followed for 48 weeks. An ITP response was defined as a platelet count of >100 × 109/L 24 weeks after treatment, together with an increase in the platelet count >30 × 109/L over the baseline value. HP infection was detected in 79 (61%) patients. HP‐positive patients were significantly older than HP‐negative subjects (P = 0.018). HP eradication was successful in 87% (62/71) of those who completed the eradication therapy. Whereas 48% (30/62) of HP‐eradicated patients showed an ITP response, no HP‐negative patient had an ITP response. The ITP response persisted for 48 weeks in 93% (28/30) of the responders. The ITP responders had a shorter disease duration than the nonresponders (P = 0.002). The management of mild‐to‐moderate chronic ITP in Iranian patients, especially those with a recent onset of disease, should include an investigation for and eradication of infection with HP. Am. J. Hematol., 2008.

Crimean-Congo hemorrhagic fever in Iran.

The presence of Crimean-Congo hemorrhagic fever virus (CCHFV) in Iran was first identified in studies of livestock sera and ticks in the 1970s, but the first human infection was not diagnosed until 1999. Since that time, the number of cases of CCHF in Iran has markedly increased. Through January 2012, articles in the published literature have reported a total of 870 confirmed cases, with 126 deaths, for a case fatality rate (CFR) of 17.6%. The disease has been seen in 26 of the countrys 31 provinces, with the greatest number of cases in Sistan and Baluchestan, Isfahan, Fars, Tehran, Khorasan, and Khuzestan provinces. The increase in CCHF in Iran has paralleled that in neighboring Turkey, though the number of cases in Turkey has been much larger, with an overall CFR of around 5%. In this article, we review the features of CCHF in Iran, including its history, epidemiology, animal and tick reservoirs, current surveillance and control programs, diagnostic methods, clinical features and experience with ribavirin therapy, and consider possible explanations for the difference in the CFR of CCHF between Iran and Turkey. The emergence of CCHF in Iran calls for countermeasures at many levels to protect the population, but also provides opportunities for studying the epidemiology, diagnosis and management of the disease.

Photo Quiz. A 59-Year-Old Man With Multiple Liver Lesions, Rash, and Uveitis.

A 59-year-old man with a medical history significant for earlystage chronic lymphocytic leukemia (CLL), diagnosed 6 years prior, was referred for infectious diseases evaluation due to rash and liver lesions. The patient’s pertinent clinical history began 8 months prior when he experienced 1–2 weeks of night sweats and fatigue, followed by transient numbness and pain in his hands, abdomen, and back, then severe bilateral back pain for several weeks and weight loss of at least 10 pounds. A diffuse nonpruritic rash also developed. Computed tomographic (CT) scan of his chest, abdomen, and pelvis raised concerns for metastatic disease in his liver and possible lytic lesions in his iliac bones. Consequently, he was given a poor prognosis with 6 months to live. The patient had been temporarily residing in Florida, so he returned home to Pennsylvania to be with family. After returning to Pennsylvania, the patient underwent additional studies, including magnetic resonance imaging of his abdomen. This showed multiple, rounded, enhancing lesions of varying sizes in the liver, compatible with metastatic disease (Figure 1). Further investigations suggested that the abnormalities in his iliac bones likely were related to his CLL. CT-guided biopsy of a focal liver lesion demonstrated fibroblastic tissue with moderate mixed inflammatory infiltrate with no evidence of malignancy. He continued to feel unwell, with severe fatigue, generalized weakness, anorexia, and progressive weight loss, and over the ensuing months became almost bedridden. Approximately 6 months following the onset of his initial symptoms, he developed bilateral eye redness and pain with a gritty sensation and blurred vision. Ophthalmologic evaluation revealed uveitis and episcleritis, and he was started on topical cyclopentolate and prednisolone with gradual amelioration. Two empiric courses of oral prednisone were prescribed at about this time, and each course led to a sense of overall improvement by the patient, as well as transient reduction of his rash. Several physicians had examined the rash Figure 1. Enhanced abdominal magnetic resonance imaging (liver protocol). Coronal (A) and transverse (B) T1-weighted images of the liver obtained 20 minutes after administration of Eovist gadolinium-based contrast.